Subject Matter Experts Identify Health Equity Concerns in Breastfeeding for African American Women.

Although the rate of breastfeeding initiation in the United States has continued to rise since 1972, African American mothers continue to experience a significant disparity in initiation. The aim of this study was to explore the perceptions of the facilitators and barriers of breastfeeding initiation among African American mothers from the perspective of subject matter experts (SMEs). This study was part of a larger study that also involved focus group methodology with African American women. The purpose of this article is to describe the opinions, knowledge, and perceptions of SMEs who work with African American mothers. A semistructured interview guide was used to interview 7 SMEs at which point no new themes emerged from the data. SMEs highlighted the significance of modifiable factors in breastfeeding initiation decisions and validated many perceptions of African American mothers. SMEs identified many critical issues foundational to community perspective and shaping future success in raising breastfeeding initiation rates. To increase breastfeeding initiation rates among African American mothers, strategies beyond the individual level are necessary. SMEs recognize the importance of addressing fundamental issues related to historical perspectives, normalization, education, and disparities in breastfeeding as critical.

Elevations of inflammatory proteins in neonatal blood are associated with obesity and overweight among 2-year-old children born extremely premature.

BackgroundChildhood obesity is associated with elevated blood concentrations of inflammation markers. It is not known to what extent inflammation precedes the development of obesity.MethodsIn a cohort of 882 infants born before 28 weeks of gestation, we examined relationships between concentrations of 25 inflammation-related proteins in blood obtained during the first two postnatal weeks and body mass index at 2 years of age.ResultsAmong children delivered for spontaneous indications (n=734), obesity was associated with elevated concentrations of four proteins (IL-1ß, IL-6, TNF-R1, and MCP-1) on the first postnatal day; one protein (IL-6) on postnatal day 7; and two proteins (ICAM-3 and VEGF-R1) on postnatal day 14. Among children delivered for maternal or fetal indications (n=148), obesity was associated with elevated concentrations of seven proteins on the 14th postnatal day. In multivariable models in the spontaneous indications subsample, elevated IL-6 on day 1 predicted obesity (odds ratio: 2.9; 95% confidence limits: 1.2, 6.8), whereas elevated VCAM-1 on day 14 predicted overweight at 2 years of age (odds ratio: 2.3; 95% confidence limits: 1.2, 4.3).ConclusionsIn this cohort, neonatal systemic inflammation preceded the onset of obesity, suggesting that inflammation might contribute to the development of obesity.

Outcome of Pediatric Gastroenterology Outpatients With Fever and Central Line.

OBJECTIVE: Although management algorithms for fever and central venous catheters (CVCs) have been implemented for pediatric oncology (PO) patients, management of pediatric outpatients with noncancer diagnoses and CVCs lacks clear protocols. The aim of the study was to assess outcomes for pediatric outpatients with gastrointestinal disorders presenting with fever and CVC. METHODS: Using a microbiology database and emergency department records, we created a database of pediatric gastroenterology (PGI) and PO outpatients with fever and a CVC who presented to our emergency department or clinics from January 2010 through December 2012. We excluded patients who had severe neutropenia (absolute neutrophil count, <500/mm). We performed chart reviews to assess demographic and clinical characteristics. RESULTS: A total of 334 episodes in 144 patients were evaluated. Fifty-three percent (95% confidence interval, 38%-68%) of PGI patients had a bloodstream infection, whereas only 9% (95% confidence interval, 5%-14%) of PO patients had a bloodstream infection (P < 0.001). Among patients with a bloodstream infection, the PGI patients were more likely than the PO patients to have polymicrobial infections (46% vs 15%), gram-negative infections (57% vs 27%), and/or infection with enteric organisms (61% vs 23%). The PGI patients had higher rates of CVC removal (19% vs 4%) but no statistical difference in intensive care unit needs (11% vs 4%). CONCLUSIONS: Pediatric gastroenterology outpatients with fever and a CVC have a high prevalence of bloodstream infection. Algorithms for management need to be subspecialty specific. Pediatric gastroenterology patients presenting to emergency departments or clinics with fever and CVC require admission for monitoring and management.

Ignoring regression to the mean leads to unsupported conclusion about obesity.

Childhood obesity remains a substantial health concern for our population and thoughtful attempts to develop and evaluate the utility of programs to reduce childhood obesity levels are needed. Unfortunately, we believe the conclusion by Burke et al. that the HealthMPowers program produces positive change in body composition is incorrect because the results obtained are likely due to regression to the mean (RTM), a well-known threat to the validity of studies that is often overlooked. Using empirical data, we demonstrate that RTM is likely to be the cause for the changes reported. A more reasonable conclusion than the one of effectiveness the authors offered would be that the results did not support the effectiveness of the intervention. Public health officials, parents, school leaders, community leaders, and regulators need and deserve valid evidence free from spin on which they can base decisions.

Weight-for-length trajectories in the first year of life in children of mothers with eating disorders in a large Norwegian Cohort.

OBJECTIVE: To describe weight-for-length (WFL) trajectories in the children (birth-12 months) of mothers with and without eating disorders. METHOD: This study is based on the Norwegian Mother and Child Cohort Study (MoBa) conducted by the Norwegian Institute of Public Health. We categorized women (N = 57,185) based on diagnosis prior to and during pregnancy: anorexia nervosa, bulimia nervosa, eating disorder not otherwise specified-purging subtype, binge eating disorder, or no eating disorder. The primary analysis included a shape invariant model fitted with nonlinear mixed effects to compare growth rates across eating disorder subtypes. RESULTS: The children of mothers reporting any eating disorder had a lower WFL growth rate from birth to 12 months than the children of mothers without eating disorders, even after adjusting for relative birth weight and some confounders known to affect growth. DISCUSSION: In this cohort, child WFL was related to maternal eating disorder status before and/or during pregnancy. These differences in growth trajectories warrant further study of long-term health outcomes and, if replicated, tailoring counseling to mothers with eating disorders during pregnancy.

Racial disparities across provider specialties in opioid prescriptions dispensed to medicaid beneficiaries with chronic noncancer pain.

OBJECTIVE: Chronic pain affects both psychological and physical functioning, and is responsible for more than $60 billion in lost productivity annually in the United States. Although previous studies have demonstrated racial disparities in opioid treatment, there is little evidence regarding disparities in treatment of chronic noncancer pain (CNCP) and the role played by physician specialty in these disparities. DESIGN: A retrospective cohort study. SETTING: We analyzed North Carolina Medicaid claims data, from July 1, 2009 to May 31, 2010, to examine disparities by different provider specialties in beneficiaries' dispensed prescriptions for opioids. SUBJECTS: The population included white and black North Carolina Medicaid beneficiaries with CNCP (N = 75,458). METHODS: We used bivariate statistics and logistic regression analysis to examine race-based discrepancies in opioid prescribing by physician specialty. RESULTS: Compared with white beneficiaries with CNCP (N = 49,197), black beneficiaries (N = 26,261) were less likely (odds ratio [OR] 0.91 [confidence interval {CI}: 0.88-0.94]) to fill an opioid prescription. Our hypothesis was partially supported: we found that race-based differences in beneficiaries' dispensed opioid prescriptions were more prominent in certain specialties. In particular, these differences were most salient among patients of specialists in obstetrics and gynecology (OR 0.78 [CI: 0.67-0.89]) and internal medicine (OR 0.86 [CI: 0.79-0.92]), as well as general practitioners/family medicine physicians (OR 0.91 [CI: 0.85-0.97]). CONCLUSIONS: Our findings suggest that, in our study population, black beneficiaries with CNCP are less likely than whites to fill prescriptions for opioid analgesics as a function of their provider's specialty. Although race-based differences in patients filling opioid prescriptions have been noted in previous studies, this is the first study that clearly demonstrates these disparities by provider specialty.

World peace, to be a millionaire, and hoop dreams: adolescent wishes on health screening surveys.

OBJECTIVE: This study sought to learn the wishes of young adolescents via an open-ended survey question and to determine the association of these wishes with sociodemographic variables. METHODS: We performed a cross-sectional study of consecutive adolescents aged 11-14 years who had a well-child visit at a clinic with a diverse patient population, who completed a Guidelines for Adolescent Preventive Services (GAPS) previsit health questionnaire, and who answered the question, "If you could have three wishes come true, what would they be?" Responses to this question were double-coded according to thematic content and whether wishes were for self, others, or both. RESULTS: Among 96 respondents, wishes for others were listed more frequently by girls than by boys (54% versus 31%; P = .02). Girls also had more family-oriented wish themes (27% versus 10%; P = .04). Boys were more likely to wish for success (17% versus 4%; P = .05). Among respondents with private insurance, 45% wished for the good for the world, with responses such as "world peace"; only 12% of respondents with Medicaid wished for the good of the world (P = .01). No statistically significant differences were identified by race/ethnicity or age. Positive future orientation themes such as career were not as prioritized as previously suggested in the literature. LIMITATIONS: The sample population derives from a single university-based clinic in North Carolina; while diverse, this population may not be representative of larger groups. CONCLUSIONS: Many wishes seemed predictable (ie, for wealth, athleticism), but occasionally wishes were poignant and original ("to have papers for my parents to pass the border"); this finding reinforces the value of listening to adolescents' wishes. Both sex and insurance status were related to wish themes. Further research should determine how knowledge of adolescents' wishes can be used to best direct individual care.

The importance of screening for healthy weight and recommending healthy lifestyles in pediatric patients.

Regular pediatric care should focus on early obesity prevention and healthy lifestyles and should include obesity screening with sensitive and culturally appropriate communication, beginning at age 2 years. North Carolina is a leader with its Eat Smart, Move More campaign and tools that can help pediatric care providers achieve greater self-efficacy.

Patient Retention in Pediatric Weight Management Programs in the United States: Analyses of Data from the Pediatrics Obesity Weight Evaluation Registry.

Objective: Meeting recommended provider contact hours in multicomponent pediatric weight management (PWM) programs is difficult when patient retention is low. Our objective was to examine associations between individual patient characteristics, program characteristics, and patient retention. Methods: Using the Pediatric Obesity Weight Evaluation Registry, a prospective longitudinal study of 32 PWM programs, we included children (≤18 years; n = 6502) enrolled for a full year. We examined associations between retention (any follow-up visit) and patient and program characteristics using multivariable models with site-clustering random effects. Results: Sixty-seven percent of children had at least one follow-up visit, whereas 12% had four or more visits. Compared with non-Hispanic white children, non-Hispanic black children were less likely to have a follow-up visit [adjusted odds ratio (aOR) = 0.79], whereas Hispanic children (any race) were more likely (aOR = 1.22). Children with Medicaid had similar retention to those with private insurance. Retention did not differ by age, gender, weight status, or comorbidities, nor by program characteristics. Conclusions: Few characteristics of PWM programs are clearly associated with retention, indicating that a variety of formats can support continued treatment and likely reflect the influence of unmeasured characteristics. Clearer ways to identify and overcome barriers for individual patients will be needed to improve retention in PWM.

The relationship between glaucoma medication adherence, eye drop technique, and visual field defect severity.

OBJECTIVE: The purpose of the study was to examine (1) how patient adherence and eye drop technique were associated with visual field defect severity and (2) how general glaucoma adherence self-efficacy and eye drop technique self-efficacy were related to visual field defect severity. DESIGN: Cross-sectional study conducted at a single private practice site. PARTICIPANTS: Patients using eye drops for their glaucoma. METHODS: Subject adherence to glaucoma medications through Medication Events Monitoring System (MEMS) devices were measured, and eye drop instillation technique was assessed by video recording. General glaucoma medication adherence self-efficacy was measured using a 10-item scale, and eye drop technique self-efficacy was measured using a 6-item scale. Multivariate logistic regression was used to analyze the data. MAIN OUTCOME MEASURES: Visual field defect severity. RESULTS: Patients who were less than 80% adherent according to the MEMS devices were significantly more likely to have worse defect severity. Patients with lower scores on the general glaucoma medication adherence self-efficacy scale also were significantly more likely to have worse defect severity. Eye drop technique and eye drop technique self-efficacy were not related significantly to visual field defect severity. CONCLUSIONS: Eye care providers need to assess patient adherence and to work with those patients with poor adherence to find ways to improve their ability and self-efficacy in using their glaucoma medications. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Use of a tool to determine perceived barriers to children's healthy eating and physical activity and relationships to health behaviors.

This pilot investigation assesses whether barriers to children's healthy eating and physical activity reported by parents on a newly developed brief pediatric obesity screening and counseling tool are related to healthy eating and physical activity behaviors. The sample included parents of 115 Medicaid-enrolled children in a general pediatric clinic. Of 10 barriers, 7 were statistically associated with parent-reported behaviors with odds ratios (ORs) ranging from 0.6 to 9.4. Relationships remained significant when child characteristics were controlled in the analysis. Although additional testing is needed, the tool provides clinicians with an approach to identify barriers and behaviors for targeted counseling.

Carrying the Weight: Athletics and Obesity in High School Football Players.

This article determines the prevalence of obesity among high school football players nationwide and compares obesity between position groups of football players and across team sports. We calculate body mass index (BMI) for 391 212 males participating in baseball, basketball, football, lacrosse, and soccer, then stratify BMI into commonly accepted categories and subdivide football players by position played, comparing BMI across position groups and sports. A total of 47.4% of high school football players are healthy weight (BMI = 18.5-24.9 kg/m2), 18.0% have obesity (BMI = 30-34.9 kg/m2: 12.4%) or class 2 obesity (BMI >34.9 kg/m2: 5.6%). Among linemen, 14.8% are healthy weight, 14.6% have class 2 obesity, and another 29.3% have obesity. Among non-linemen, the combined prevalence of obesity and class 2 obesity is 2.7%, comparable to other team sports. Obesity is common among high school football players, more so than among other high school athletes. Obesity and class 2 obesity are only common among linemen.

Concordance of Child and Parent Reports of Children's Screen Media Use.

OBJECTIVE: Little is known about the concordance of parent and child reports of children's media consumption, even though parents are often asked to report for their children in clinical care settings. Our objective was to understand how parent and child reports of children's media consumption differ in an era of changing screen media consumption via personal devices. METHODS: As part of a larger study about the reception of health-related cues from children's media, children ages 9 to 11 years (N = 114) and their parents independently completed identical questionnaires about specific media use and health behaviors. To examine concordance between child and parent reports of children's screen media use, we calculated the mean number of minutes per day and proportions reported by the child and parent and assessed concordance with t-tests and chi-square tests. RESULTS: On a typical day, children reported nearly an hour each of video and app game use, computer use, and television exposure. Overall, child and parent reports were similar, usually within 10 minutes of each other; however, among 3 measures of TV use, parents consistently reported less TV exposure than children. There was significant discordance in the percentages of parents and children reporting the presence of a TV in the child's room. CONCLUSIONS: Parent and child reports of children's media use were generally concordant; however, there were important disagreements, such as TV use in the child's room and during meals. We discuss possible causes of discrepancies and implications.

Factors That Influence Breastfeeding Initiation Among African American Women.

OBJECTIVE: To examine cultural and socioenvironmental factors that affect breastfeeding initiation among African American women. DESIGN: Qualitative descriptive design and conventional content analysis. SETTING: A large, inner-city, primary care center affiliated with a 500-bed children's hospital within a large, Northeastern U.S. city. PARTICIPANTS: Participants were 34 U.S.-born African American mothers of healthy term infants 0 to 3 months of age. METHODS: Six focus groups were conducted using a 16-question, scripted interview guide. RESULTS: A number of complex factors that influenced breastfeeding initiation included certain cultural beliefs about sexuality, the influence of family and peer networks, information sources, intentions, and a variety of other barriers and facilitators. CONCLUSION: Our findings suggest that the decision to initiate breastfeeding is not solely determined by the woman within the African American community. Because this decision is contingent on multiple factors external to the woman, it is important to recognize the role that partners, grandmothers, communities, information sources, and health care providers/organizations play in women's decisions. Implementation of multilevel strategies is critical to increase breastfeeding initiation among African American mothers.

Prevalence of Obesity and Severe Obesity in US Children, 1999-2016.

OBJECTIVES: To provide updated prevalence data on obesity trends among US children and adolescents aged 2 to 19 years from a nationally representative sample. METHODS: We used the NHANES for years 1999 to 2016. Weight status was determined by using measured height and weight from the physical examination component of the NHANES to calculate age- and sex-specific BMI. We report the prevalence estimates of overweight and obesity (class I, class II, and class III) by 2-year NHANES cycles and compared cycles by using adjusted Wald tests and linear trends by using ordinary least squares regression. RESULTS: White and Asian American children have significantly lower rates of obesity than African American children, Hispanic children, or children of other races. We report a positive linear trend for all definitions of overweight and obesity among children 2-19 years old, most prominently among adolescents. Children aged 2 to 5 years showed a sharp increase in obesity prevalence from 2015 to 2016 compared with the previous cycle. CONCLUSIONS: Despite previous reports that obesity in children and adolescents has remained stable or decreased in recent years, we found no evidence of a decline in obesity prevalence at any age. In contrast, we report a significant increase in severe obesity among children aged 2 to 5 years since the 2013-2014 cycle, a trend that continued upward for many subgroups.

Feasibility of a Clinic-Community Partnership to Treat Childhood Obesity.

BACKGROUND: "Bull City Fit" is a childhood obesity treatment partnership between Duke Children's pediatric weight management clinic and Durham Department of Parks and Recreation. OBJECTIVES: Report on feasibility and implementation, characteristics of participants, and predictors of attendance. METHODS: Mixed methods study consisting of (1) a retrospective cohort analysis (n = 171) reporting demographic, attendance, and clinical data and (2) structured focus groups among stakeholders to identify implementation facilitators and barriers. RESULTS: Higher attendance was associated with Spanish language ( P = .07), more clinic visits ( P = .03), shorter time to first attendance ( P = .06), lower child z-body mass index (BMI) at baseline ( P = .08), and lower parent BMI ( P = .02). Associations were mitigated after controlling for demographic characteristics. BMI z-score did not differ between low- and moderate/high attenders at 6 months. Family inclusion and community engagement emerged as positive themes during focus groups. CONCLUSIONS: Clinic-community partnerships engage diverse populations in fitness and nutrition activities, but no specific patient characteristics appear to predict greater attendance.

Effects of insurance status on children's access to specialty care: a systematic review of the literature.

BACKGROUND: The current climate of rising health care costs has led many health insurance programs to limit benefits, which may be problematic for children needing specialty care. Findings from pediatric primary care may not transfer to pediatric specialty care because pediatric specialists are often located in academic medical centers where institutional rules determine accepted insurance. Furthermore, coverage for pediatric specialty care may vary more widely due to systematic differences in inclusion on preferred provider lists, lack of availability in staff model HMOs, and requirements for referral. Our objective was to review the literature on the effects of insurance status on children's access to specialty care. METHODS: We conducted a systematic review of original research published between January 1, 1992 and July 31, 2006. Searches were performed using Pubmed. RESULTS: Of 30 articles identified, the majority use number of specialty visits or referrals to measure access. Uninsured children have poorer access to specialty care than insured children. Children with public coverage have better access to specialty care than uninsured children, but poorer access compared to privately insured children. Findings on the effects of managed care are mixed. CONCLUSION: Insurance coverage is clearly an important factor in children's access to specialty care. However, we cannot determine the structure of insurance that leads to the best use of appropriate, quality care by children. Research about specific characteristics of health plans and effects on health outcomes is needed to determine a structure of insurance coverage that provides optimal access to specialty care for children.

Rural/urban differences in barriers to and burden of care for children with special health care needs.

PURPOSE: To examine the barriers and difficulties experienced by rural families of children with special health care needs (CSHCN) in caring for their children. METHODS: The National Survey of Children with Special Health Care Needs was used to examine rural-urban differences in types of providers used, reasons CSHCN had unmet health care needs, insurance and financial difficulties encountered, and the family burden of providing the child's medical care. We present both unadjusted and adjusted results to allow consideration of the causes of rural-urban differences. FINDINGS: Rural CSHCN are less likely to be seen by a pediatrician than urban children. They are more likely to have unmet health care needs due to transportation difficulties or because care was not available in the area; there were minimal other differences in barriers to care. Families of rural CSHCN are more likely to report financial difficulties associated with their children's medical needs and more likely to provide care at home for their children. CONCLUSIONS: Examining results from both unadjusted and adjusted odds ratios shows that the burden of care for families of rural CSHCN stems both from socioeconomic differences and health system differences. Policies aimed at achieving equity for rural children will require focusing on both individual factors and the health care infrastructure, including increasing insurance coverage to lessen financial difficulties and addressing the availability of providers in rural areas.

Intensive care in critical access hospitals.

CONTEXT: Although critical access hospitals (CAHs) have limitations on number of acute care beds and average length of stay, some of them provide intensive care unit (ICU) services. PURPOSE: To describe the facilities, equipment, and staffing used by CAHs for intensive care, the types of patients receiving ICU care, and the perceived impact of closing the ICU on CAH staff and the local community. METHODS: A semistructured interview of directors of nursing at CAHs that provide intensive care services. RESULTS: Two thirds of CAHs that provide intensive care do so in a distinct unit. Most have continuous or computerized electrocardiography and ventilators. Other ICU equipment common in larger hospitals was reported less frequently. Nurse:patient ratio ranged from 1:1 to 1:3, and some or all nursing staff have advanced cardiac life support certification. Most CAHs admit patients to the ICU daily or weekly, primarily treating cardiac, respiratory, gastrointestinal, endocrine, and drug- or alcohol-related conditions. ICUs are also used for postsurgical recovery. Respondents felt that closure of the ICU would be burdensome to patients and families, result in lost revenue, negatively impact staff, and affect the community's perception of the hospital. CONCLUSIONS: Intensive care services provided by CAHs fall along a continuum, ranging from care in a unit that resembles a scaled-down version of ICUs in larger hospitals to care in closely monitored medical-surgical beds. Nurse to patient ratio, not technology, is arguably the defining characteristic of intensive care in CAHs. Respondents believe these services to be important to the well-being of the hospital and of the community.