Systematic review and meta analysis of psychological interventions to prevent or treat pediatric chronic disease in rural communities.

OBJECTIVE: The purpose of this systematic review and meta-analysis was to examine the effectiveness of psychological interventions at improving physical or mental health outcomes for youth living in rural communities who have, or are at-risk for, any chronic medical condition in comparison to control interventions conducted in rural communities. METHODS: Following prospective registration (OSF.IO/7TDQJ), 7 databases were searched through July 1, 2023. Studies were included if they were a randomized control trial of a psychological intervention conducted with youth living in a rural area who had, or were at-risk for, a chronic medical condition. Risk of bias was assessed with the Cochrane risk of bias version 2 tool. A qualitative synthesis and meta-analysis were conducted. RESULTS: 15 studies met inclusion criteria. Obesity studies (n = 13) primarily focused on body mass index metrics, with limited significant findings across studies. Asthma treatment interventions (n = 2) showed no impact on hospitalizations. 3 studies evaluated mental health outcomes with no significant group differences observed. We meta-analytically analyzed 9 studies that evaluated body mass index z-scores and identified an overall null effect (Hedge's g = 0.01, 95% CI [-0.07, 0.09], p = .85). CONCLUSIONS: Most included studies focused on pediatric obesity, and there was a limited range of health outcomes reported. Compared to controls, minimal significant improvements in health outcomes were identified for psychological interventions for youth living in rural communities. Future efforts may benefit from situating this work more systematically within a health disparities framework with a focus on understanding mechanisms of disparities and translating this work into interventions and policy changes.

Prospective associations of neighborhood healthy food access and walkability with weight status in a regional pediatric health system.

BACKGROUND: Most neighborhood food and activity related environment research in children has been cross-sectional. A better understanding of prospective associations between these neighborhood environment factors and children's weight status can provide stronger evidence for informing interventions and policy. This study examined associations of baseline and changes in neighborhood healthy food access and walkability with changes in children's weight status over 5 years. METHODS: Height, weight, and home address were obtained for 4,493 children (> 75% were Black or Latinx) from primary care visits within a large pediatric health system. Eligible participants were those who had measures collected during two time periods (2012-2014 [Time 1] and 2017-2019 [Time 2]). Data were integrated with census tract-level healthy food access and walkability data. Children who moved residences between the time periods were considered 'movers' (N = 1052; 23.4%). Mixed-effects models, accounting for nesting of children within census tracts, were conducted to model associations of baseline and changes in the neighborhood environment variables with Time 2 weight status (BMIz and overweight or obese vs. healthy weight). Models adjusted for weight status and child and neighborhood sociodemographics at baseline. RESULTS: Children living in a neighborhood with [ample] healthy food access at Time 1 had a lower BMIz at Time 2, regardless of mover status. A decrease in healthy food access was not significantly associated with children's weight status at Time 2. Baseline walkability and improvements in walkability were associated with a lower BMIz at Time 2, regardless of mover status. CONCLUSIONS: Findings provide evidence that residing in a neighborhood with healthy food access and walkability may support a healthy weight trajectory in children. Findings on changes in the neighborhood environment suggested that improved walkability in the neighborhood may support children's healthy weight. The greater and more consistent findings among movers may be due to movers experiencing greater changes in neighborhood features than the changes that typically occur within a neighborhood over a short period of time. Future research is needed to investigate more robust environmental changes to neighborhoods.

Prevalence of Parent Mental Health Problems in an Interdisciplinary Feeding Clinic: Short Communication.

Parents of children with pediatric feeding disorder (PFD) often experience high stress and may be at advanced risk for mental health conditions. We conducted a retrospective chart review of 413 parents who completed intake surveys at an interdisciplinary feeding clinic to determine the prevalence and types of mental health conditions among parents; 41.8% of parents reported a mental health diagnosis among the mother and/or father. Of the parents with mental health conditions, the most prevalent conditions reported were anxiety (71.1% for mothers, 50% for fathers) and mood disorders (62.7% for mothers, 40.9% for fathers). For mothers, 21.1% indicated their mental health disorder had a postpartum onset. Parents of children with birth complications were more likely to have a mental health condition (50.9%) than parents of children without a birth complication (38.7%), and parents reporting mental health conditions had children with significantly more co-occurring medical conditions. Since parent stress and mental health can influence parent-child interactions during mealtime, this study suggests the importance of addressing both parent mental health factors and child factors when treating children for PFD. Future studies are needed to develop novel interventions that support the specific mental health needs of parents of children with PFD.

Addressing Barriers to Career Development Awards for Early Career Women in Pediatric Psychology.

OBJECTIVE: To provide person and system-level recommendations for supporting early career women in the field of pediatric psychology in writing and submitting National Institutes of Health (NIH) Career Development Award (K award) applications. Recommendations are provided in the context of common barriers, with a focus on practical solutions. METHODS: Publicly available NIH reporter data were compiled to examine rates of funding for Society of Pediatric Psychology (SPP) members. Barriers that women face when initiating programs of research are described and applied to the field of pediatric psychology. RESULTS: Of current SPP members, 3.9% (n = 50) have ever received an NIH K award. Approximately 88.5% of SPP members identify as women, including 89.0% of SPP K award recipients. A table of person- and systems-level recommendations is provided to offer strategies for mentees, mentors/sponsors, institutions, and national organizations to address the barriers discussed. CONCLUSIONS: By addressing gender-specific barriers to submitting K award applications, we hope to increase the number of women K awardees and support the scientific advancement of pediatric psychology.

Pediatric Tube Weaning: A Meta-Analysis of Factors Contributing to Success.

Approximately 3-10% of children have severe feeding issues, and some require enteral/tube nutrition to grow and thrive. For many children, tube feeding is temporary, making efficacious interventions for tube weaning essential. We conducted a systematic review and meta-analysis of tube weaning treatments. Outcomes included percentage of participants completely weaned from the tube, and mean percentage of kilocalories consumed orally following treatment. Data were extracted from 42 studies, including cohort studies and single-subject research design studies. We evaluated moderators of treatment success, including treatment setting, use of behavioral approaches, use of hunger provocation, and use of a multidisciplinary approach. Results indicated that, after treatment, children received significantly more calories orally, and 67-69% of children were fully weaned. These analyses suggest that current interventions are generally effective; however, variability within treatments exist. Prospective randomized clinical trials are needed to understand effective components of weaning interventions.

Commercial Devices Provide Estimates of Energy Balance with Varying Degrees of Validity in Free-Living Adults.

BACKGROUND: The challenges of accurate estimation of energy intake (EI) are well-documented, with self-reported values 12%-20% below expected values. New approaches rely on gold-standard assessments of the other components of energy balance, energy expenditure (EE) and energy storage (ES), to estimate EI. OBJECTIVES: The purpose of this study was to evaluate the validity, repeatability, and measurement error of consumer devices when estimating energy balance in a free-living population. METHODS: Twenty-four healthy adults (14 women, 10 men; mean ± SD age: 30.7 ± 8.2 y) completed two 14-d assessment periods, including assessments of EE and ES using gold-standard [doubly labeled water (DLW) and DXA] and commercial devices [Fitbit Alta HR activity monitor (Alta) and Fitbit Aria wireless body composition scale (Aria)], and of EI by dietician-administered recalls. Accuracy and validity were assessed using Spearman correlation, interclass correlation, mean absolute percentage error, and equivalency testing. We also applied linear measurement error modeling including error in gold-standard devices and within-subject repeated-measures design to calibrate consumer devices and quantify error. RESULTS: There was moderate to strong agreement for EE between the Fitbit Alta and DLW at each time point (rs = 0.82 and 0.66 for Times 1 and 2, respectively). There was weak agreement for ES between the Fitbit Aria and DXA (rs = 0.15 and 0.49 for Times 1 and 2, respectively). Correlations between methods to assess EI ranged from weak to strong, with agreement between the DXA/DLW-calculated EI and dietary recalls being the highest (rs = 0.63 for Time 1 and 0.73 for Time 2). Only EE from the Fitbit Alta at Time 1 was equivalent to the DLW value using equivalency testing. CONCLUSIONS: Commercial devices provide estimates of energy balance in free-living adults with varying degrees of validity compared to gold-standard techniques. EE estimates were the most robust overall, whereas ES estimates were generally poor.

SPR perspectives: Environmental influences on Child Health Outcomes (ECHO) Program: overcoming challenges to generate engaged, multidisciplinary science.

The US National Institutes of Health-funded Environmental influences on Child Health Outcomes (ECHO) Program brings together 69 cohorts and over 57,000 children from across the nation to address five key pediatric outcome areas with high public health impact: pre-, peri-, and postnatal outcomes; upper and lower airway health; obesity; neurodevelopment; and positive health. We describe (1) the ECHO Program infrastructure that was designed to facilitate collaboration across over 1200 investigators and support the development of a cohort-wide data collection protocol and (2) the many challenges that were overcome in rapidly launching this large-scale program. Guided by a commitment to transparency, team science, and end user stakeholder engagement, ECHO successfully launched a unified study protocol and is working across disciplines to generate high-impact, solution-oriented research to improve children's lives for generations to come. IMPACT: Many children in the United States experience chronic health conditions or do not reach their developmental potential. The Environmental influences on Child Health Outcomes (ECHO) Program brings together 69 existing cohort studies comprising over 57,000 children to identify modifiable aspects of the early environment associated with pediatric outcomes with high public health impact: pre-, peri-, and postnatal outcomes; upper and lower airway health; obesity; neurodevelopment; and positive health. We describe the collaborative, team science-informed approach by which over 1200 investigators convened to form the ECHO Program and foster solution-oriented research to improve the health of children for generations to come.

Validation of remote height and weight assessment in a rural randomized clinical trial.

BACKGROUND: The purpose of this study is to describe and assess a remote height and weight protocol that was developed for an ongoing trial conducted during the SARS COV-2 pandemic. METHODS: Thirty-eight rural families (children 8.3 ± 0.7 years; 68% female; and caregivers 38.2 ± 6.1 years) were provided detailed instructions on how to measure height and weight. Families obtained measures via remote data collection (caregiver weight, child height and weight) and also by trained staff. Differences between data collection methods were examined. RESULTS: Per absolute mean difference analyses, slightly larger differences were found for child weight (0.21 ± 0.21 kg), child height (1.53 ± 1.29 cm), and caregiver weight (0.48 ± 0.42 kg) between school and home measurements. Both analyses indicate differences had only minor impact on child BMI percentile (- 0.12, 0.68) and parent BMI (0.05, 0.13). Intraclass coefficients ranged from 0.98 to 1.00 indicating that almost all of the variance was due to between person differences and not measurement differences within a person. CONCLUSION: Results suggest that remote height and weight collection is feasible for caregivers and children and that there are minimal differences in the various measurement methods studied here when assessing group differences. These differences did not have clinically meaningful impacts on BMI. This is promising for the use of remote height and weight measurement in clinical trials, especially for hard-to reach-populations. TRIAL REGISTRATION: Clinical. Registered in clinicaltrials.gov ( NCT03304249 ) on 06/10/2017.

Walking School Bus Programs: Implementation Factors, Implementation Outcomes, and Student Outcomes, 2017-2018.

PURPOSE AND OBJECTIVES: Walking school bus programs increase children's physical activity through active travel to school; however, research to inform large-scale implementation of such programs is limited. We investigated contextual factors, implementation outcomes, and student outcomes in existing walking school bus programs in the United States and internationally. INTERVENTION APPROACH: Walking school bus programs involve a group of children walking to school together with an adult leader. On the trip to school, these adults provide social support, address potential traffic and interpersonal safety, and serve as role models to the children while children increase their physical activity levels. EVALUATION METHODS: We conducted surveys with existing walking school bus programs identified through internet searches, referrals, and relevant email listservs. Leaders from 184 programs that operated at least 1 trip per week completed the survey. We used regression analyses to compare differences in contextual factors by area income and location, associations between contextual factors and implementation outcomes, and associations between implementation outcomes and student outcomes. RESULTS: Walking school bus programs in low-income communities had more route leaders and engaged in more active travel to school-related activities of being sustained than those in higher income. Programs that had no external funding, multiple route leaders, and coordination by a school or district staff member (as opposed to a parent) had greater student participation than other programs. Providing more trips than other programs per week was associated with reduced tardiness, reduced bullying, and improved neighborhood walkability. The greatest barriers to implementation were recruiting and maintaining students and identifying and maintaining route leaders. IMPLICATIONS FOR PUBLIC HEALTH: Walking school bus programs can be implemented successfully in many contexts using various models. The involvement of several people in leadership roles is critical for sustainability. Evidence-based implementation strategies that overcome barriers can improve reach, implementation, and sustainability of walking school bus programs and can increase children's physical activity.

Weight change before and after adenotonsillectomy in children: An analysis based upon pre-surgery body mass category.

OBJECTIVES: To determine the standardised body mass index (BMIz) trajectory before and after adenotonsillectomy/tonsillectomy between children in different weight classifications in a larger sample than has been studied previously, and to identify which patient factors would explain the difference in these outcomes. DESIGN: We used a retrospective chart review and leveraged data of weight status pre- and post-adenotonsillectomy/tonsillectomy from a cohort of paediatric patients seen between May 2004 and April 2017. SETTING: Data were collected from an electronic medical record at a single Midwest paediatric health system. PARTICIPANTS: The study population included a convenience sample of 1,751 paediatric patients who underwent adenotonsillectomy or tonsillectomy and had at least two height and weight measurements recorded on the same date both before and after surgery. MAIN OUTCOME MEASURES: Change in BMIz trajectories before and after surgery. RESULTS: Of 1751 paediatric patients (ages 3-11) underwent adenotonsillectomy/tonsillectomy procedures. Age at time of surgery and gender were not significant predictors. Children in different weight classifications demonstrated differences in BMIz trajectory after surgery. Children with overweight/obesity experience a decrease in BMIz, whereas children with underweight or normal weight experience an increase in BMIz. CONCLUSIONS: Improvement in weight status is seen after surgery: increased BMI for those underweight and decreased BMI for those with overweight/obesity. We advocate for behavioural strategies as a first-line treatment in children with underweight or overweight/obesity, and results suggest that coordinating these efforts alongside adenotonsillectomy/tonsillectomy when indicated for medical reasons may be warranted. However, further research is needed to confirm these findings due to the observational nature of this study.

Factor Structure of a Spanish Translation of an Obesity-Specific Parent-Report Measure of Health-Related Quality of Life.

Objective: Latino youth are disproportionately affected by pediatric obesity and consequently experience impaired health-related quality of life (HRQOL). Although many caregivers of Latino youth do not speak English fluently, no validated Spanish translations of obesity-specific HRQOL measures exist for this population. Therefore, non-English-speaking Latino parents have typically been excluded from analyses related to HRQOL. This study assesses the factor structure of a Spanish translation of a parent-report measure of obesity-specific HRQOL, Sizing Them Up, in a treatment-seeking sample of children with obesity. Methods: Structural equation modeling was used to assess the factor structure of the 6-subscale, 22-item Sizing Them Up measure in 154 parents of treatment-seeking Latino youth (5-18 years of age). Analyses exploring internal consistency and convergent validity were also conducted. Results: Acceptable measurement fit was achieved for the six-factor solution. However, the higher-order model assessing Total HRQOL did not reach acceptable levels, as results found that the Positive Social Attributes (PSA) subscale was not representative of Total HRQOL; internal consistency and convergent validity results also supported this finding. Conclusions: The current study provides support for the utility of a modified version of Sizing Them Up, excluding the PSA Scale, as a parent-report measure of obesity-specific HRQOL in treatment-seeking Latino youth with obesity.

Confirmatory Factor Analysis of Sizing Me Up: Validation of an Obesity-Specific Health-Related Quality of Life Measure in Latino Youth.

Objectives: This study aims to validate an obesity-specific health-related quality of life (HRQOL) measure, Sizing Me Up (SMU), in treatment-seeking Latino youth. Pediatric obesity has been associated with reduced HRQOL; therefore, valid measures are important for use in diverse populations that may be at increased risk for obesity and related comorbidities. Methods: Structural equation modeling tested the fit of the 5-subscale, 22-item SMU measure in Latino youth, 5-13 years of age, with obesity ( N = 204). Invariance testing was conducted to examine equivalence between Latino and non-Latino groups ( N = 250). Results: SMU achieved acceptable fit in a Latino population [χ 2 = 428.33, df = 199, p < .001, Root Mean Squared Error of Approximation = 0.072 (0.062-0.082), Comparative Fit Index = 0.915, Tucker-Lewis Index = 0.901, Weighted Root Mean Square Residual = 1.2230]. Additionally, factor structure and factor loadings were invariant across Latino and non-Latino groups, but thresholds were not invariant. Conclusions: SMU is a valid measure of obesity-specific HRQOL in treatment-seeking Latino youth with obesity.

How PAs became licensed to practice in the United States.

The history of how PAs in the United States were first granted practice authority under the medical practice acts of the various states and territories begins in the 1960s with an imaginative way to circumvent the moratorium on licensure of new healthcare occupations in place at the time, while allowing the requisite flexibility for the new profession to take hold and thrive. In the subsequent decades, separate licensure for PAs was required and adopted. Despite the enormous success of the PA profession over its first 50 years, challenges remain.

A Randomized Controlled Trial of an Outpatient Protocol for Transitioning Children from Tube to Oral Feeding: No Need for Amitriptyline.

OBJECTIVE: To assess the role of amitriptyline in the effectiveness of an outpatient protocol for weaning medically complicated children from tube to oral feeding. STUDY DESIGN: Twenty-one children seen in multidisciplinary outpatient feeding teams across 4 sites were recruited to a randomized placebo-controlled trial of a 6-month outpatient treatment protocol with behavioral, oral-motor, nutrition, and medication components. RESULTS: All of the children who completed the 6-month program (73%) were weaned to receive only oral feeding, regardless of group assignment. The transition from tube to oral feeding resulted in decreases in body mass index percentile and pain, some improvements in quality of life, and no statistically significant changes in cost. CONCLUSIONS: Amitriptyline is not a key component of this otherwise effective outpatient, interdisciplinary protocol for weaning children from tube to oral feeding. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01206478.

Patient Attendance and Outcomes in a Structured Weight Management Program.

OBJECTIVES: To determine service utilization and identify patient characteristics associated with service utilization in youth with obesity presenting for structured weight management, and to explore weight-related outcomes associated with service utilization. STUDY DESIGN: In this retrospective study conducted between January 2008 and December 2013, we examined variables associated with the care of 2089 patients aged 2-18 years presenting for an initial visit to 2 tertiary care-based, multidisciplinary structured weight management clinics. RESULTS: Only 53% of patients returned for a second visit, 29% returned for a third visit, and virtually none (0.5%) completed the recommended 6 visits within 6 months. Patients who were Hispanic, government-insured, and whose parent/s spoke Spanish were more likely to return to clinic. Of those patients who returned for at least a second visit, 70% demonstrated a reduction in or maintenance of body mass index z-score. CONCLUSIONS: Patient retention remains a significant barrier to effective pediatric weight management. Structured weight management programs should increase their efforts to engage patients and families at the initial visit and identify and address barriers to follow up.

Making the Business Case for Coverage of Family-Based Behavioral Group Interventions for Pediatric Obesity.

BACKGROUND: Pediatric obesity presents a significant burden. However, family-based behavioral group (FBBG) obesity interventions are largely uncovered by our health care system. The present study uses Return on Investment (ROI) and Internal Rate of Return (IRR) analyses to analyze the business side of FBBG interventions. METHODS: ROI and IRR were calculated to determine longitudinal cost-effectiveness of a FBBG intervention. Multiple simulations of cost savings are projected using three estimated trajectories of weight change and variations in assumptions. RESULTS: The baseline model of child savings gives an average IRR of 0.2% ± 0.08% and an average ROI of 20.8% ± 0.4%, which represents a break-even IRR and a positive ROI. More pessimistic simulations result in negative IRR values. CONCLUSIONS: Under certain assumptions, FBBGs offer a break-even proposition. Results are limited by lack of data regarding several assumptions, and future research should evaluate changes in cost savings following changes in child and adult weight.

Systematic review: mealtime behavior measures used in pediatric chronic illness populations.

OBJECTIVE: This systematic review evaluates the utility and psychometric properties of pediatric mealtime assessments (direct observation and parent-report measures) using evidence-based criteria developed by the Division 54 Evidence-Based Assessment Task Force. METHOD: Measures of mealtime behavior used in at least one chronic illness pediatric population were eligible for inclusion. A total of 23 assessment measures were reviewed (16 parent-/self-report; 7 direct observation). RESULTS: 3 parent-report and 4 direct observation measures were classified as well-established, 3 met criteria for approaching well-established, and 13 were categorized as promising. Measures have been primarily used in children with feeding disorders, cystic fibrosis, and autism spectrum disorders. CONCLUSIONS: Overall, the literature of pediatric mealtime assessment tools shows a strong evidence base for many direct observation methods and subjective parent-report measures. Exploratory and confirmatory factor analyses are available for some measures; recommendations for future validation research and measure development across pediatric populations are discussed.

Apples or candy? Internal and external influences on children's food choices.

The goal of this concise narrative review is to examine the current literature regarding endogenous and exogenous influences on youth food choices. Specifically, we discuss internal factors such as interoception (self-awareness) of pain and hunger, and neural mechanisms (neurofunctional aspects) of food motivation. We also explore external factors such as early life feeding experiences (including parenting), social influences (peers), and food marketing (advertising). We conclude with a discussion of the overlap of these realms and future directions for the field of pediatric food decision science.

Measurement of mealtime behaviors in rural overweight children: an exploratory factor analysis of the Behavioral Pediatrics Feeding Assessment Scale.

OBJECTIVE: The current study presents results of an exploratory factor analysis (EFA) of the Behavioral Pediatric Feeding Assessment Scale (BPFAS) in a sample of rural children with overweight and obesity. Relationships between mealtime behavior and health outcomes are also explored. METHODS: EFA was used to assess the fit of the BPFAS in a group of 160 treatment-seeking children (Mage = 9.11, SD = 1.77) living in rural Midwest communities. Correlations were also computed between factor scores and select health variables (child body mass index z-score and diet variables). RESULTS: The EFA identified a 5-factor solution as the best fitting model (Tucker-Lewis Index = .96, root mean square error of approximation = .05), although several items (i.e., 7 of 25) did not load on any factor. 2 factors were correlated with health variables of interest. CONCLUSION: Study results suggest that certain items on the BPFAS may not be appropriate for use with rural children with pediatric overweight or obesity. Implications for future research and practice are discussed.

Health-related quality of life in obese and overweight, treatment-seeking youth.

OBJECTIVE: This study evaluated health related quality of life (HRQOL) in obese children using obesity-specific HRQOL measures and examined potential race and sex differences. PARTICIPANTS: Two-hundred and four children aged 5.03 to 13.48 years (mean +/- SD = 10.18 +/- 1.95) and their parents participated. METHODS: All participants enrolled in a family-based weight loss intervention study. Their height and weight were measured before and after the intervention, and demographic information was collected. Participants also completed a weight related quality of life measure; children completed a self-report version, and parents completed a parent-proxy version. RESULTS: Higher child body mass index z-scores (BMIz) were related to poorer HRQOL per parent and child report. Males reported higher emotional functioning than females, and for race, African American parents reported higher physical functioning for their children than Caucasian parents. No difference in total HRQOL was found for race. CONCLUSIONS: Childhood BMIz is inversely related to quality of life. Compared with male children, females have more impairment in quality of life. However, HRQOL did not differ by race. Also, although parent and child reports do overlap in certain areas, they also each provide unique information. Future researchers and clinicians would be wise to capture both child and parent perspectives regarding quality of life among obese children.