Obesity class versus the Edmonton Obesity Staging System for Pediatrics to define health risk in childhood obesity: results from the CANPWR cross-sectional study.

BACKGROUND: Disease severity in paediatric obesity is usually defined using the body-mass index (BMI). Although informative at the population level, its usefulness on an individual level has limitations. The use of a clinical staging system-Edmonton Obesity Staging System for Pediatrics (EOSS-P)-in identifying health risk has been proposed. This study aimed to examine the association between BMI class and EOSS-P stage. METHODS: This cross-sectional study was done in children with obesity aged 5-17 years who enrolled in the Canadian Pediatric Weight Management Registry (CANPWR) between May 31, 2013, and Oct 27, 2017, involving ten multidisciplinary paediatric weight management clinics in Canada. We classified participants into WHO BMI classes (class I as 2-3 SD scores, class II as >3 SD scores, and class III as >4 SD scores above the WHO growth standard median), and applied the EOSS-P staging system (stages 0, 1, and 2/3) based on the clinical assessment of coexisting metabolic, mechanical, mental health, and social milieu issues. Clinical information was extracted from medical records and reported using standardised case report forms. Associations of BMI class with EOSS-P stage were examined in children with complete data. FINDINGS: Of the 847 children with complete data, 546 (64%) had severe obesity based on BMI class (ie, class II or III) and 678 (80%) were EOSS-P stage 2/3. Stage 2/3 obesity-related health issues were common; mental health concerns were most common (520 [61%] of 847 children), followed by metabolic (349 [41%] of 847 children), social milieu (179 [21%] of 847 children), and mechanical (86 [10%] of 847 children) health issues. Mental health issues (eg, anxiety and attention-deficit hyperactivity disorder) were equally distributed across BMI classes, metabolic health issues were slightly more common in higher BMI classes, and mechanical (eg, musculoskeletal issues and sleep apnoea) and social milieu (eg, bullying and low household income) issues increased with increasing BMI class. Of children with class I obesity, 206 (76%) of 270 had overall EOSS-P stage 2/3, compared with 195 (85%) of 229 with class III obesity. INTERPRETATION: Physical and mental health issues were highly prevalent among children with obesity irrespective of BMI class. Participants with class III obesity carried the greatest health risk across subcategories of the EOSS-P. As BMI class increased, a concomitant increased disease burden in mechanical and social milieu issues was observed, whereas metabolic and mental health risks were high across BMI classes. FUNDING: Canadian Institutes of Health Research, Ontario Ministry of Health, McMaster University, and McMaster Children's Hospital.

Building a common pediatric research terminology for accelerating child health research.

Longitudinal observational clinical data on pediatric patients in electronic format is becoming widely available. A new era of multi-institutional data networks that study pediatric diseases and outcomes across disparate health delivery models and care settings are also enabling an innovative collaborative rapid improvement paradigm called the Learning Health System. However, the potential alignment of routine clinical care, observational clinical research, pragmatic clinical trials, and health systems improvement requires a data infrastructure capable of combining information from systems and workflows that historically have been isolated from each other. Removing barriers to integrating and reusing data collected in different settings will permit new opportunities to develop a more complete picture of a patient's care and to leverage data from related research studies. One key barrier is the lack of a common terminology that provides uniform definitions and descriptions of clinical observations and data. A well-characterized terminology ensures a common meaning and supports data reuse and integration. A common terminology allows studies to build upon previous findings and to reuse data collection tools and data management processes. We present the current state of terminology harmonization and describe a governance structure and mechanism for coordinating the development of a common pediatric research terminology that links to clinical terminologies and can be used to align existing terminologies. By reducing the barriers between clinical care and clinical research, a Learning Health System can leverage and reuse not only its own data resources but also broader extant data resources.

Health of children classified as underweight by CDC reference but normal by WHO standard.

OBJECTIVE: To ascertain measures of health status among 6- to 24-month-old children classified as below normal weight-for-age (underweight) by the Centers for Disease Control and Prevention (CDC) 2000 growth reference but as normal weight-for-age by the World Health Organization (WHO) 2006 standard. METHODS: Data were gathered from children and primary caregivers at emergency departments and primary care clinics in 7 US cities. Outcome measures included caregiver rating of child health, parental evaluation of developmental status, history of hospitalizations, and admission to hospital at the time of visit. Children were classified as (1) not underweight by either CDC 2000 or WHO 2006 criteria, (2) underweight by CDC 2000 but not by WHO 2006 criteria, or (3) underweight by both criteria. Associations between these categories and health outcome measures were assessed by using multiple logistic regression analysis. RESULTS: Data were available for 18 420 children. For each health outcome measure, children classified as underweight by CDC 2000 but normal by WHO 2006 had higher adjusted odds ratios (aORs) of adverse health outcomes than children not classified as underweight by either; children classified as underweight by both had the highest aORs of adverse outcomes. For example, compared with children not underweight by either criteria, the aORs for fair/poor health rating were 2.54 (95% confidence interval: 2.20-2.93) among children underweight by CDC but not WHO and 3.76 (3.13-4.51) among children underweight by both. CONCLUSIONS: Children who are reclassified from underweight to normal weight in changing from CDC 2000 to WHO 2006 growth charts may still be affected by morbidities associated with underweight.

Generic patient-reported outcomes in child health research: a review of conceptual content using World Health Organization definitions.

AIM: Our aims were to (1) describe the conceptual basis of popular generic instruments according to World Health Organization (WHO) definitions of functioning, disability, and health (FDH), and quality of life (QOL) with health-related quality of life (HRQOL) as a subcomponent of QOL; (2) map the instruments to the International Classification of Functioning, Disability and Health (ICF); and (3) provide information on how the analyzed instruments were used in the literature. This should enable users to make valid choices about which instruments have the desired content for a specific context or purpose. METHOD: Child health-based literature over a 5-year period was reviewed to find research employing health status and QOL/HRQOL instruments. WHO definitions of FDH and QOL were applied to each item of the 15 most used instruments to differentiate measures of FDH and QOL/HRQOL. The ICF was used to describe the health and health-related content (if any) in those instruments. Additional aspects of instrument use were extracted from these articles. RESULTS: Many instruments that were used to measure QOL/HRQOL did not reflect WHO definitions of QOL. The ICF domains within instruments were highly variable with respect to whether body functions, activities and participation, or environment were emphasized. INTERPRETATION: There is inconsistency among researchers about how to measure HRQOL and QOL. Moreover, when an ICF content analysis is applied, there is variability among instruments in the health components included and emphasized. Reviewing content is important for matching instruments to their intended purpose.

Development of pediatric sleep questionnaires as diagnostic or epidemiological tools: a brief review of dos and don'ts.

Questionnaires are a useful and extensively used tool in clinical sleep medicine and in sleep research. The number of sleep questionnaires targeting the pediatric age range has tremendously increased in recent years, and with such explosion in the number of instruments, their heterogeneity has become all the more apparent. Here, we explore the theoretical and pragmatic processes required for instrument design and development, i.e., how any questionnaire, inventory, log, or diary should be created and evaluated, and also provide illustrative examples to further underline the potential pitfalls that are inherently embedded in every step of tool development.

Secondary traumatic stress and burnout in child welfare workers: a comparative analysis of occupational distress across professional groups.

This study describes predictors of secondary traumatic stress and burnout in a national sample of helping professionals, with a specific focus on the unique responses of child welfare (CW) workers. Specific worker and exposure characteristics are examined as possible predictors of these forms of occupational distress in a sample of 669 professionals from across the country who responded to mailed (e-mail and post) invitations to participate in an online survey. E-mail and home mailing addresses were secured from licensure boards and professional membership organizations in six states from across the country that had high rates of child related deaths in 2009. Respondents completed the Professional Quality of Life IV (Stamm, 2005) to ascertain compassion fatigue (CF) and burnout symptoms. Being male, young, Hispanic, holding rural residence, and endorsing a lack of religious participation were significant predictors of secondary traumatic stress. Similarly, being male and young predicted high burnout rates, while actively participating in religious services predicted lower burnout. CW worker job status as a professional was significantly more likely to predict CF and burnout compared to all other types of behavioral healthcare professionals. Based on the findings from this study, this paper proposes strategies for enhancing self-care for CW workers, and describes the essential elements of a trauma-informed CW agency that addresses secondary traumatic stress and burnout.

Review Article: Mapping of children's health and development data on population level using the classification system ICF-CY.

AIM: The aim of this study was to investigate if essential health and development data of all children in Sweden in the Child Health Service (CHS) and School Health Service (SHS) can be linked to the classification system International Classification of Functioning, Disability and Health--Children and Youth (ICF-CY). METHOD: Lists of essential health terms, compiled by professionals from CHS and SHS, expected to be used in the national standardised records form the basis for the analysis in this study. The essential health terms have been linked to the codes of ICF-CY by using linking rules and a verification procedure. RESULTS: After exclusion of terms not directly describing children's health, a majority of the health terms could be linked into the ICF-CY with a high proportion of terms in body functions and a lower proportion in activity/participation and environment respectively. Some health terms had broad description and were linked to several ICF-CY codes. The precision of the health terms was at a medium level of detail. CONCLUSION: ICF-CY can be useful as a tool for documenting child health. It provides not only a code useful for statistical purposes but also a language useful for the CHS and SHS in their work on individual as well as population levels. It was noted that the health terms used by services mainly focused on health related to body function. This indicates that more focus is needed on health data related to child's functioning in everyday life situations.

Children, ADHD, and citizenship.

The diagnosis of attention-deficit hyperactivity disorder is a subject of controversy, for a host of reasons. This paper seeks to explore the manner in which children's interests may be subsumed to those of parents, teachers, and society as a whole in the course of diagnosis, treatment, and labeling, utilizing a framework for children's citizenship proposed by Elizabeth Cohen. Additionally, the paper explores aspects of discipline associated with the diagnosis, as well as distributional pathologies resulting from the application of the diagnosis in potentially biased ways.

Recognising and responding to child maltreatment.

Professionals in child health, primary care, mental health, schools, social services, and law-enforcement services all contribute to the recognition of and response to child maltreatment. In all sectors, children suspected of being maltreated are under-reported to child-protection agencies. Lack of awareness of the signs of child maltreatment and processes for reporting to child-protection agencies, and a perception that reporting might do more harm than good, are among the reasons for not reporting. Strategies to improve recognition, mainly used in paediatric practice, include training, use of questionnaires for asking children and parents about maltreatment, and evidence-based guidelines for who should be assessed by child-protection specialists. Internationally, studies suggest that policies emphasising substantiation of maltreatment without concomitant attention to welfare needs lead to less service provision for maltreated children than do those in systems for which child maltreatment is part of a broad child and family welfare response.

Perception of teacher sexual misconduct by age of student.

This study explored whether student age influenced perceptions of teacher sexual misconduct. Participants (300 undergraduates) read scenarios depicting teacher sexual misconduct in which the student's age was varied (9, 12, 15), and then answered questions about their perceptions. Data were analyzed with 2 (respondent gender) 2 (cross-gender dyads) 3 (student age) MANOVAs. Experiences involving the youngest student were viewed as the most abusive, followed by the 12-year-old, and the 15-year-old. Gender differences were evident, with women viewing the experiences more negatively. Scenarios involving a male teacher/female student were viewed more negatively than a female teacher/male student dyad. These findings illustrate the importance of educating students and school personnel about teacher sexual misconduct.

Morbidity at elementary school entry differs by sex and level of residence urbanization: a comparative cross-sectional study.

BACKGROUND: Health is vital to a child's learning in school and success in life. Therefore, early physical examination, and follow-up if necessary, would bring parents' attention to their child's health and would likely improve outcomes. The purposes of this study are twofold: to assess the health status of first-graders and to examine the health status differences between sexes, levels of residence urbanization, and quantity of available medical resources. METHODS: This is a comparative descriptive study. Data from the 2002 Student Entry Physical Examination (SEPE) and Student Medical History Inventory (SMHI) were obtained from 203 public and private elementary schools in northern Taiwan where a population of 53,053 students was included. Frequencies, independent sample t test, one-way ANOVA along with Scheff's post hoc test, and Pearson's correlation were conducted using SPSS. RESULTS: This study showed that 13.7% of students had at least one diagnosed disease from the SMHI reported by parents. Moreover, the SEPE indicated that 79.5% students had at least one health concern. Dental caries, myopia, and obesity were the most prevalent health problems among the first-graders (69.6%, 27.1%, and 9.5%, respectively). Research results show that there were significant differences in the prevalence of dental caries, myopia, and obesity between different sexes and among levels of urbanization. However, the quantity of available medical resources made no significant difference. CONCLUSION: Elementary school entry physical examination is an important way to detect students' health problems. It is suggested that school health interventions consider students' health profiles along with their sex and level of urbanization in planning. More research is needed to find the risk factors of the health problems. Additionally, the creation of a school health committee is suggested to implement and evaluate the entry health examination program.

Creating and field-testing child maltreatment definitions: improving the reliability of substantiation determinations.

The decision to substantiate a case of maltreatment is pivotal to myriad stakeholders; however, the reliability (and therefore, accuracy) of substantiation determinations is suspect. The authors tested if (a) they could develop more reliable substantiation definitions and processes and (b) case workers would be comfortable with and accepting of a new approach. Determinations from five field sites were compared with those of master reviewers (made while listening to the field sites' case presentations). Agreement, sensitivity, specificity, positive predictive values, and negative predictive values were high overall (.87, .96, .97, .89, and .97, respectively) and for each form of maltreatment. Agreement was substantially improved. The definitions and the determination process were well liked by case workers and other stakeholders. Clearly, implementing standardized definitions in a typical child protective environment would pose myriad political challenges. However, our results suggest achieving reliable substantiation determinations may be a feasible goal.

[Surname as a marker of ethnicity. A study from child health services shows that immigrant respective Swedish families seem to be isolated in different ways]. / Efternamn som markör för etnicitet. Studie inom barnhälsovården visar att invandrarfamiljer och svenska familjer tycks vara isolerade på olika sätt.

A practical method was tested for identifying ethnicity through family names in the absence of precise demographic information. In a questionnaire study of children covered by the Swedish child health services in some different counties, all potential participants (the children's mothers) were classified as "Swedish" or "non-Swedish" using family names. Inter-rater reliability was assessed by comparing the scores of two independent raters (Cohen's kappa: 0.89). Cases in which the raters did not agree were settled through discussion. The method's validity was roughly measured by comparing assigned classifications against ethnicity information provided by the 63.8 percent of the mothers who returned the questionnaire (1039 of 1628). Assigned and self-reported classifications were the same in 86.5 percent of the cases. Information from child health services about mothers who had agreed to participate in the study revealed health-related differences between those who returned the questionnaires and those who did not. The family name classification method indicated an ethnic selectivity in drop-out rates, which was helpful in interpreting these health differences.

Reliability and validity of health status measurement by the TAPQOL.

BACKGROUND: In addition to clinical measures in the evaluation of paediatric interventions, health related quality of life (HRQoL) is an important outcome. The TAPQOL (TNO-AZL Preschool children Quality of Life) was developed to measure HRQoL in preschool children. It is a generic instrument consisting of 12 scales that cover the domains physical, social, cognitive, and emotional functioning. AIMS: To evaluate the feasibility, score distribution, internal consistency, test-retest reliability, and discriminative and concurrent validity of the TAPQOL multi-item scales in preschool children, aged 2-48 months. Also to evaluate the feasibility, reliability, and validity separately for infants (2-12 months old) and toddlers (12-48 months old). METHODS: Parents of a random general population sample of 500 preschool children were sent a questionnaire by mail. A random subgroup of 159 parents who participated received a retest after two weeks. RESULTS: The response rate was 83% at the test and 75% at the retest. There were few missing answers. Six scales showed ceiling effects. Nine scales had Cronbach's alphas >0.70. In general, score distributions and Cronbach's alphas were comparable for infants and toddlers. Test-retest showed no significant differences in mean scale scores; two scales had intra-class correlations <0.50. Five scales showed significant differences between children with no conditions versus children with two or more parent reported chronic conditions. CONCLUSION: Results showed that the TAPQOL is a feasible instrument to measure HRQoL and support the reliability and discriminative validity of the majority of its scales for infants as well as toddlers.

[Well-child care: two distinct views]. / Puericultura: duas concepções distintas.

OBJECTIVE: To present, in an essay form, two distinct views on well-child care. METHODS: Using several different methods of historical analysis, the two most common views on well-child care are presented: the positivist one, whose foundation is essentially based upon historical facts, and that of social criticism, concerned with how historical facts are inserted in society at different levels. RESULTS: The coexistence of two distinct views on well-child care reveals two conflicting ideologies, but it does not invalidate the two different types of knowledge. CONCLUSIONS: Even though the understanding of well-child care through a historical approach does not allow for definitive conclusions on what it is or what it will be, it encourages reflections on more practical meanings, namely: the possibility to consider practices that gather an ensemble of positive knowledge without disregarding their limitations, and the formulation of well-child care practices concerned with social care, determined by several aspects, instead of by ideological interest.

Puericultura: duas concepções distintas / Well-child care: two distinct views

OBJETIVO: Apresentar, na forma de ensaio, a existência de dois discursos que definem a puericultura e sua história de maneiras distintas. MÉTODOS: Através de métodos diferentes de análise histórica, as duas leituras mais comuns sobre a puericultura são sintetizadas: a positivista, baseada fundamentalmente em fatos históricos, e a da crítica social, que procura contextualizar os fatos históricos em meio aos acontecimentos nas várias esferas da sociedade. RESULTADOS: A coexistência de duas concepções distintas de puericultura revela a presença de ideologias em conflito, mas não invalida as duas formas diferentes de conhecimento. CONCLUSÕES: A compreensão da puericultura através da história, embora não permita conclusões definitivas sobre o que a puericultura é ou será, permite reflexões concernentes aos seus significados mais práticos, quais sejam: a possibilidade de um olhar, no campo de práticas, que reúna o conjunto de saberes positivos, sem, no entanto, deixar de reconhecer suas limitações; e a elaboração de normas de puericultura que já tenham a preocupação com o seu caráter de prática social, determinado por dimensões diversas, e não por um interesse ideológico.

Child abuse in South Africa: an examination of how child abuse and neglect are defined.

OBJECTIVE: The purpose of this study was to explore which of 17 categories of child maltreatment South Africans evaluated as most serious and to determine if those working with abuse and neglect evaluated abuse and neglect differently from those who did not. METHOD: A revised version of Giovannoni and Becerra's [Giovannoni, J., & Becerra, R. (1979). Defining child abuse. New York: The Free Press] questionnaire exploring the definition of abuse and neglect was completed by 181 residents of Cape Town, South Africa. The new form had 17 categories of child maltreatment, including 4 categories of societal abuse. Respondents were social workers (n = 57), human service workers (n = 42), laypersons (n = 65), and members of the child protection unit of the South African Police (n = 18). ANOVA was used to compare the groups' responses. When significant differences among groups were found, a Bonferroni post hoc test was run to determine differences between groups. RESULTS: The respondents ranked sexual abuse and child prostitution as most serious and housing and child labor as least serious of the 17 categories. There was a significant difference (p < or = .01) between groups on nine categories. When post hoc tests were run, differences were found for eight categories with laypersons generally evaluating categories as significantly more serious than social workers. CONCLUSIONS: Reasons for the order of the rankings are discussed, but concern remains that differences in the evaluation of child maltreatment will lead to difficulty in implementing a protocol for identifying and responding to incidents of abuse and neglect.

Ready or not: uses of the stages of change model in child welfare.

This article reviews the popular stages of change model, its potential applications in child welfare, and relevant research. Empirical evidence indicates that behavioral change does not occur in a series of stages. The article considers the validity of the stage model, its underlying assumptions, and other conceptualizations of readiness for change. Although the stage model may have some heuristic value, the empirical evidence suggests that its practical applications are severely limited.

Gender bias among children in India in their diet and immunisation against disease.

This paper conducts an econometric analysis of data for a sample of over 4000 children in India, between the ages of 1 and 2 years, with a view to studying two aspects of the neglect of children: their likelihood of being immunised against disease and their likelihood of receiving a nutritious diet. The starting hypothesis, consistent with an universal interest in gender issues, was that girls were more likely to be neglected than boys. The analysis confirmed this hypothesis. In respect of vaccinations, the likelihood of girls being fully vaccinated, after controlling for other variables, was 5 percentage points lower than that for boys. In respect of receiving a nutritious diet, the treatment of girls depended very much on whether or not their mothers were literate: there was no gender discrimination between children of literate mothers; on the other hand, when the mother was illiterate, girls were 5 percentage points less likely to be well-fed relative to their brothers and the presence of a literate father did little to dent this gender gap. But the analysis also pointed to a broader conclusion which was that all children in India suffered from sharper, but less publicised forms of disadvantage than that engendered solely by gender. These were the consequences which stemmed from children being born to illiterate mothers and being brought up in the more impoverished parts of India.

Feasibility and reliability of a mailed questionnaire to obtain visual analogue scale valuations for health states defined by the Health Utilities Index Mark 3.

To establish the generalizability (external validity) of the Health Utilities Index Mark 3 (HUI3) as a single-summary score generic outcome measure in numerous countries/subgroups (including children), repeated studies of community preferences should be performed in various settings. In performing multiple HUI3 studies, a mailed questionnaire approach, if feasible and reliable, might be substituted for oral interviews. In the present study, we assessed the feasibility and reliability of a mailed questionnaire approach originally developed for the EQ-5D, for the purpose of collecting Visual Analogue Scale (VAS) valuations from parents as surrogate responders for 65 pediatric HUI3 health states and for the state of being dead. Untransformed mean VAS scores of the health states and scores converted into preliminary Standard Gamble (SG)-utilities were compared with Canadian and French multiattribute utility estimates. A random sample of 1920 parents of schoolchildren (aged 4 to 13) received a mailed questionnaire. Each parent was asked to rate 6 HUI3 health states on a 0 to 100 VAS. Response was 70%. Mean completion time was 20 minutes (SD 9). The questionnaire was rated difficult by only 9%. The current format was, however, inappropriate for valuing the state of being dead. Interrater reliability of health state valuations was.87. Spearman's rank correlations, Pearson-R correlations and intra class correlation coefficients (ICCs) between untransformed VAS valuations and Canadian/French utility estimates were > or =.87. However, preliminary SG-utilities showed diminished ICCs (.71 to.72). The data support the feasibility and reliability of mailed HUI3 valuation questionnaires to a considerable extent, but further methodological studies regarding other formats and different populations are recommended.