The Impact of Celiac Disease on Caregivers' Well-being: An Integrative Review.

OBJECTIVES: A diagnosis of celiac disease (CD) requires individuals to adopt a strict gluten-free diet. As children with CD must rely on their caregivers for guidance and support with managing the gluten-free diet, CD may challenge the caregiver's emotional and social well-being. The primary objective of this mixed-methods systematic review was to synthesize research investigating the impact of CD on caregiver's well-being. METHODS: Five databases were systematically searched from 1990 to 2018 to identify all empirical studies that assessed well-being in caregivers of children (0-18 years) with CD. Qualitative and quantitative data were extracted separately before being integrated to explore key themes across the studies. RESULTS: Twelve studies were identified that explored the well-being of caregivers of children with CD (3 qualitative, 9 quantitative), reporting on 665 caregivers. The quality of evidence was limited across studies. Synthesis of results revealed 3 themes (Caregiver Responsibility, Caregiver Well-Being and Concern for Child's Health, Implications for the Family) describing the impact of a child with CD on caregiver well-being. CONCLUSIONS: Caregivers of children with CD may experience difficulties that impact their well-being; specific difficulties identified included the impact of caregivers' social activities, finances, and anxiety. The findings detailed in this review point toward factors that may guide health care personnel to provide support for the caregivers of children with CD.

A Quantitative Assessment of Gluten Cross-contact in the School Environment for Children With Celiac Disease.

OBJECTIVES: A gluten-free (GF) diet is the primary treatment for celiac disease (CD). Gluten is used in schools, particularly in early childhood, art, and home-economics classrooms. This study aimed to measure gluten transfer from school supplies to GF foods that a child with CD may eat. Also, to measure efficacy of washing techniques to remove gluten from hands and tables. METHODS: Five experiments measured potential gluten cross-contact in classrooms: Play-Doh (n = 30); baking project (n = 30); paper mâché (n = 10); dry pasta in sensory table (n = 10); cooked pasta in sensory table (n = 10). Thirty participants ages 2 to 18 were enrolled. Following activities, gluten levels were measured on separate slices of GF bread rubbed on participant's hands and table surfaces. Participants were assigned 1 of 3 handwashing methods (soap and water, water alone, or wet wipe). Repeat gluten transfer measurements were taken from hands and tables. Gluten measurements made using R-Biopharm R7001 R5-ELISA Sandwich assay. RESULTS: Paper mâché, cooked pasta in sensory tables, and baking project resulted in rates of gluten transfer far greater than the 20 ppm threshold set by Codex Alimentarius Commission. Play-Doh and dry pasta, however, resulted in few gluten transfers to GF bread >20 ppm. Soap and water was consistently the most effective method for removing gluten, although other methods proved as effective in certain scenarios. CONCLUSIONS: The potential for gluten exposure at school is high for some materials and low for others. For high-risk materials, schools should provide GF supplies and have a robust strategy to prevent gluten cross-contact with food.

Does a multimethod approach improve identification of medication nonadherence in adolescents with chronic kidney disease?

BACKGROUND: Medical provider assessment of nonadherence is known to be inaccurate. Researchers have suggested using a multimethod assessment approach; however, no study has demonstrated how to integrate different measures to improve accuracy. This study aimed to determine if using additional measures improves the accurate identification of nonadherence beyond provider assessment alone. METHODS: Eighty-seven adolescents and young adults (AYAs), age 11-19 years, with chronic kidney disease (CKD) [stage 1-5/end-stage renal disease (ESRD)] and prescribed antihypertensive medication, their caregivers, and 17 medical providers participated in the multisite study. Five adherence measures were obtained: provider report, AYA report, caregiver report, electronic medication monitoring (MEMS), and pharmacy refill data [medication possession ratio (MPR)]. Concordance was calculated using kappa statistic. Sensitivity, specificity, positive predictive power, and negative predictive power were calculated using MEMS as the criterion for measuring adherence. RESULTS: There was poor to fair concordance (kappas = 0.12-0.54), with 35-61% of AYAs classified as nonadherent depending on the measure. While both providers and MEMS classified 35% of the AYAs as nonadherent, sensitivity (0.57) and specificity (0.77) demonstrated poor agreement between the two measures on identifying which AYAs were nonadherent. Combining provider report of nonadherence and MPR < 75% resulted in the highest sensitivity for identifying nonadherence (0.90) and negative predictive power (0.88). CONCLUSIONS: Nonadherence is prevalent in AYAs with CKD. Providers inaccurately identify nonadherence, leading to missed opportunities to intervene. Our study demonstrates the benefit to utilizing a multimethod approach to identify nonadherence in patients with chronic disease, an essential first step to reduce nonadherence.

Multiple domains of stress predict postpartum depressive symptoms in low-income Mexican American women: the moderating effect of social support.

Prenatal stress can have a lasting effect on women's mental health after childbirth. The negative effects may be particularly salient in women from low income and ethnic minority backgrounds, who are at increased risk for postpartum depression. However, social support may have the potential to attenuate the negative impact of stress. The present study evaluated 269 Mexican American women (ages 18-42; 83 % Spanish-speaking; median income $10,000-$15,000) for prenatal stress (daily hassles, family stress, partner stress, and culture-specific stress) in relation to depressive symptoms 6 weeks postpartum. Prenatal social support was examined as a buffer against the impact of prenatal stress. Partner stress, family stress, and daily hassles uniquely predicted depressive symptoms. Moderate and high levels of social support attenuated risk for depression due to family stressors. Prenatal interpersonal and daily stressors negatively impact the mental health of women after birth, but social support can mitigate some of these effects. Among Mexican American pregnant women, effective interpersonal support and stress management may be associated with reduced risk for postpartum depression.

Evaluating provider communication in pediatric chronic kidney disease care using a global coding system.

OBJECTIVE: Among adolescents and young adults (AYAs) with chronic illness, effective provider communication is essential for patient-centered care during a sensitive developmental period. However, communication in chronic illness care for AYAs is not well studied. Our objectives were to describe the provider communication skills in pediatric chronic kidney disease (CKD) care visits; and determine if communication skills differ by AYA characteristics. METHODS: We adapted a global consultation rating system for pediatric subspecialty care using audiotaped clinic encounters of 18 pediatric nephrologists with 99 AYAs (age M(SD) = 14.9(2.6)) with CKD stages 1-5 and 96 caregivers. We hypothesized that provider communication skills would differ by AYA characteristics (age, gender, and race). RESULTS: The strongest provider skills included initiating the session and developing rapport; lowest rated skills were asking patient's perspective and checking understanding. Communication scores did not consistently differ by AYA age or race, but were rated higher with female AYAs in several domains (ps<0.05). CONCLUSIONS: Pediatric providers generally had adequate or good communication scores with AYAs, but improvement in certain skills, particularly with male AYAs, may further support patient-centered care. PRACTICE IMPLICATIONS: To achieve consistent, patient-centered communication with AYAs, an observation-based global assessment may identify areas for provider improvement.

Prenatal stress, partner support, and infant cortisol reactivity in low-income Mexican American families.

Maternal exposure to significant prenatal stress can negatively affect infant neurobiological development and increase the risk for developmental and health disturbances. These effects may be pronounced in low SES and ethnic minority families. We explored prenatal partner support as a buffer of the impact of prenatal stress on cortisol reactivity of infants born to low-income Mexican American women. Women (N=220; age 18-42; 84% Spanish-speaking; 89% foreign born; modal family income $10,000-$15,000) reported on economic stress and satisfaction with spousal/partner support during the prenatal period (26-38 weeks gestation), and infant salivary cortisol reactivity to mildly challenging mother-infant interaction tasks was assessed at women's homes at six weeks postpartum. Multilevel models estimated the interactive effect of prenatal stress and partner support on cortisol reactivity, controlling for covariates and potential confounds. Infants born to mothers who reported high prenatal stress and low partner support exhibited higher cortisol reactivity relative to those whose mothers reported high support or low stress. The effects did not appear to operate through birth outcomes. For low-income Mexican American women, partner support may buffer the impact of prenatal stress on infant cortisol reactivity, potentially promoting more adaptive infant health and development.