Design of the Intervention to Reduce Early Peanut Allergy in Children (iREACH): A practice-based clinical trial.

BACKGROUND: Introducing peanut products early can prevent peanut allergy (PA). The "Addendum guidelines for the prevention of PA in the United States" (PPA guidelines) recommend early introduction of peanut products to low and moderate risk infants and evaluation prior to starting peanut products for infants at high risk for PA (those with severe eczema and/or egg allergy). Rapid adoption of guidelines could aid in lowering the prevalence of PA. The Intervention to Reduce Early (Peanut) Allergy in Children (iREACH) trial was designed to promote PPA guideline adherence by pediatric clinicians. METHODS: A two-arm, cluster-randomized, controlled clinical trial was designed to measure the effectiveness of an intervention that included clinician education and accompanying clinical decision support tools integrated in electronic health records (EHR) versus standard care. Randomization was at the practice level (n = 30). Primary aims evaluated over an 18-month trial period assess adherence to the PPA guidelines using EHR documentation at 4- and 6-month well-child care visits aided by natural language processing. A secondary aim will evaluate the effectiveness in decreasing the incidence of PA by age 2.5 years using EHR documentation and caregiver surveys. The unit of observation for evaluations are individual children with clustering at the practice level. CONCLUSION: Application of this intervention has the potential to inform the development of strategies to speed implementation of PPA guidelines.

Testing for rare genetic causes of obesity: findings and experiences from a pediatric weight management program.

BACKGROUND: Genetic screening for youth with obesity in the absence of syndromic findings has not been part of obesity management. For children with early onset obesity, genetic screening is recommended for those having clinical features of genetic obesity syndromes (including hyperphagia). OBJECTIVES: The overarching goal of this work is to report the findings and experiences from one pediatric weight management program that implemented targeted sequencing analysis for genes known to cause rare genetic disorders of obesity. SUBJECTS/METHODS: This exploratory study evaluated youth tested over an 18-month period using a panel of 40-genes in the melanocortin 4 receptor pathway. Medical records were reviewed for demographic and visit information, including body mass index (BMI) percent of 95th percentile (%BMIp95) and two eating behaviors. RESULTS: Of 117 subjects: 51.3% were male; 53.8% Hispanic; mean age 10.2 years (SD 3.8); mean %BMIp95 157% (SD 29%). Most subjects were self- or caregiver-reported to have overeating to excess or binge eating (80.3%) and sneaking food or eating in secret (59.0%). Among analyzed genes, 72 subjects (61.5%) had at least one variant reported; 50 (42.7%) had a single variant reported; 22 (18.8%) had 2-4 variants reported; most variants were rare (<0.05% minor allele frequency [MAF]), and of uncertain significance; all variants were heterozygous. Nine subjects (7.7%) had a variant reported as PSCK1 "risk" or MC4R "likely pathogenic"; 39 (33.3%) had a Bardet-Biedl Syndrome (BBS) gene variant (4 with "pathogenic" or "likely pathogenic" variants). Therefore, 9 youth (7.7%) had gene variants previously identified as increasing risk for obesity and 4 youth (3.4%) had BBS carrier status. CONCLUSIONS: Panel testing identified rare variants of uncertain significance in most youth tested, and infrequently identified variants previously reported to increase the risk for obesity. Further research in larger cohorts is needed to understand how genetic variants influence the expression of non-syndromic obesity.

A Scoping Review: Family and Child Perspectives of Clinic-Based Obesity Treatment.

PROBLEM: Interventions for children with obesity lead to only modest improvements in BMI and long-term outcomes, and data are limited on the perspectives of families of children with obesity in clinic-based treatment. This scoping review seeks to answer the question: What is known about the perspectives of families and children who receive care in clinic-based child obesity treatment? ELIGIBILITY CRITERIA: Studies were eligible for inclusion in this review that 1) reported parent, family or child perspectives of obesity treatment; 2) addressed concepts identified in the obesity literature as barriers or facilitators to success in obesity treatment from the perspective of the parent/family/child, including reasons for failure to return to clinic and satisfaction with care. SAMPLE: Twelve studies qualified for final inclusion in this scoping review RESULTS: Families report a lack of interventions tailored to their unique needs and resources. Barriers and facilitators encompass 1) structural issues (e.g., clinic location and scheduling); 2) financial issues; 3) patient and family issues; and 4) personal behaviors, motivation, and expectations. CONCLUSION: Data are lacking on the clinic-based treatment of children with severe obesity, and few studies report on non-maternal perspectives. IMPLICATIONS: Clinical practice must be tailored to individual family needs. Future research should concentrate on identifying missing variables which impact successful treatment outcomes through more rigorous qualitative studies, standardized outcome measures, focus on children with severe obesity, and fathers' and siblings' perspectives.

Family Management of Severe Obesity in Adolescents.

PURPOSE: Severe obesity, defined as a body mass index (BMI) ≥120th percent of the 95th BMI percentile for age and sex, is the fastest growing subcategory of obesity among youth, yet little is known about how this group understands and incorporates weight management strategies. The aims of this study were to explore how parents and adolescents understand severe obesity and incorporate management into their daily lives and evaluate the applicability of the Family Management Styles Framework (FMSF) to better understand the impact of severe obesity for adolescents. DESIGN AND METHODS: Directed content analysis grounded in a modified version of the FMSF was used to analyze one-time in-home face-to-face interviews with adolescents aged 12-17 years (N = 14) who received pediatric weight management care and a parent (N = 17). RESULTS: Both adolescents and parents described the day-to-day management as challenging and impactful to parent-child and sibling relationships. They described the need for sustained support and coaching in meeting daily physical activity requirements and related stories of weight stigma experienced. Further, parents' and adolescents' views were mostly congruent, except in their view of effectiveness of daily routines and how family attitudes and actions did or did not support the adolescent. CONCLUSIONS: The FMSF was successfully applied to understand family management of adolescents with severe obesity. These adolescents have complex physical and psychological needs impacting effective weight management and family life. PRACTICE IMPLICATIONS: Technology interventions should be considered to improve physiological and psychological outcomes for youth with severe obesity.

Characteristics Associated with Successful Weight Management in Youth with Obesity.

OBJECTIVE: To identify the medical, demographic, and behavioral factors associated with a reduction of body mass index percent of the 95th percentile (BMIp95) after 1 year for patients receiving care at a tertiary care obesity management clinic. STUDY DESIGN: A retrospective review of data from first and 12 ± 3-month follow-up visits of subjects aged 8-17 years with obesity. Data included anthropometrics, demographics, medical/psychological history, reported diet patterns, and participation in moderate/vigorous physical activity. After analyzing factors associated with 1-year follow-up, we used a forward conditional logistic regression model, controlling for subject's sex, to examine associations with a BMIp95 ≥5-point decrease at 1 year. RESULTS: Of 769 subjects, 184 (23.9%) had 1-year follow-up. Boys more often had follow-up (28.4% vs girls, 19.1%; P = .003). The follow-up sample was 62.0% male, 65.8% Hispanic, and 77.7% with public insurance; 33.2% achieved a ≥5-point decrease in BMIp95. In regression results, the ≥5-point decrease group was more likely to have completed an initial visit in April-September (OR 2.0, 95% CI 1.1-3.9); have increased physical activity by 1-2 d/wk (OR 3.4, 95% CI 1.4-7.8) or increased physical activity by ≥ 3 d/wk at 1 year (OR 2.7, 95% CI 1.1-6.3); and less likely to have been depressed at presentation (OR 0.4, 95% CI 0.2-0.9). Demographic and dietary factors were not significantly associated with BMIp95 group status. CONCLUSIONS: Strategies improving follow-up rates, addressing mental health concerns, and promoting year-round physical activity are needed to increase the effectiveness of obesity management clinics.

Recognition of elevated blood pressure in an outpatient pediatric tertiary care setting.

OBJECTIVE: To assess the prevalence of elevated blood pressure (BP) and its identification among outpatients at a pediatric tertiary care hospital and to assess clinician attitudes towards BP management. STUDY DESIGN: A retrospective review was undertaken of electronic medical record data of visits over the course of 1 year to 10 subspecialty divisions and 3 primary care services at an urban tertiary care hospital. Interviews of division/service representatives and a clinician survey on perceived role on BP care, practices, and protocols related to BP management were conducted. Elevated BP was defined as ≥90th percentile (using US references); identification of elevated BP was defined as the presence of appropriate codes in the problem list or visit diagnoses. RESULTS: Among 29,000 patients (ages 2-17 years), 70% (those with ≥1 BP measurement) were analyzed. Patients were as follows: 50% male; 42% white, 31% Hispanic, 16% black, 5% Asian, and 5% other/missing; 52% had Medicaid insurance. A total of 64% had normal BPs, 33% had 1-2 elevated BP measurements, and 3% had ≥3 elevated BP measurements. Among those with ≥3 elevated BP measurements, the median frequency of identification by division/service was 17%; the greatest identification was for Kidney Diseases (67%), Wellness & Weight Management (60%), and Cardiology (33%). Among patients with ≥3 elevated BP measurements, 21% were identified vs 7% identified among those with 1-2 increased measurements (P<.001). All clinician survey respondents perceived self-responsibility for identification of elevated BP, but opinions varied for their role in the management of elevated BP. CONCLUSIONS: The identification of patients with elevated BP measurements was low. Strategies to increase the identification of elevated BPs in outpatient tertiary care settings are needed.

Exploring Genetic Testing for Rare Disorders of Obesity: Experience and Perspectives of Pediatric Weight Management Providers.

Background: This study describes experiences and perspectives of pediatric weight management (PWM) providers on the implementation of genetic testing for rare causes of obesity. Methods: Purposive and snowball sampling recruited PWM providers via email to complete a 23-question survey with multiple choice and open-ended questions. Analyses include descriptive statistics, Fisher's exact test, one-way ANOVA with Tukey's post hoc test, and qualitative analysis. Results: Of the 55 respondents, 80% reported ordering genetic testing. Respondents were primarily physicians (82.8%) in practice for 11-20 years (42%), identified as female (80%), White (76.4%), and non-Hispanic (92.7%) and provided PWM care 1-4 half day sessions per week. Frequently reported patient characteristics that prompted testing did not vary by provider years of experience (YOE). These included obesity onset before age 6, hyperphagia, dysmorphic facies, and developmental delays. The number of patient characteristics that prompted testing varied by YOE (p = 0.03); respondents with 6-10 YOE indicated more patient characteristics than respondents with >20 YOE (mean 10.3 vs. mean 6.2). The reported primary benefit of testing was health information for patients/families; the primary drawback was the high number of indeterminate tests. Ethical concerns expressed were fear of increasing weight stigma, discrimination, and impact on insurance coverage. Respondents (42%) desired training and guidance on interpreting results and counseling patients and families. Conclusions: Most PWM providers reported genetic testing as an option for patient management. Provider training in genetics/genomics and research into provider and family attitudes on the genetics of obesity and the value of genetic testing are next steps to consider.

Diabetes screening outcomes in youth presenting for paediatric weight management: A report of the Paediatric Obesity Weight Evaluation Registry.

OBJECTIVE: Rising prevalence of obesity has led to increased rates of prediabetes and diabetes mellitus (DM) in children. This study compares rates of prediabetes and diabetes using two recommended screening tests (fasting plasma glucose [FPG] and haemoglobin A1c [HbA1c]). STUDY DESIGN: Data were collected prospectively from 37 multi-component paediatric weight management programs in POWER (Paediatric Obesity Weight Evaluation Registry). RESULTS: For this study, 3962 children with obesity without a known diagnosis of DM at presentation and for whom concurrent measurement of FPG and HbA1c were available were evaluated (median age 12.0 years [interquartile range, IQR 9.8, 14.6]; 48% males; median body mass index 95th percentile [%BMIp95] 134% [IQR 120, 151]). Notably, 10.7% had prediabetes based on FPG criteria (100-125 mg/dL), 18.6% had prediabetes based on HbA1c criteria (5.7%-6.4%), 0.9% had DM by FPG abnormality (≥126 mg/dL) and 1.1% had DM by HbA1c abnormality (≥6.5%). Discordance between the tests was observed for youth in both age groups (10-18 years [n = 2915] and age 2-9 years [n = 1047]). CONCLUSION: There is discordance between FPG and HbA1c for the diagnosis of prediabetes and DM in youth with obesity. Further studies are needed to understand the predictive capability of these tests for development of DM (in those diagnosed with prediabetes) and cardiometabolic risk.

Vitamin D levels, insulin resistance, and cardiovascular risks in very young obese children.

OBJECTIVE: To examine the relationships of 25-hydroxyvitamin D (25-OHD) levels with the measures of insulin resistance and cardiovascular risk, and identify the clinical factors associated with low 25-OHD in young obese children. DESIGN AND METHODS: Data from 83 children ages 2-6 years seen for obesity care (clinic latitude 42°N) were analyzed. Insulin resistance [homeostasis model assessment of insulin resistance (HOMA-IR)] and cardiovascular risks were examined in relationship to 25-OHD levels using correlation statistics. χ2 and logistic regression models were applied to identify the factors associated with vitamin D deficiency (25-OHD levels <20 ng/mL) and insufficiency (<30 ng/mL). RESULTS: Children's mean age was mean 4.9 years and they were predominantly Hispanic. Mean body mass index (BMI) Z-score was 3.2 and mean HOMA-IR was 2.8. Mean 25-OHD was 30.9 ng/mL (6% <20 ng/mL and 46% 20-29 ng/mL). There were no significant correlations between 25-OHD and BMI (Spearman's ρ=-0.096, p=0.389), BMI Z-score (Spearman's ρ=0.104, p=0.350), HOMA-IR (Spearman's ρ=-0.144, p=0.269), total cholesterol (Spearman's ρ=-0.028, p=0.833), or triglycerides (Spearman's ρ=-0.026, p=0.846). Vitamin D deficiency was significantly associated with older age, lower milk intake, and testing in winter months. 25-OHD level <30 ng/mL was associated with older age, African-American and Hispanic race/ethnicity, and testing in winter months. All factors retained significance in a multivariate logistic regression model, with African-American (odds ratio=14.4) and Hispanic (odds ratio=7.2) race/ethnicity being the strongest predictors of 25-OHD levels <30 ng/mL. CONCLUSIONS: In these children, 25-OHD was not associated with insulin resistance or cardiovascular risks. Considering age, race/ethnicity, diet, and season may help identify young obese children needing vitamin D management.

Seasonal variability in body mass index change among children enrolled in the Pediatric Obesity Weight Evaluation Registry: A step in the right direction.

BACKGROUND: Research has shown children disproportionately gain excess weight over the summer months (vs. school months), with stronger effects for children with obesity. However, the question has not been investigated among children receiving care in paediatric weight management (PWM) programs. OBJECTIVE: To test for seasonal variability in weight change among youth with obesity in PWM care enrolled in the Pediatric Obesity Weight Evaluation Registry (POWER). METHOD: Longitudinal evaluation of a prospective cohort from 2014 to 2019 among youth in 31 PWM programs. Change in percentage of the 95th percentile for BMI (%BMIp95) was compared by quarter. RESULTS: Participants (N = 6816) were primarily ages 6-11 (48%), female (54%), 40% non-Hispanic White, 26% Hispanic and 17% Black, and 73% had severe obesity. Children were enrolled on average 424.9 ± 401.5 days. Participants reduced their %BMIp95 every season, but compared with Quarter 3 (July-September), reductions were significantly greater in Q1 (Jan-March, b = -0.27, 95%CI -0.46, -0.09), Q2 (April-June, b = -0.21, CI -0.40, -0.03), and Q4 (October-December, b = -0.44, CI -0.63, -0.26). CONCLUSION AND RELEVANCE: Across 31 clinics nationwide, children reduced their %BMIp95 every season, but reductions were significantly smaller during the summer quarter. While PWM successfully mitigated excess weight gain during every period, summer remains a high-priority time.

Obesity care strategies in primary care practices.

We evaluated pediatric obesity clinics for internal referrals developed at 5 primary care offices. Clinics developed site-specific strategies: 1 group approach and 4 clinics providing individualized care only. Clinicians reported patient/family motivation as an important referral consideration and compliance as the greatest challenge and perceive clinics to have provided some help.

Perceptions of Weight Management: Interviews with Adolescents with Severe Obesity and Their Mothers.

Background: Adolescence is a challenging time for families, which is intensified when managing a chronic health condition. In adolescents with severe obesity, little is known about how adolescent/mother dyads approach management. Our study aims to (1) explore similarities/differences in adolescent/mother dyads' perceptions of weight management behaviors and (2) describe their experiences with successes and challenges related to weight management. Methods: This was a qualitative descriptive analysis of interviews from 21 adolescent/mother dyads. Conventional content analysis was used to identify themes characterizing dyads' weight management efforts. Results: Two patterns of perceptions were identified across the dyads specific to weight management behaviors: collaborative (dyads agreed) and conflicting (dyads disagreed). Weight management themes with collaborative perceptions were food preferences; food and emotion; the adolescent is active; exercise is not enjoyable; the family is active together; and stopping medications. Weight management themes with conflicting perceptions were responsibility for initiating and maintaining exercise, motivation and willingness to exercise, and responsibility for medications. Dyads had collaborative pattern responses on perceptions of success and challenges. Themes related to successes were weight loss and supportive relationships. Themes related to challenges were inconsistent daily routines and schedules, and unsupportive relationships. Conclusions: Dyads responded with collaborative or conflicting perceptions to weight management behaviors and with collaborative responses to success and challenges. Sustaining healthy habits was difficult from the perspectives of dyads. For youth with severe obesity, providing care that recognizes and addressees issues youth and their families experience may require improved and innovative interventions.

Characteristics of paediatric weight management in the United States: Associations with program retention and BMI outcomes in the paediatric obesity weight evaluation registry (POWER).

OBJECTIVE: To describe characteristics of paediatric weight management (PWM) programs across the United States and evaluate associations with program-specific retention rates and body mass index (BMI) outcomes at 6 months. METHODS: A program profile survey was administered to 33 programs within the Paediatric Obesity Weight Evaluation Registry (POWER) to assess program staffing, services, and treatment format. Patient retention and percent of the 95th BMI percentile (%BMIp95) changes were assessed for each program. RESULTS: At 6 months program retention rates ranged from 15% to 74% (median: 41%), and program %BMIp95 changes ranged from -9.0 to +0.5 percentage points (median: -1.7). Percent of patients with ≥5 percentage-point decrease in %BMIp95 ranged from 17% to 71% across programs (median: 29%). No associations were detected between program characteristics and retention or %BMIp95 changes. CONCLUSIONS: Six-month patient retention and BMI outcomes vary substantially in PWM programs across the United States. Yet, no associations were found between PWM treatment factors and these program-level patient outcomes.

Elevated blood pressure in youth in pediatric weight management programs in the Pediatric Obesity Weight Evaluation Registry (POWER).

Blood pressure (BP) assessment and management are important aspects of care for youth with obesity. This study evaluates data of youth with obesity seeking care at 35 pediatric weight management (PWM) programs enrolled in the Pediatric Obesity Weight Evaluation Registry (POWER). Data obtained at a first clinical visit for youth aged 3-17 years were evaluated to: (1) assess prevalence of BP above the normal range (high BP); and (2) identify characteristics associated with having high BP status. Weight status was evaluated using percentage of the 95th percentile for body mass index (%BMIp95); %BMIp95 was used to group youth by obesity class (class 1, 100% to < 120% %BMIp95; class 2, 120% to < 140% %BMIp95; class 3, ≥140% %BMIp95; class 2 and class 3 are considered severe obesity). Logistic regression evaluated associations with high BP. Data of 7943 patients were analyzed. Patients were: mean 11.7 (SD 3.3) years; 54% female; 19% Black non-Hispanic, 32% Hispanic, 39% White non-Hispanic; mean %BMIp95 137% (SD 25). Overall, 48.9% had high BP at the baseline visit, including 60.0% of youth with class 3 obesity, 45.9% with class 2 obesity, and 37.7% with class 1 obesity. Having high BP was positively associated with severe obesity, older age (15-17 years), and being male. Nearly half of treatment-seeking youth with obesity presented for PWM care with high BP making assessment and management of BP a key area of focus for PWM programs.

Is smoking during pregnancy a risk factor for psychopathology in young children? A methodological caveat and report on preschoolers.

OBJECTIVE: While studies of the effects of prenatal smoking on child psychopathology have found positive relationships, most studies (1) failed to control for a range of correlates of maternal smoking that could affect children's behavior; (2) have been conducted with school-age rather than younger children, so it is not clear when such problems emerge; and (3) have not examined the effects on internalizing problems. METHOD: This study examined the effects of prenatal smoke exposure on behaviors associated with externalizing and internalizing behavior problems and negative temperament in a diverse community sample of 679 4-year-olds. RESULTS: After controlling for correlates that include socioeconomic status, life stress, family conflict, maternal depression, maternal scaffolding skills, mother-child attachment, child negative affect and effortful control, smoking during pregnancy was no longer associated with child behavior or emotional problems. CONCLUSIONS: Future studies need to control for a wide range of covariates of maternal smoking.

Identifying characteristics and outcomes in youth with obesity and developmental disabilities.

BACKGROUND: Youth with developmental disability are at increased risk of obesity; literature focusing on the two is rare. OBJECTIVE: To identify characteristics and outcomes of youth presenting for obesity care having a disability as compared to without. METHODS: A medical record review of youth aged 2-18 years initiating obesity care 2013-2015 at a tertiary care obesity management program. Youth were grouped by disability status to identify differences in presenting characteristics and factors associated with a reduction in body mass index (BMI) percent of the 95th BMI percentile (BMIp95) over 12 months. Logistic regression (LR) models examined associations with BMIp95 drop (<5-points versus ≥5-points) for each disability group. RESULTS: Of 887 subjects, 253 (28.5%) had a disability. At presentation, youth with disability were more often (p < 0.01) male (58.5% versus 47.9%), had birth weight <2500 g (14.1% versus 8.4%), had a father who was not obese (61.6% versus 47.4%), and were on weight influencing medications. Overall, 182 subjects (20.5%) completed 12-month follow-up. At follow-up, the with disability group (n = 63) had mean -2.3 (SD 10.7) BMIp95 change (p = 0.679); youth having a motor disability less often had ≥5-point BMIp95 drop (odds ratio 0.15, 95% confidence interval 0.04-0.59). At follow-up, the no disability group (n = 119) had mean -2.9 (SD 8.5) BMIp95 change; youth identified as having initial severe obesity status and not having a parent with diabetes more often had ≥5-point BMIp95 drop. CONCLUSION: Youth with developmental disabilities were as successful in obesity care as those without disabilities. Predictors of success differed between the groups.

Estimation of Body Fat Percentage for Clinical Pharmacokinetic Studies in Children.

Obesity is a prevalent childhood condition and the degree of adiposity appears likely to be an important covariate in the pharmacokinetics (PKs) of many drugs. We undertook these studies to facilitate the evaluation and, where appropriate, quantification of the covariate effect of body fat percentage (BF%) on PK parameters in children. We examined two large databases to determine the values and variabilities of BF% in children with healthy body weights and in those with obesity, comparing the accuracy and precision of BF% estimation by both clinical methods and demographically derived techniques. Additionally, we conducted simulation studies to evaluate the utility of the several methods for application in clinical trials. BF% was correlated with body mass index (BMI), but was highly variable among both children with healthy body weights and those with obesity. Bio-impedance and several demographically derived techniques produced mean estimates of BF% that differed from dual x-ray absorptiometry by < 1% (accuracy) and a SD of 5% or less (precision). Simulation studies confirmed that when the differences in precision among the several methods were small compared with unexplained between-subject variability of a PK parameter, the techniques were of similar value in assessing the contribution of BF%, if any, as a covariate for that PK parameter. The combination of sex and obesity stage explained 68% of the variance of BF% with BMI. The estimation of BF% from sex and obesity stage can routinely be applied to PK clinical trials to evaluate the contribution of BF% as a potential covariate.

Do hospitalized pediatric patients have weight and blood pressure concerns identified?

OBJECTIVES: To assess the frequency and recognition of abnormal nutritional status and elevated admitting blood pressure (BP) in hospitalized children. STUDY DESIGN: From children aged 3 to 18 years who were hospitalized during 4 months of 2005 (n = 1143), a stratified sample of paper-based medical records were reviewed for demographics, anthropometric and BP measurements and interpretations, care related to nutrition and BP, and discharge diagnoses. Records of 317 of 337 (94%) selected patients were reviewed, and data from 277 of these patients (records with weight and height documented) were analyzed. US references were applied to assign body mass index and BP percentiles. Data were weighted to account for sampling. RESULTS: A total of 51% of subjects were Medicaid/self-pay, with a median age of 9.1 years; and 20% of subjects were obese (14% overweight, 58% healthy weight, 8% underweight). Body mass index was plotted/calculated for 35% of subjects. Six percent of subjects had BP >99th percentile + 5 mm Hg (18% BP 95th to < or =99th percentile + 5 mm Hg). A nutrition referral was documented for 61% of subjects who were underweight and 39% of subjects who were obese. BP concerns were documented for 26% of subjects with BP >99th percentile + 5 mm Hg. CONCLUSIONS: Many pediatric inpatients had abnormal nutritional status or elevated BP. Systems to improve interpretation of these measures, which are commonly obtained in pediatric hospital settings, are needed.

Promoting growth interpretation and lifestyle counseling in primary care.

OBJECTIVE: To pilot a practice-directed intervention to promote growth interpretation and lifestyle counseling during child health supervision visits. STUDY DESIGN: The intervention at 4 diverse primary care practices included education, facilitation by a practice-change leadership team, tools, and guidance from the study team. Preintervention and postintervention evaluations used were clinician interviews, in-office surveys of parents, 1-month post-visit telephone survey, visit observations, and medical record reviews. Outcomes evaluated growth interpretation documentation, clinician recognition of overweight, topic discussed at health supervision visit, and parental visit content recall and health behavior changes. RESULTS: The intervention was well accepted, and tools provided were deemed helpful. Documentation of growth interpretation was higher after intervention (pre versus post: 32% vs 87%; P< .001). Parent reports of topics discussed were similar between evaluation periods (pre versus post: growth 96% vs 99%; diet 90% vs 93%; physical activity 81% vs 85%). Observed topics at health supervision visits were similarly high and were unchanged between periods. Parental recall of topics at 1 month was also high and similar between periods. Parental report of adoption of a healthier behavior for themselves or their child at 1 month did not significantly change. CONCLUSIONS: The Systematic Nutritional Assessment in Pediatric Practice intervention provides a promising model to increase interpretation and documentation of growth.