Office blood pressure versus ambulatory blood pressure measurement in childhood obesity.

BACKGROUND: The prevalence of obesity-related co-morbidities is rising parallel to the childhood obesity epidemic. High blood pressure (BP), as one of these co-morbidities, is detected nowadays at increasingly younger ages. The diagnosis of elevated BP and hypertension, especially in the childhood population, presents a challenge to clinicians. The added value of ambulatory blood pressure measurement (ABPM) in relation to office blood pressure (OBP) measurements in obese children is unclear. Furthermore, it is unknown how many overweight and obese children have an abnormal ABPM pattern. In this study we evaluated ABPM patterns in a population of overweight and obese children and adolescents, and compared these patterns with regular OBP measurements. METHODS: In this cross-sectional study in overweight or obese children and adolescents aged 4-17 years who were referred to secondary pediatric obesity care in a large general hospital in The Netherlands, OBP was measured during a regular outpatient clinic visit. Additionally, all participants underwent a 24-hour ABPM on a regular week-day. Outcome measures were OBP, mean ambulatory SBP and DBP, BP load (percentage of readings above the ambulatory 95th blood pressure percentiles), ambulatory BP pattern (normal BP, white-coat hypertension, elevated BP, masked hypertension, ambulatory hypertension), and BP dipping. RESULTS: We included 82 children aged 4-17 years. They had a mean BMI Z-score of 3.3 (standard deviation 0.6). Using ABPM, 54.9% of the children were normotensive (95% confidence interval 44.1-65.2), 26.8% had elevated BP, 9.8% ambulatory hypertension, 3.7% masked hypertension, and 4.9% white-coat hypertension. An isolated night-time BP load > 25% was detected in almost a quarter of the children. 40% of the participants lacked physiologic nocturnal systolic BP dipping. In the group of children with normal OBP, 22.2% turned out to have either elevated BP or masked hypertension on ABPM. CONCLUSIONS: In this study a high prevalence of abnormal ABPM patterns in overweight or obese children and adolescents was detected. Additionally, OBP poorly correlated with the child's actual ABPM pattern. Herewith, we emphasized the usefulness of ABPM as an important diagnostic tool in this population.

Paediatric departments need to improve residents' training in adolescent medicine and health: a position paper of the European Academy of Paediatrics.

In many European countries, paediatric junior staff has no formal training in adolescent medicine and is ill-equipped to deal with issues and health problems such as substance use, unprotected sex, eating disorders and transition to adult care. This position paper of the European Academy of Paediatrics proposes a set of competency-based training goals and objectives as well as pedagogic approaches that are expected to improve the capacity of paediatricians to meet the needs of this important segment of the paediatric population. The content has been developed from available publications and training programmes and mostly covers the generic aspects of adolescent healthcare, such as how to communicate effectively, how to review and address lifestyles, how to perform a respectful and relevant physical examination, how to address common problems of adolescents and how to support adolescents in coping with a chronic condition. CONCLUSION: The European Academy of Paediatrics urges national bodies, paediatric associations and paediatric teaching departments to adopt these training objectives and put them into practice, so that paediatricians will be better prepared in the future to meet the challenge of delivering appropriate and effective healthcare to adolescents.

Functional platelet defects in children with severe chronic ITP as tested with 2 novel assays applicable for low platelet counts.

Immune thrombocytopenia (ITP) is an autoimmune disease with a complex heterogeneous pathogenesis and a bleeding phenotype that is not necessarily correlated to platelet count. In this study, the platelet function was assessed in a well-defined cohort of 33 pediatric chronic ITP patients. Because regular platelet function test cannot be performed in patients with low platelet counts, 2 new assays were developed to determine platelet function: first, the microaggregation test, measuring in platelets isolated from 10 mL of whole blood the platelet potential to form microaggregates in response to an agonist; second, the platelet reactivity assay, measuring platelet reactivity to adenosine diphosphate (ADP), convulxin (CVX), and thrombin receptor activator peptide in only 150 µL of unprocessed whole blood. Patients with a severe bleeding phenotype demonstrated a decreased aggregation potential upon phorbol myristate acetate stimulation, decreased platelet degranulation following ADP stimulation, and a higher concentration of ADP and CVX needed to activate the glycoprotein IIbIIIa complex compared with patients with a mild bleeding phenotype. In conclusion, here we have established 2 functional tests that allow for evaluation of platelet function in patients with extremely low platelet counts (<10(9)). These tests show that platelet function is related to bleeding phenotype in chronic ITP.

Quality of life of children and adolescents with clinical obesity, perspectives of children and parents.

BACKGROUND/OBJECTIVES: Childhood obesity can have important psychological impacts. The objective of this study was to evaluate the Health Related Quality of Life (HRQoL) of children and adolescents with overweight and obesity. The participants were referred to an outpatient hospital-based obesity treatment. Additionally, we investigated the differences between parent- and self-reported HRQoL. SUBJECTS/METHODS: Children and adolescents aged 3-18 years with overweight or obesity, referred by their general practitioner or youth health care physician to the pediatric outpatient clinic of Hospital Gelderse Vallei (Ede, the Netherlands) for multidisciplinary obesity treatment, were enrolled in this cross-sectional study (n = 119). INTERVENTIONS/METHODS: Parent-proxy reported HRQoL was assessed using the Child Health Questionnaire Parental Form 50 (CHQ-PF50, n = 119) and the Infant Toddler Quality of Life Questionnaire 97 (ITQOL-97). Adolescents completed CHQ Child Form 87 (CHQ-CF87, n = 45) and Impact of Weight on Quality of Life-Kids (IWQOL-Kids, n = 38) to assess self-reported HRQoL. RESULTS: The mean age of the children was 9.6 years (SD 4.3). Both parent-proxy reports and child self-reports showed lower HRQoL in children with a higher degree of obesity, especially in the physical domains of HRQoL (p < 0.05). Child self-reported scores were significantly lower than parent-proxy scores on the subscales 'bodily pain/discomfort' and 'general health perceptions', and significantly higher on 'behavior' and 'family cohesion' (p < 0.05). CONCLUSIONS: Childhood obesity has a negative effect on HRQoL, especially on the physical aspects. The discordance between parent and child reports underscores the importance of using a combination of parent-proxy and child self-reports to assess HRQoL.

Differential adipokine receptor expression on circulating leukocyte subsets in lean and obese children.

BACKGROUND: Childhood obesity prevalence has increased worldwide and is an important risk factor for type 2 diabetes (T2D) and cardiovascular disease (CVD). The production of inflammatory adipokines by obese adipose tissue contributes to the development of T2D and CVD. While levels of circulating adipokines such as adiponectin and leptin have been established in obese children and adults, the expression of adiponectin and leptin receptors on circulating immune cells can modulate adipokine signalling, but has not been studied so far. Here, we aim to establish the expression of adiponectin and leptin receptors on circulating immune cells in obese children pre and post-lifestyle intervention compared to normal weight control children. METHODS: 13 obese children before and after a 1-year lifestyle intervention were compared with an age and sex-matched normal weight control group of 15 children. Next to routine clinical and biochemical parameters, circulating adipokines were measured, and flow cytometric analysis of adiponectin receptor 1 and 2 (AdipoR1, AdipoR2) and leptin receptor expression on peripheral blood mononuclear cell subsets was performed. RESULTS: Obese children exhibited typical clinical and biochemical characteristics compared to controls, including a higher BMI-SD, blood pressure and circulating leptin levels, combined with a lower insulin sensitivity index (QUICKI). The 1-year lifestyle intervention resulted in stabilization of their BMI-SD. Overall, circulating leukocyte subsets showed distinct adipokine receptor expression profiles. While monocytes expressed high levels of all adipokine receptors, NK and iNKT cells predominantly expressed AdipoR2, and B-lymphocytes and CD4+ and CD8+ T-lymphocyte subsets expressed AdipoR2 as well as leptin receptor. Strikingly though, leukocyte subset numbers and adipokine receptor expression profiles were largely similar in obese children and controls. Obese children showed higher naïve B-cell numbers, and pre-intervention also higher numbers of immature transition B-cells and intermediate CD14++CD16+ monocytes combined with lower total monocyte numbers, compared to controls. Furthermore, adiponectin receptor 1 expression on nonclassical CD14+CD16++ monocytes was consistently upregulated in obese children pre-intervention, compared to controls. However, none of the differences in leukocyte subset numbers and adipokine receptor expression profiles between obese children and controls remained significant after multiple testing correction. CONCLUSIONS: First, the distinct adipokine receptor profiles of circulating leukocyte subsets may partly explain the differential impact of adipokines on leukocyte subsets. Second, the similarities in adipokine receptor expression profiles between obese children and normal weight controls suggest that adipokine signaling in childhood obesity is primarily modulated by circulating adipokine levels, instead of adipokine receptor expression.

Maintenance interventions for overweight or obese children and adolescents who participated in a treatment program: study protocol for a systematic review.

BACKGROUND: Childhood overweight and obesity are associated with significant health consequences. Early and successful treatment of this public health issue is necessary. Although several intervention programs for children result in weight loss or stabilisation in the short term, preventing relapse after weight loss remains an important challenge. Weight loss maintenance approaches in childhood are thought to be promising, but a structured overview of these maintenance interventions is lacking. The aim of the systematic review described in this protocol is to provide an overview of reports published about maintenance interventions in childhood overweight and obesity following initial treatment, in order to guide future directions in the development of maintenance programs for childhood obesity. METHODS/DESIGN: The electronic databases PubMed, Embase, Cochrane Library, CINAHL, Web of Science, PsycINFO, Scopus, and SocINDEX will be searched for this review. Reference lists of eligible study reports will be scanned for relevant references. Article selection including risk of bias assessment will be performed independently in an unblinded standardised manner by three authors. All reports describing a maintenance intervention in overweight or obese children with a mean or median age of <18 years who have followed a treatment program, regardless of the type of intervention, will be included. Data extraction will be performed using a predesigned pilot-tested data extraction sheet that covers participant characteristics, details about the treatment preceding the maintenance intervention, and the maintenance intervention itself. Body mass index standard deviation score (BMI-SDS or BMI-Z-score) will be used to compare studies. If possible, a meta-analysis will be performed using the inverse-variance random-effects method. Studies that are not included in the meta-analysis will be described in a narrative way in tables and/or in the text. DISCUSSION: This systematic review will give an overview of the existing knowledge on programs and initiatives aimed at long-term maintenance of a healthy or reduced weight in children and adolescents following initial treatment of overweight. It will form a basis for future research and practice in this area, a topic on which studies are scarce but highly necessary. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42014008698.

Prenatal screening for major congenital heart disease: assessing performance by combining national cardiac audit with maternity data.

OBJECTIVE: Determine maternity hospital and lesion-specific prenatal detection rates of major congenital heart disease (mCHD) for hospitals referring prenatally and postnatally to one Congenital Cardiac Centre, and assess interhospital relative performance (relative risk, RR). METHODS: We manually linked maternity data (3 hospitals prospectively and another 16 retrospectively) with admissions, fetal diagnostic and surgical cardiac data from one Congenital Cardiac Centre. This Centre submits verified information to National Institute for Cardiovascular Outcomes Research (NICOR-Congenital), which publishes aggregate antenatal diagnosis data from infant surgical procedures. We included 120 198 unselected women screened prospectively over 11 years in 3 maternity hospitals (A, B, C). Hospital A: colocated with fetal medicine, proactive superintendent, on-site training, case-review and audit, hospital B: on-site training, proactive superintendent, monthly telemedicine clinics, and hospital C: sonographers supported by local obstetrician. We then studied 321 infants undergoing surgery for complete transposition (transposition of the great arteries (TGA), n=157) and isolated aortic coarctation (CoA, n=164) screened in hospitals A, B, C prospectively, and 16 hospitals retrospectively. RESULTS: 385 mCHD recorded prospectively from 120 198 (3.2/1000) screened women in 3 hospitals. Interhospital relative performance (RR) in Hospital A:1.68 (1.4 to 2.0), B:0.70 (0.54 to 0.91), C:0.65 (0.5 to 0.8). Standardised prenatal detection rates (funnel plots) demonstrating inter-hospital variation across 19 hospitals for TGA (37%, 0.00 to 0.81) and CoA (34%, 0.00 to 1.06). CONCLUSIONS: Manually linking data sources produced hospital-specific and lesion-specific prenatal mCHD detection rates. More granular, rather than aggregate, data provides meaningful feedback to improve screening performance. Automatic maternal and infant record linkage on a national scale, requires verified, prospective maternity audit and integration of health information systems.