Design of the Intervention to Reduce Early Peanut Allergy in Children (iREACH): A practice-based clinical trial.

BACKGROUND: Introducing peanut products early can prevent peanut allergy (PA). The "Addendum guidelines for the prevention of PA in the United States" (PPA guidelines) recommend early introduction of peanut products to low and moderate risk infants and evaluation prior to starting peanut products for infants at high risk for PA (those with severe eczema and/or egg allergy). Rapid adoption of guidelines could aid in lowering the prevalence of PA. The Intervention to Reduce Early (Peanut) Allergy in Children (iREACH) trial was designed to promote PPA guideline adherence by pediatric clinicians. METHODS: A two-arm, cluster-randomized, controlled clinical trial was designed to measure the effectiveness of an intervention that included clinician education and accompanying clinical decision support tools integrated in electronic health records (EHR) versus standard care. Randomization was at the practice level (n = 30). Primary aims evaluated over an 18-month trial period assess adherence to the PPA guidelines using EHR documentation at 4- and 6-month well-child care visits aided by natural language processing. A secondary aim will evaluate the effectiveness in decreasing the incidence of PA by age 2.5 years using EHR documentation and caregiver surveys. The unit of observation for evaluations are individual children with clustering at the practice level. CONCLUSION: Application of this intervention has the potential to inform the development of strategies to speed implementation of PPA guidelines.

Testing for rare genetic causes of obesity: findings and experiences from a pediatric weight management program.

BACKGROUND: Genetic screening for youth with obesity in the absence of syndromic findings has not been part of obesity management. For children with early onset obesity, genetic screening is recommended for those having clinical features of genetic obesity syndromes (including hyperphagia). OBJECTIVES: The overarching goal of this work is to report the findings and experiences from one pediatric weight management program that implemented targeted sequencing analysis for genes known to cause rare genetic disorders of obesity. SUBJECTS/METHODS: This exploratory study evaluated youth tested over an 18-month period using a panel of 40-genes in the melanocortin 4 receptor pathway. Medical records were reviewed for demographic and visit information, including body mass index (BMI) percent of 95th percentile (%BMIp95) and two eating behaviors. RESULTS: Of 117 subjects: 51.3% were male; 53.8% Hispanic; mean age 10.2 years (SD 3.8); mean %BMIp95 157% (SD 29%). Most subjects were self- or caregiver-reported to have overeating to excess or binge eating (80.3%) and sneaking food or eating in secret (59.0%). Among analyzed genes, 72 subjects (61.5%) had at least one variant reported; 50 (42.7%) had a single variant reported; 22 (18.8%) had 2-4 variants reported; most variants were rare (<0.05% minor allele frequency [MAF]), and of uncertain significance; all variants were heterozygous. Nine subjects (7.7%) had a variant reported as PSCK1 "risk" or MC4R "likely pathogenic"; 39 (33.3%) had a Bardet-Biedl Syndrome (BBS) gene variant (4 with "pathogenic" or "likely pathogenic" variants). Therefore, 9 youth (7.7%) had gene variants previously identified as increasing risk for obesity and 4 youth (3.4%) had BBS carrier status. CONCLUSIONS: Panel testing identified rare variants of uncertain significance in most youth tested, and infrequently identified variants previously reported to increase the risk for obesity. Further research in larger cohorts is needed to understand how genetic variants influence the expression of non-syndromic obesity.

Health Outcomes of Youth in Clinical Pediatric Weight Management Programs in POWER.

OBJECTIVE: To describe treatment outcomes of children and adolescents enrolled in the Pediatric Obesity Weight Evaluation Registry, a consortium of multicomponent pediatric weight management programs in the US. STUDY DESIGN: This multicenter prospective observational cohort study, established in 2013, includes youth (2-18 years of age) with obesity enrolled from 31 Pediatric Obesity Weight Evaluation Registry (POWER) sites over a 2-year period and followed up to 12 months. Weight status was evaluated by the percentage of the 95th percentile for body mass index (%BMIp95). Associations of weight status outcomes with patient characteristics and program exposure were analyzed with multivariable mixed effects modeling. RESULTS: We included 6454 children and adolescents (median age, 11 years; IQR, 9-14 years; 53% white, 32% Hispanic; 73% with severe obesity) who were enrolled in POWER. Median changes in %BMIp95 for this cohort were -1.88 (IQR, -5.8 to 1.4), -2.50 (IQR, -7.4 to 1.8), -2.86 (IQR, -8.7 to 1.9), at 4-6, 7-9, and 10-12 of months follow-up, respectively (all P < .05). Older age (≥12 years), greater severity of obesity, and Hispanic race/ethnicity were associated with better improvement in %BMIp95. A 5-percentage point decrease in %BMIp95 was associated with improvement in cardiometabolic risk factors. CONCLUSIONS: Overall, treatment in pediatric weight management programs is associated with a modest median decrease in BMI as measured by change in %BMIp95. Further studies are needed to confirm these findings, as well as to identify additional strategies to enhance the effectiveness of these multicomponent interventions for youth with severe obesity. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02121132.

[Overweight and obesity: review and update]. / Sobrepeso y obesidad: revisión y puesta al día de la Sociedad Latinoamericana de Gastroenterología, Hepatología y Nutrición Pediátrica (SLAGHN.

Obesity is an epidemic with important health repercussions in addition to high treatment-related costs. Between 2006 and 2007 the WHO developed new assessment tools, which aren't being globally used. In fact, there is no unified problem management across the hemisphere. Objectives: To update obesity epidemiology, to promote application of WHO's standards, to review new findings on physiopathology (i.e., fatty tissue as endocrine organ, intestinal microbiota), to update epidemiological information, and to provide management guidelines that can be integrated in clinical care. Methods: LAPSGHAN called up its members to collaborate in preparing this review article under the direction of an editor/coordinator, who selected the contents and literature with the best evidencetogether with the members. Each member prepared a separate document for each content. The chosen contents were later collated, unified, and edited. Results. This documents highlights the following: 1) Although extreme obesity is increasing in the US, overweight and obesity prevalence has stabilized, while in other countries it is alarmingly increasing; 2) New information regarding role of fatty tissue as endocrine organ and self-regulator of obesity; 3) The promising role of microbiota; and 4) Guidelines for children handling during consultation and follow-up. Conclusions: There is no widespread implementation of standards and guidelines from the World Health Organization (WHO). There is no agreement as to whether z-scores or percentiles should be used, especially regarding children under 2 due to their changing body complexion. The most accepted tool to assess overweight, obesity and severe obesity is the Body Mass Index (BMI). This document provides recommendations on how to approach clinical care with affected children.

Recognition of elevated blood pressure in an outpatient pediatric tertiary care setting.

OBJECTIVE: To assess the prevalence of elevated blood pressure (BP) and its identification among outpatients at a pediatric tertiary care hospital and to assess clinician attitudes towards BP management. STUDY DESIGN: A retrospective review was undertaken of electronic medical record data of visits over the course of 1 year to 10 subspecialty divisions and 3 primary care services at an urban tertiary care hospital. Interviews of division/service representatives and a clinician survey on perceived role on BP care, practices, and protocols related to BP management were conducted. Elevated BP was defined as ≥90th percentile (using US references); identification of elevated BP was defined as the presence of appropriate codes in the problem list or visit diagnoses. RESULTS: Among 29,000 patients (ages 2-17 years), 70% (those with ≥1 BP measurement) were analyzed. Patients were as follows: 50% male; 42% white, 31% Hispanic, 16% black, 5% Asian, and 5% other/missing; 52% had Medicaid insurance. A total of 64% had normal BPs, 33% had 1-2 elevated BP measurements, and 3% had ≥3 elevated BP measurements. Among those with ≥3 elevated BP measurements, the median frequency of identification by division/service was 17%; the greatest identification was for Kidney Diseases (67%), Wellness & Weight Management (60%), and Cardiology (33%). Among patients with ≥3 elevated BP measurements, 21% were identified vs 7% identified among those with 1-2 increased measurements (P<.001). All clinician survey respondents perceived self-responsibility for identification of elevated BP, but opinions varied for their role in the management of elevated BP. CONCLUSIONS: The identification of patients with elevated BP measurements was low. Strategies to increase the identification of elevated BPs in outpatient tertiary care settings are needed.

A Precision Mental Health Model for Predicting Stability of 4-year-olds' Attention Deficit/Hyperactivity Disorder Symptoms to Age 6 Diagnostic Status.

OBJECTIVE: Estimates of the stability of a preschooler's diagnosis of Attention Deficit/Hyperactivity Disorder (ADHD) into early elementary school vary greatly. Identified factors associated with diagnostic instability provide little guidance about the likelihood a particular child will have ADHD in elementary school. This study examined an approach to predicting age 6 ADHD-any subtype (ADHD-any) from preschoolers' demographics and ADHD symptoms. METHOD: Participants were 796 preschool children (Mage = 4.44; 51% boys; 54% White, non-Hispanic) recruited from primary pediatric care and school settings. Parents completed ADHD Rating Scales at child ages 4 and 5 years, and a structured diagnostic interview (DISC-YC) at ages 4 and 6. Classification tree analyses (CTAs) examined the predictive utility of demographic and symptom variables at ages 4 and 5 years for age 6 ADHD. RESULTS: Over half (52.05%) of preschoolers meeting diagnostic criteria for ADHD-any at age 4 did not meet those criteria at age 6; more than half (52.05%) meeting criteria for ADHD-any at age 6 had not met those criteria at age 4. A CTA conducted at age 4 predicted age 6 ADHD-any diagnosis 65.82% better than chance; an age 5 CTA predicted age 6 ADHD-any 70.60% better than chance. At age 4, likelihood of age 6 ADHD-any diagnosis varied from <5% to >40% across CTA tree branches and from <5% to >78% at age 5. CONCLUSIONS: Parent-reported patterns of preschool-age symptoms may differentially predict ADHD-any at age 6. Psychoeducation regarding these patterns may aid in decision about pursuing multidisciplinary evaluations or initiating treatment.

Exploring Genetic Testing for Rare Disorders of Obesity: Experience and Perspectives of Pediatric Weight Management Providers.

Background: This study describes experiences and perspectives of pediatric weight management (PWM) providers on the implementation of genetic testing for rare causes of obesity. Methods: Purposive and snowball sampling recruited PWM providers via email to complete a 23-question survey with multiple choice and open-ended questions. Analyses include descriptive statistics, Fisher's exact test, one-way ANOVA with Tukey's post hoc test, and qualitative analysis. Results: Of the 55 respondents, 80% reported ordering genetic testing. Respondents were primarily physicians (82.8%) in practice for 11-20 years (42%), identified as female (80%), White (76.4%), and non-Hispanic (92.7%) and provided PWM care 1-4 half day sessions per week. Frequently reported patient characteristics that prompted testing did not vary by provider years of experience (YOE). These included obesity onset before age 6, hyperphagia, dysmorphic facies, and developmental delays. The number of patient characteristics that prompted testing varied by YOE (p = 0.03); respondents with 6-10 YOE indicated more patient characteristics than respondents with >20 YOE (mean 10.3 vs. mean 6.2). The reported primary benefit of testing was health information for patients/families; the primary drawback was the high number of indeterminate tests. Ethical concerns expressed were fear of increasing weight stigma, discrimination, and impact on insurance coverage. Respondents (42%) desired training and guidance on interpreting results and counseling patients and families. Conclusions: Most PWM providers reported genetic testing as an option for patient management. Provider training in genetics/genomics and research into provider and family attitudes on the genetics of obesity and the value of genetic testing are next steps to consider.

Vitamin D levels, insulin resistance, and cardiovascular risks in very young obese children.

OBJECTIVE: To examine the relationships of 25-hydroxyvitamin D (25-OHD) levels with the measures of insulin resistance and cardiovascular risk, and identify the clinical factors associated with low 25-OHD in young obese children. DESIGN AND METHODS: Data from 83 children ages 2-6 years seen for obesity care (clinic latitude 42°N) were analyzed. Insulin resistance [homeostasis model assessment of insulin resistance (HOMA-IR)] and cardiovascular risks were examined in relationship to 25-OHD levels using correlation statistics. χ2 and logistic regression models were applied to identify the factors associated with vitamin D deficiency (25-OHD levels <20 ng/mL) and insufficiency (<30 ng/mL). RESULTS: Children's mean age was mean 4.9 years and they were predominantly Hispanic. Mean body mass index (BMI) Z-score was 3.2 and mean HOMA-IR was 2.8. Mean 25-OHD was 30.9 ng/mL (6% <20 ng/mL and 46% 20-29 ng/mL). There were no significant correlations between 25-OHD and BMI (Spearman's ρ=-0.096, p=0.389), BMI Z-score (Spearman's ρ=0.104, p=0.350), HOMA-IR (Spearman's ρ=-0.144, p=0.269), total cholesterol (Spearman's ρ=-0.028, p=0.833), or triglycerides (Spearman's ρ=-0.026, p=0.846). Vitamin D deficiency was significantly associated with older age, lower milk intake, and testing in winter months. 25-OHD level <30 ng/mL was associated with older age, African-American and Hispanic race/ethnicity, and testing in winter months. All factors retained significance in a multivariate logistic regression model, with African-American (odds ratio=14.4) and Hispanic (odds ratio=7.2) race/ethnicity being the strongest predictors of 25-OHD levels <30 ng/mL. CONCLUSIONS: In these children, 25-OHD was not associated with insulin resistance or cardiovascular risks. Considering age, race/ethnicity, diet, and season may help identify young obese children needing vitamin D management.

Perceptions on Management of Atopic Dermatitis in Children Under 2 Years by Community Pediatricians: A Focus Group Study.

Atopic dermatitis (AD) is a common skin condition and is undertreated in children under 2 years, whom there are no specific guidelines for. We sought to understand barriers to AD treatment and primary care pediatricians' (PCPs) suggested solutions. We conducted semi-structured focus groups (n = 5) with PCPs (n = 17) on how the undertreatment of AD can be addressed. Data were analyzed using an inductive qualitative approach. Participants noted that the perceived undertreatment of AD in children under 2 years could be explained by topical corticosteroid (TCS) use hesitancy, lack of caregiver adherence to PCP recommendations, and under-documentation of AD in the electronic medical record (EMR). Proposed suggestions for improving AD management included caregiver and PCP education on TCS safety; stepwise management guidelines for this age group; and EMR aids to help document and manage AD. Research is warranted to create and disseminate clinician-friendly AD management guidelines for this age group.

Challenges and solutions to sustaining paediatric weight management programs in the United States.

Paediatric weight management (PWM) programs in the United States (US) face challenges in providing sustainable multidisciplinary care for patients. The aim of this study was to report PWM program approaches to sustaining program delivery. A survey of 39 PWM programs was administered to identify challenges and solutions to program sustainability. Common and useful strategies for optimizing reimbursement for services included the use of applicable reimbursable diagnostic codes and management, billing for assessments and non-medical personnel services, and the use of hospital outpatient department clinic billing. Increasing clinical breadth and capacity was achieved by offering telemedicine and other services, such as psychotherapy, pharmacotherapy, and metabolic and bariatric surgery, as well as active management of schedules. Securing institutional and extramural funding was also reported. One of the positive changes during the pandemic was the fast adoption of telemedicine services. Although delivering sustainable evidence-based multidisciplinary PWM under the current US payment models has its challenges, PWM programs implement practical operational strategies to support this work.

Obesity care strategies in primary care practices.

We evaluated pediatric obesity clinics for internal referrals developed at 5 primary care offices. Clinics developed site-specific strategies: 1 group approach and 4 clinics providing individualized care only. Clinicians reported patient/family motivation as an important referral consideration and compliance as the greatest challenge and perceive clinics to have provided some help.

Elevated blood pressure in youth in pediatric weight management programs in the Pediatric Obesity Weight Evaluation Registry (POWER).

Blood pressure (BP) assessment and management are important aspects of care for youth with obesity. This study evaluates data of youth with obesity seeking care at 35 pediatric weight management (PWM) programs enrolled in the Pediatric Obesity Weight Evaluation Registry (POWER). Data obtained at a first clinical visit for youth aged 3-17 years were evaluated to: (1) assess prevalence of BP above the normal range (high BP); and (2) identify characteristics associated with having high BP status. Weight status was evaluated using percentage of the 95th percentile for body mass index (%BMIp95); %BMIp95 was used to group youth by obesity class (class 1, 100% to < 120% %BMIp95; class 2, 120% to < 140% %BMIp95; class 3, ≥140% %BMIp95; class 2 and class 3 are considered severe obesity). Logistic regression evaluated associations with high BP. Data of 7943 patients were analyzed. Patients were: mean 11.7 (SD 3.3) years; 54% female; 19% Black non-Hispanic, 32% Hispanic, 39% White non-Hispanic; mean %BMIp95 137% (SD 25). Overall, 48.9% had high BP at the baseline visit, including 60.0% of youth with class 3 obesity, 45.9% with class 2 obesity, and 37.7% with class 1 obesity. Having high BP was positively associated with severe obesity, older age (15-17 years), and being male. Nearly half of treatment-seeking youth with obesity presented for PWM care with high BP making assessment and management of BP a key area of focus for PWM programs.

Identifying characteristics and outcomes in youth with obesity and developmental disabilities.

BACKGROUND: Youth with developmental disability are at increased risk of obesity; literature focusing on the two is rare. OBJECTIVE: To identify characteristics and outcomes of youth presenting for obesity care having a disability as compared to without. METHODS: A medical record review of youth aged 2-18 years initiating obesity care 2013-2015 at a tertiary care obesity management program. Youth were grouped by disability status to identify differences in presenting characteristics and factors associated with a reduction in body mass index (BMI) percent of the 95th BMI percentile (BMIp95) over 12 months. Logistic regression (LR) models examined associations with BMIp95 drop (<5-points versus ≥5-points) for each disability group. RESULTS: Of 887 subjects, 253 (28.5%) had a disability. At presentation, youth with disability were more often (p < 0.01) male (58.5% versus 47.9%), had birth weight <2500 g (14.1% versus 8.4%), had a father who was not obese (61.6% versus 47.4%), and were on weight influencing medications. Overall, 182 subjects (20.5%) completed 12-month follow-up. At follow-up, the with disability group (n = 63) had mean -2.3 (SD 10.7) BMIp95 change (p = 0.679); youth having a motor disability less often had ≥5-point BMIp95 drop (odds ratio 0.15, 95% confidence interval 0.04-0.59). At follow-up, the no disability group (n = 119) had mean -2.9 (SD 8.5) BMIp95 change; youth identified as having initial severe obesity status and not having a parent with diabetes more often had ≥5-point BMIp95 drop. CONCLUSION: Youth with developmental disabilities were as successful in obesity care as those without disabilities. Predictors of success differed between the groups.

Estimation of Body Fat Percentage for Clinical Pharmacokinetic Studies in Children.

Obesity is a prevalent childhood condition and the degree of adiposity appears likely to be an important covariate in the pharmacokinetics (PKs) of many drugs. We undertook these studies to facilitate the evaluation and, where appropriate, quantification of the covariate effect of body fat percentage (BF%) on PK parameters in children. We examined two large databases to determine the values and variabilities of BF% in children with healthy body weights and in those with obesity, comparing the accuracy and precision of BF% estimation by both clinical methods and demographically derived techniques. Additionally, we conducted simulation studies to evaluate the utility of the several methods for application in clinical trials. BF% was correlated with body mass index (BMI), but was highly variable among both children with healthy body weights and those with obesity. Bio-impedance and several demographically derived techniques produced mean estimates of BF% that differed from dual x-ray absorptiometry by < 1% (accuracy) and a SD of 5% or less (precision). Simulation studies confirmed that when the differences in precision among the several methods were small compared with unexplained between-subject variability of a PK parameter, the techniques were of similar value in assessing the contribution of BF%, if any, as a covariate for that PK parameter. The combination of sex and obesity stage explained 68% of the variance of BF% with BMI. The estimation of BF% from sex and obesity stage can routinely be applied to PK clinical trials to evaluate the contribution of BF% as a potential covariate.

Do hospitalized pediatric patients have weight and blood pressure concerns identified?

OBJECTIVES: To assess the frequency and recognition of abnormal nutritional status and elevated admitting blood pressure (BP) in hospitalized children. STUDY DESIGN: From children aged 3 to 18 years who were hospitalized during 4 months of 2005 (n = 1143), a stratified sample of paper-based medical records were reviewed for demographics, anthropometric and BP measurements and interpretations, care related to nutrition and BP, and discharge diagnoses. Records of 317 of 337 (94%) selected patients were reviewed, and data from 277 of these patients (records with weight and height documented) were analyzed. US references were applied to assign body mass index and BP percentiles. Data were weighted to account for sampling. RESULTS: A total of 51% of subjects were Medicaid/self-pay, with a median age of 9.1 years; and 20% of subjects were obese (14% overweight, 58% healthy weight, 8% underweight). Body mass index was plotted/calculated for 35% of subjects. Six percent of subjects had BP >99th percentile + 5 mm Hg (18% BP 95th to < or =99th percentile + 5 mm Hg). A nutrition referral was documented for 61% of subjects who were underweight and 39% of subjects who were obese. BP concerns were documented for 26% of subjects with BP >99th percentile + 5 mm Hg. CONCLUSIONS: Many pediatric inpatients had abnormal nutritional status or elevated BP. Systems to improve interpretation of these measures, which are commonly obtained in pediatric hospital settings, are needed.

Promoting growth interpretation and lifestyle counseling in primary care.

OBJECTIVE: To pilot a practice-directed intervention to promote growth interpretation and lifestyle counseling during child health supervision visits. STUDY DESIGN: The intervention at 4 diverse primary care practices included education, facilitation by a practice-change leadership team, tools, and guidance from the study team. Preintervention and postintervention evaluations used were clinician interviews, in-office surveys of parents, 1-month post-visit telephone survey, visit observations, and medical record reviews. Outcomes evaluated growth interpretation documentation, clinician recognition of overweight, topic discussed at health supervision visit, and parental visit content recall and health behavior changes. RESULTS: The intervention was well accepted, and tools provided were deemed helpful. Documentation of growth interpretation was higher after intervention (pre versus post: 32% vs 87%; P< .001). Parent reports of topics discussed were similar between evaluation periods (pre versus post: growth 96% vs 99%; diet 90% vs 93%; physical activity 81% vs 85%). Observed topics at health supervision visits were similarly high and were unchanged between periods. Parental recall of topics at 1 month was also high and similar between periods. Parental report of adoption of a healthier behavior for themselves or their child at 1 month did not significantly change. CONCLUSIONS: The Systematic Nutritional Assessment in Pediatric Practice intervention provides a promising model to increase interpretation and documentation of growth.

Influences on parents' decisions for home and automobile smoking bans in households with smokers.

OBJECTIVE: To understand clinician influence on use of home and automobile smoking bans in homes of children living with a smoker. METHODS: Parents were surveyed on tobacco use, smoking bans, demographics and opinions about tobacco, including harm from environmental tobacco smoke (ETS). Responses from 463 diverse households with smokers were analyzed. RESULTS: 42% of respondents smoked; 50% had a home smoking ban and 58% an automobile smoking ban. Nonsmokers living with a smoker, those who strongly agreed in ETS harm, and those having a child < or = 5 years more often had a home smoking ban. Those recalling their child's doctor ever asking the respondent about their smoking status and African American respondents less frequently had a home ban. Automobile smoking bans were more often held by those with strong agreement in ETS harm and less often found in families having a child receiving Medicaid/uninsured. CONCLUSIONS: Having a strong perception of harm from ETS exposure was associated with having smoking bans. Aspects of health encounters not measured by this study may be negatively influencing adoption of home smoking bans or lead to recall bias. PRACTICE IMPLICATIONS: Clinicians should examine the strength, focus, and response to their messages to parents about tobacco.

Characteristics of Children Referred to a Lipid Clinic Before and After the Universal Screening Guidelines.

In 2011, universal lipid screening was recommended for children aged 9 to 11 years; the impact of this recommendation on the lipid clinic setting is unknown. We examined the rate of primary and secondary dyslipidemia diagnoses in a lipid clinic before (2010-2011) and after (2012-2015) the guideline recommendation. We conducted a retrospective study of new clinic patients aged 0 to 20 years seen between April 2010 and April 2015. Chi-square testing was applied. The 345 subjects were 58% males; 48% ≥13 years; 56% Hispanic; and 59% obese. There was no difference in the rate of dyslipidemia diagnoses between periods (before: primary 23%, secondary 73%, no dyslipidemia 4% vs after: 22%, 72%, 6%, respectively; P = .616). There was no significant difference between periods in subject demographics for the total sample, but among those with primary dyslipidemia, pre- to post-guideline percentage of subjects with public insurance decreased (71% to 39%; P = .006). Additional strategies to increase identification of children with dyslipidemia are needed.

Does History of Prematurity Prompt Blood Pressure Evaluations at Primary Care Visits?

Prematurity is a risk factor for elevated blood pressure (BP). We performed a mixed-methods study of care patterns and awareness of early BP screening recommendations for infants born prematurely (IBP) by interviewing/surveying providers on practice- and provider-level BP screening. IBP's records were reviewed for BP screening documentation, demographics, and gestational age (GA). Visits <33 months were reviewed for anthropometrics, BP, and comorbidities. Chi-square analysis evaluated BP screening by GA and comorbidities. Twenty-six of 49 practices completed interviews; 81% had infant BP equipment available; 4% had BP measurement protocol for IBP. Twenty-eight of 86 providers were aware of screening guidelines; none reported routine assessment. Twenty-eight of 118 IBP had ≥1 BP documented; 43% had BP ≥90th percentile. Screening did not differ by GA group. Kidney-related diagnosis was associated with more frequent BP screening (P = .0454). BP is not routinely measured though often elevated before age 3 in IBP.

Case Reports: Multifaceted Experiences Treating Youth with Severe Obesity.

The management of youth with severe obesity is strongly impacted by social determinants of health and family dynamics. We present case studies of three patients seen in our tertiary care obesity treatment clinic as examples of the challenges faced by these patients and their families, as well as by the medical team. We discuss how these cases illustrate potential barriers to care, the role of child protective services, and we reflect upon lessons learned through the care of these patients. These cases highlight the need for comprehensive care in the management of youth with severe obesity, which can include: visits to multiple medical specialists, and mental and behavioral health providers; school accommodations; linkage to community resources; and, potentially, child protective services involvement. Through the care of these youth, our medical team gained more experience with using anti-obesity medications and meal replacements. The care of these youth also heightened our appreciation for the integral role of mental health services and community-based resources in the management of youth with severe obesity.