Longitudinal Associations Between Neighborhood Child Opportunity and Physical Fitness for New York City Public School Youth.

Neighborhood environments can support fitness-promoting behavior, yet little is known about their influence on youth physical fitness outcomes over time. We examined longitudinal associations between neighborhood opportunity and youth physical fitness among New York City (NYC) public school youth. The Child Opportunity Index (COI), a composite index of 29 indicators measuring neighborhood opportunity at the census-tract level, along with scores on 4 selected COI indicators were linked to NYC FITNESSGRAM youth data at baseline. Fitness outcomes (measured annually, 2011-2018) included body mass index, curl-ups, push-ups, and Progressive Aerobic Cardiovascular Endurance Run (PACER) laps. Unstratified and age-stratified, adjusted, 3-level generalized linear mixed models, nested by census tract and time, estimated the association between COI and fitness outcomes. The analytical sample (n = 204,939) lived in very low (41%) or low (30%) opportunity neighborhoods. Unstratified models indicated that overall COI is modestly associated with improved youth physical fitness outcomes. The strongest opportunity-fitness associations were observed for PACER. Stratified models show differences in associations across younger vs. older youth. We find that neighborhood factors are associated with youth fitness outcomes over time, with the strength of the associations dependent on age. Future implications include better informed place-based interventions tailored to specific life stages to promote youth health.

Timing and Magnitude of Peak Body Mass Index and Peak Weight Velocity in Infancy Predict Body Mass Index at 2 Years in a Retrospective Cohort of Electronic Health Record Data.

OBJECTIVES: To use growth data from electronic health records to describe and model infant growth (weight velocity and peak body mass index [pBMI]) characteristics. STUDY DESIGN: We extracted data from all children born at ≥34 weeks of gestation within one health system between 2014 and 2017. After excluding implausible growth data with an algorithm created for childhood growth, we estimated pBMI, peak weight and length velocities, and the odds of obesity at 2 years, adjusted for race, sex, ethnicity, and birth weight, by the magnitude of peak weight velocity, peak length velocity, and pBMI. RESULTS: Among 6425 children (41% White, 28% Black, 26% other race; 16% Hispanic ethnicity), mean pBMI was 17.9 kg/m2 (SD 1.5) and mean age at pBMI was 9.6 months (SD 2.7). Mean peak weight velocity was 949 g (SD 165) per 2 weeks, and the mean peak length velocity was 3.4 cm (SD 0.3) per 2 weeks. Children with obesity at 2 years (n = 931, 14.5%) were more likely to be Hispanic, had greater peak weight and peak length velocities, and had 2 kg/m2 greater magnitude of pBMI than children without obesity. For each unit increase in pBMI, children had more than 4 times greater odds of obesity at age 2 years. CONCLUSIONS: In a large sample of infants with clinical growth data tracked via electronic health records, we found associations between the magnitude and timing of peak infant BMI and obesity at 2 years of age.

Severe obesity and fitness in New York City public school youth, 2010-2018.

BACKGROUND: Obesity is associated with poorer youth fitness. However, little research has examined the magnitude of this relationship in youth with severe obesity. Therefore, we sought to determine the relationship between increasing weight status and fitness within a sample of children and adolescents from New York City public schools. METHODS: This study utilized longitudinal data from the NYC Fitnessgram dataset years 2010-2018. Height and weight along with fitness were measured annually during physical education classes. Severity of obesity was defined using body mass index relative to the 95th percentile and then categorized into classes. A composite measure of fitness was calculated based on scores for three fitness tests: aerobic capacity, muscular strength, and muscular endurance. To examine the weight status-fitness relationship, repeated measures mixed models with random-intercepts were constructed. Stratified models examined differences by demographic factors. RESULTS: The sample included 917,554 youth (51.8% male, 39.3% Hispanic, 29.9% non-Hispanic Black, 14.0%, 4.6%, and 1.6% class I, II and III obesity, respectively). Compared to youth with healthy weight, increasing severity of obesity was associated with decreased fitness: overweight (ß = - 0.28, 95% CI:-0.29;-0.28), class I obesity (ß = - 0.60, 95% CI:-0.60; - 0.60), class II obesity (ß = - 0.94, 95% CI:-0.94; - 0.93), and class III obesity (ß = - 1.28; 95% CI:-1.28; - 1.27). Stratified models showed the association was stronger among male and non-Hispanic White youth. CONCLUSION: Findings revealed that more severe obesity was associated with lower fitness. Future research is needed to develop targeted interventions to improve fitness in youth with obesity.

The Association Between the Supply of Nonpharmacologic Providers, Use of Nonpharmacologic Pain Treatments, and High-risk Opioid Prescription Patterns Among Medicare Beneficiaries With Persistent Musculoskeletal Pain.

BACKGROUND: Opioids are prescribed more frequently than nonpharmacologic treatments for persistent musculoskeletal pain (MSP). We estimate the association between the supply of physical therapy (PT) and mental health (MH) providers and early nonpharmacologic service use with high-risk opioid prescriptions among Medicare beneficiaries with persistent MSP. RESEARCH DESIGN: We retrospectively studied Medicare beneficiaries (>65 y) enrolled in Fee-for-Service and Part D (2007-2014) with a new persistent MSP episode and no opioid prescription during the prior 6 months. Independent variables were nonpharmacologic provider supply per capita and early nonpharmacologic service use (any use during first 3 mo). One year outcomes were long-term opioid use (LTOU) (≥90 days' supply) and high daily dose (HDD) (≥50 mg morphine equivalent). We used multinomial regression and generalized estimating equations and present adjusted odds ratios (aORs). RESULTS: About 2.4% of beneficiaries had LTOU; 11.9% had HDD. The supply of MH providers was not associated with LTOU and HDD. Each additional PT/10,000 people/county was associated with greater odds of LTOU [aOR: 1.06; 95% confidence interval (CI), 1.01-1.11). Early MH use was associated with lower odds of a low-risk opioid use (aOR: 0.81; 95% CI, 0.68-0.96), but greater odds of LTOU (aOR: 1.93; 95% CI, 1.28-2.90). Among beneficiaries with an opioid prescription, early PT was associated with lower odds of LTOU (aOR: 0.75; 95% CI, 0.64-0.89), but greater odds of HDD (aOR: 1.25; 95% CI, 1.15-1.36). CONCLUSIONS: The benefits of nonpharmacologic services on opioid use may be limited. Research on effective delivery of nonpharmacologic services to reduce high-risk opioid use for older adults with MSP is needed.

Long-term opioid therapy definitions and predictors: A systematic review.

PURPOSE: This review sought to (a) describe definitions of long-term opioid therapy (LTOT) outcome measures, and (b) identify the predictors associated with the transition from short-term opioid use to LTOT for opioid-naïve individuals. METHODS: We conducted a systematic review of the peer-reviewed literature (January 2007 to July 2018). We included studies examining opioid use for more than 30 days. We classified operationalization of LTOT based on criteria used in the definitions. We extracted LTOT predictors from multivariate models in studies of opioid-naïve individuals. RESULTS: The search retrieved 5,221 studies, and 34 studies were included. We extracted 41 unique variations of LTOT definitions. About 36% of definitions required a cumulative duration of opioid use of 3 months. Only 17% of definitions considered consecutive observation periods, 27% used days' supply, and no definitions considered dose. We extracted 76 unique predictors of LTOT from seven studies of opioid-naïve patients. Common predictors included pre-existing comorbidities (21.1%), non-opioid prescription medication use (13.2%), substance use disorders (10.5%), and mental health disorders (10.5%). CONCLUSIONS: Most LTOT definitions aligned with the chronic pain definition (pain more than 3 months), and used cumulative duration of opioid use as a criterion, although most did not account for consistent use. Definitions were varied and rarely accounted for prescription characteristics, such as days' supply. Predictors of LTOT were similar to known risk factors of opioid abuse, misuse, and overdose. As LTOT becomes a central component of quality improvement efforts, researchers should incorporate criteria to identify consistent opioid use to build the evidence for safe and appropriate use of prescription opioids.

Rationale and design of "Hearts & Parks": study protocol for a pragmatic randomized clinical trial of an integrated clinic-community intervention to treat pediatric obesity.

BACKGROUND: The prevalence of child and adolescent obesity and severe obesity continues to increase despite decades of policy and research aimed at prevention. Obesity strongly predicts cardiovascular and metabolic disease risk; both begin in childhood. Children who receive intensive behavioral interventions can reduce body mass index (BMI) and reverse disease risk. However, delivering these interventions with fidelity at scale remains a challenge. Clinic-community partnerships offer a promising strategy to provide high-quality clinical care and deliver behavioral treatment in local park and recreation settings. The Hearts & Parks study has three broad objectives: (1) evaluate the effectiveness of the clinic-community model for the treatment of child obesity, (2) define microbiome and metabolomic signatures of obesity and response to lifestyle change, and (3) inform the implementation of similar models in clinical systems. METHODS: Methods are designed for a pragmatic randomized, controlled clinical trial (n = 270) to test the effectiveness of an integrated clinic-community child obesity intervention as compared with usual care. We are powered to detect a difference in body mass index (BMI) between groups at 6 months, with follow up to 12 months. Secondary outcomes include changes in biomarkers for cardiovascular disease, psychosocial risk, and quality of life. Through collection of biospecimens (serum and stool), additional exploratory outcomes include microbiome and metabolomics biomarkers of response to lifestyle modification. DISCUSSION: We present the study design, enrollment strategy, and intervention details for a randomized clinical trial to measure the effectiveness of a clinic-community child obesity treatment intervention. This study will inform a critical area in child obesity and cardiovascular risk research-defining outcomes, implementation feasibility, and identifying potential molecular mechanisms of treatment response. CLINICAL TRIAL REGISTRATION: NCT03339440 .

The lock-in loophole: Using mixed methods to explain patient circumvention of a Medicaid opioid restriction program.

BACKGROUND: Lock-in programs are proliferating among private and public payers to restrict access to controlled substance prescriptions and enhance care coordination for patients exhibiting high-risk use of, primarily, opioids. Patients enrolled in lock-in programs are required to seek opioids from a designated provider and pharmacy for insurance coverage of their opioid and benzodiazepine prescriptions. Lock-in program restrictions are often circumvented by patients through out-of-pocket cash purchases of opioid prescriptions, undermining the program's intended function. This study sought to construct and explain trajectories of Medicaid-covered and cash pay opioid prescription fills among adults enrolled in an opioid lock-in program. Methods: We used sequential explanatory mixed methods, which involved a quantitative retrospective cohort analysis of opioid fill trajectories using North Carolina Medicaid administrative claims data linked with state prescription drug monitoring program data, followed by qualitative semi-structured interviews with North Carolina pharmacists. The quantitative component included adults enrolled in the North Carolina Medicaid lock-in program between 10/1/2010-3/31/2012. The qualitative component included a maximum variation sample of community pharmacists in North Carolina delivering care to lock-in patients. Quantitative outcomes included group-based trajectories of monthly Medicaid-covered and cash pay opioid prescription fills six months before and after LIP enrollment, and qualitative analyses generated themes explaining observed trajectories. Results: Two-thirds of subjects exhibited reduced Medicaid-covered opioid prescription fills and no increase in cash pay fills after lock-in enrollment, with one-third exhibiting increased cash pay fills after lock-in. Pharmacists attributed increases in cash pay fills primarily to illicit behaviors, while some cash pay behavior likely reflected new unintended barriers to care. Conclusions: Lock-in programs appear to reduce prescription opioid use for most enrolled patients. However, lock-in programs may have limited capacity to deter illicit behaviors among patients intent on abusing, misusing, or diverting these medications and may introduce new access barriers to necessary care for some.

Evaluation of a Medicaid Lock-in Program: Increased Use of Opioid Use Disorder Treatment but No Impact on Opioid Overdose Risk.

BACKGROUND: "Lock-in" programs (LIPs) identify beneficiaries demonstrating potential overutilization of opioids, and other controlled substances, and restrict their access to these medications. LIPs are expanding to address the opioid crisis and could be an effective tool for connecting people to opioid use disorder treatment. We examined the immediate and sustained effects of a Medicaid LIP on overdose risk and use of medication-assisted treatment (MAT) for opioid use disorder. METHODS: We analyzed North Carolina Medicaid claims from July 2009 through June 2013. We estimated daily risk differences and ratios of MAT use and overdose during lock-in and following release from the program, compared with periods before program enrollment. RESULTS: The daily probability of MAT use during lock-in and following release was greater, when compared with a period just before LIP enrollment [daily risk ratios: 1.50, 95% confidence interval (CI): 1.18-1.91; 2.27, 95% CI: 1.07-4.80; respectively]. Beneficiaries' average overdose risk while enrolled in the program and following release was similar to their risk just before enrollment (daily risk ratios: 1.01, 95% CI: 0.79-1.28; 1.12, 95% CI: 0.82-1.54; respectively). DISCUSSION: North Carolina's Medicaid LIP was associated with increased use of MAT during enrollment, and this increase was sustained in the year following release from the program. However, we did not observe parallel reductions in overdose risk during lock-in and following release. Identifying facilitators of MAT access and use among this population, as well as potential barriers to overdose reduction are important next steps to ensuring effective LIP design.

Using Telehealth to Disseminate Primary, Secondary, and Tertiary CVD Interventions to Rural Populations.

PURPOSE OF REVIEW: This study aims to review the evidence on telehealth interventions in rural communities that use primary, secondary, or tertiary strategies for the prevention and management of cardiovascular disease (CVD). RECENT FINDINGS: Studies focused on the reduction of CVD risk factors and mitigation of disease progression among rural populations using telehealth are limited in number but appear to be increasing in the last 5 years. These studies suggest primary-, secondary-, and tertiary-level interventions can impact CVD risk and management. The current review found more studies addressing primary CVD intervention strategies, although the evidence for efficacy at all intervention levels is in the early stages. Leveraging prevention strategies via telehealth may be an effective vehicle to facilitate improved CVD outcomes among populations traditionally marginalized by geographic location.

Trajectories of dispensed prescription opioids among beneficiaries enrolled in a Medicaid controlled substance "lock-in" program.

PURPOSE: "Lock-in" programs (LIPs) are used by health insurers to address potential substance (eg, opioid) misuse among beneficiaries. We sought to (1) examine heterogeneity in trajectories of dispensed opioids (in average daily morphine milligram equivalents (MMEs)) over time: prior to, during, and following release from a LIP, and (2) assess associations between trajectory patterns and beneficiary characteristics. METHODS: Medicaid claims were linked to Prescription Drug Monitoring Program records for a cohort of beneficiaries enrolled in the North Carolina Medicaid LIP (n = 2701). Using latent class growth analyses, we estimated trajectories of average daily MMEs of opioids dispensed to beneficiaries across specific time periods of interest. RESULTS: Five trajectory patterns appeared to sufficiently describe underlying heterogeneity. Starting values and slopes varied across the 5 trajectory groups, which followed these overall patterns: (1) start at a high level of MMEs, end at a high level of MMEs (13.1% of cohort); (2) start medium, end medium (13.2%); (3) start medium, end low (21.5%); (4) start low, end medium (22.6%); and (5) start low, end low (29.6%). We observed strong associations between patterns and beneficiaries' demographics, substance use-related characteristics, comorbid conditions, and healthcare utilization. CONCLUSIONS: In its current form, the Medicaid LIP appeared to have limited impact on beneficiaries' opioid trajectories. However, strong associations between trajectory patterns and beneficiary characteristics provide insight into potential LIP design modifications that might improve program impact (eg, LIP integration of substance use disorder assessment and referral to treatment, assessment and support for alternate pain therapies).

Kinship Care and Foster Care: A Comparison of Out-of-Home Placement From the Perspective of Child Abuse Experts in North Carolina.

BACKGROUND Children may be placed in either kinship or foster care, forms of out-of-home placement (OHP), if maltreatment is suspected. The American Academy of Pediatrics has identified them as children with special health needs requiring elevated care. While North Carolina has increased support for foster care, it is unclear whether similar support exists for kinship care. Child abuse medical providers (CAMPs) were interviewed regarding their understanding and assessment of the state of the kinship care system in North Carolina, and how it can be improved.METHODS CAMPs were individually interviewed using a semi-structured, open-ended question guide to assess their perspectives on kinship versus foster care in North Carolina. Data were coded, and the analysis was conducted in an inductive manner, allowing themes and then recommendations to emerge from interviews.RESULTS The following three themes were identified: 1) providers have a foundational understanding of the kinship care system, marked by knowledge gaps; 2) children in kinship care and foster care have equivalent, elevated health needs, but children in kinship care do not receive the same level of care; 3) individual and structural changes have to be made to the interprofessional teams working within the OHP system.LIMITATIONS The study sample was small, including eight CAMPs who had relatively homogenous demographic characteristics. CAMPs typically see the worst cases of maltreatment, which may bias responses. Additionally, the majority of children in kinship care are unknown to CAMPs and may not be fully represented in responses.CONCLUSION CAMPs' responses were summarized into a set of recommendations targeting four different components of the OHP team: the general interprofessional team, policymakers and state leaders, medical providers, and social workers.

Health Care Utilization and Comorbidity History of North Carolina Medicaid Beneficiaries in a Controlled Substance "Lock-in" Program.

BACKGROUND Medicaid "lock-in" programs (MLIPs) are a widely used strategy for addressing potential misuse of prescription drugs among beneficiary populations. However, little is known about the health care needs and attributes of beneficiaries selected into these programs. Our goal was to understand the characteristics of those eligible, enrolled, and retained in a state MLIP.METHODS Demographics, comorbidities, and health care utilization were extracted from Medicaid claims from June 2009 through June 2013. Beneficiaries enrolled in North Carolina's MLIP were compared to those who were MLIP-eligible, but not enrolled. Among enrolled beneficiaries, those completing the 12-month MLIP were compared to those who exited prior to 12 months.RESULTS Compared to beneficiaries who were eligible for, but not enrolled in the MLIP (N = 11,983), enrolled beneficiaries (N = 5,424) were more likely to have: 1) substance use (23% versus 14%) and mental health disorders, 2) obtained controlled substances from multiple pharmacies, and 3) visited more emergency departments (mean: 8.3 versus 4.2 in the year prior to enrollment). One-third (N = 1,776) of those enrolled in the MLIP exited the program prior to completion.LIMITATIONS Accurate information on unique prescribers visited by beneficiaries was unavailable. Time enrolled in Medicaid differed for beneficiaries, which may have led to underestimation of covariate prevalence.CONCLUSIONS North Carolina's MLIP appears to be successful in identifying subpopulations that may benefit from provision and coordination of services, such as substance abuse and mental health services. However, there are challenges in retaining this population for the entire MLIP duration.

Cardiometabolic Risks and Severity of Obesity in Children and Young Adults.

BACKGROUND: The prevalence of severe obesity among children and young adults has increased over the past decade. Although the prevalence of cardiometabolic risk factors is relatively low among children and young adults who are overweight or obese, those with more severe forms of obesity may be at greater risk. METHODS: We performed a cross-sectional analysis of data from overweight or obese children and young adults 3 to 19 years of age who were included in the National Health and Nutrition Examination Survey from 1999 through 2012 to assess the prevalence of multiple cardiometabolic risk factors according to the severity of obesity. Weight status was classified on the basis of measured height and weight. We used standard definitions of abnormal values for total cholesterol, high-density lipoprotein (HDL) cholesterol, low-density lipoprotein cholesterol, triglycerides, blood pressure, glycated hemoglobin, and fasting glucose and report the prevalence of abnormal values in children and young adults according to weight status. RESULTS: Among 8579 children and young adults with a body-mass index at the 85th percentile or higher (according to the Centers for Disease Control and Prevention growth charts), 46.9% were overweight, 36.4% had class I obesity, 11.9% had class II obesity, and 4.8% had class III obesity. Mean values for some, but not all, cardiometabolic variables were higher with greater severity of obesity in both male and female participants, and the values were higher in male participants than in female participants; for HDL cholesterol, the mean values were lower with greater severity of obesity. Multivariable models that controlled for age, race or ethnic group, and sex showed that the greater the severity of obesity, the higher the risks of a low HDL cholesterol level, high systolic and diastolic blood pressures, and high triglyceride and glycated hemoglobin levels. CONCLUSIONS: Severe obesity in children and young adults was associated with an increased prevalence of cardiometabolic risk factors, particularly among boys and young men.

Influence of product placement in children's movies on children's snack choices.

BACKGROUND: Media exposure affects health, including obesity risk. Children's movies often contain food placements-frequently unhealthy foods. However, it is not known if these cues influence children's food choices or consumption after viewing. We explored whether children's snack choices or consumption differs based on: 1) recent exposure to movies with high versus low product placement of unhealthy foods; and 2) children's weight status. METHODS: Children ages 9-11 were assigned to watch a high ("Alvin and the Chipmunks," n = 54) or low ("Stuart Little," n = 60) product-placement movie. After viewing, participants selected a snack choice from each of five categories, several of which were specifically featured in "Alvin." Uneaten snacks from each participant were weighed upon completion. Snack choice and amount consumed by movie were compared by t-tests, and differences in snack choices by movie were tested with logistic regression. RESULTS: Participants consumed an average of 800.8 kcal; mean kcal eaten did not vary by movie watched. Participants who watched the high product-placement movie had 3.1 times the odds (95% CI 1.3-7.2) of choosing cheese balls (most featured snack) compared to participants who watched the low product-placement movie. Children who were overweight or obese consumed a mean of 857 kcal (95% CI: 789-925) compared to 783 kcal (95% CI: 742-823, p = 0.09) for children who were underweight or healthy weight. Children's weight status did not significantly affect their choice of snack. CONCLUSIONS: Branding and obesogenic messaging in children's movies influenced some choices that children made about snack foods immediately following viewing, especially food with greatest exposure time in the film, but did not affect total calories consumed. Future studies should examine how the accumulation of these messages affects children's long-term food choices.

Screening for Major Depressive Disorder in Children and Adolescents: A Systematic Review for the U.S. Preventive Services Task Force.

BACKGROUND: Major depressive disorder (MDD) is common among children and adolescents and is associated with functional impairment and suicide. PURPOSE: To update the 2009 U.S. Preventive Services Task Force (USPSTF) systematic review on screening for and treatment of MDD in children and adolescents in primary care settings. DATA SOURCES: Several electronic searches (May 2007 to February 2015) and searches of reference lists of published literature. STUDY SELECTION: Trials and recent systematic reviews of treatment, test-retest studies of screening, and trials and large cohort studies for harms. DATA EXTRACTION: Data were abstracted by 1 investigator and checked by another; 2 investigators independently assessed study quality. DATA SYNTHESIS: Limited evidence from 5 studies showed that such tools as the Beck Depression Inventory and Patient Health Questionnaire for Adolescents had reasonable accuracy for identifying MDD among adolescents in primary care settings. Six trials evaluated treatment. Several individual fair- and good-quality studies of fluoxetine, combined fluoxetine and cognitive behavioral therapy, escitalopram, and collaborative care demonstrated benefits of treatment among adolescents, with no associated harms. LIMITATION: The review included only English-language studies, narrow inclusion criteria focused only on MDD, high thresholds for quality, potential publication bias, limited data on harms, and sparse evidence on long-term outcomes of screening and treatment among children younger than 12 years. CONCLUSION: No evidence was found of a direct link between screening children and adolescents for MDD in primary care or similar settings and depression or other health-related outcomes. Evidence showed that some screening tools are accurate and some treatments are beneficial among adolescents (but not younger children), with no evidence of associated harms. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.

The unbuilt environment: culture moderates the built environment for physical activity.

BACKGROUND: While research has demonstrated a link between the built environment and obesity, much variation remains unexplained. Physical features are necessary, but not sufficient, for physical activity: residents must choose to use these features in health-promoting ways. This article reveals a role for local culture in tempering the effect of the physical environment on physical activity behaviors. METHODS: We developed Systematic Cultural Observation (SCO) to observe place-based, health-related culture in Lenoir County, NC (population ~60,000). Photographs (N = 6450) were taken systematically from 150 most-used road segments and geocoded. Coders assessed physical activity (PA) opportunities (e.g., public or private activity spaces, pedestrian-friendly features) and presence of people in each photograph. RESULTS: 28.7% of photographs contained some PA feature. Most were private or pedestrian; 3.1% contained public PA space. Only 1.5% of photographs with any PA features (2% of those with public PA space, 0.7% of those with private) depicted people despite appropriate weather and daylight conditions. CONCLUSIONS: Even when PA opportunities existed in this rural county, they were rarely used. This may be the result of culture ("unbuilt environment") that disfavors physical activity even in the presence of features that allow it. Policies promoting built environments designed for healthy lifestyles should consider local culture (shared styles, skills, habits, and beliefs) to maximize positive outcomes.

Parental Perceptions of Weight Status in Preterm Compared with Term Infants.

Background Parents of overweight children frequently under-recognize their child's overweight status. We hypothesized that parents of preterm children would be more likely than parents of term children to incorrectly perceive their child's weight. Methods We recruited parents of term and preterm when children were 2 months to 2 years of age. Small for gestational age infants were excluded. We compared parents' perceived weight category with child's actual weight category, based on normative data (underweight, normal weight, or overweight). We based analyses on encounters and adjusted for within-child clustering across repeated measures. Results In the preterm (n = 94) and term (n = 1,263) cohorts, 12 and 13% of children, respectively, were overweight (weight-for-length ≥ 95th percentile). Among parents of overweight children, 91% in the preterm cohort and 90% in the term cohort reported their child as healthy weight. Among healthy weight children (weight-for-length 6th-94th percentile), parents in the preterm cohort were more likely to report their child as underweight compared with parents in the term cohort (24 vs. 7%; p < 0.001). Conclusion Parental perception of weight status was impaired among parents of overweight children regardless of gestational age. However, parents were more likely to perceive their healthy weight child as underweight if their child was preterm.

The Injury Prevention Program to Reduce Early Childhood Injuries: A Cluster Randomized Trial.

BACKGROUND AND OBJECTIVES: The American Academy of Pediatrics designed The Injury Prevention Program (TIPP) in 1983 to help pediatricians prevent unintentional injuries, but TIPP's effectiveness has never been formally evaluated. We sought to evaluate the impact of TIPP on reported injuries in the first 2 years of life. METHODS: We conducted a stratified, cluster-randomized trial at 4 academic medical centers: 2 centers trained their pediatric residents and implemented TIPP screening and counseling materials at all well-child checks (WCCs) for ages 2 to 24 months, and 2 centers implemented obesity prevention. At each WCC, parents reported the number of child injuries since the previous WCC. Proportional odds logistic regression analyses with generalized estimating equation examined the extent to which the number of injuries reported were reduced at TIPP intervention sites compared with control sites, adjusting for baseline child, parent, and household factors. RESULTS: A total of 781 parent-infant dyads (349 TIPP; 432 control) were enrolled and had sufficient data to qualify for analyses: 51% Hispanic, 28% non-Hispanic Black, and 87% insured by Medicaid. Those at TIPP sites had significant reduction in the adjusted odds of reported injuries compared with non-TIPP sites throughout the follow-up (P = .005), with adjusted odds ratios (95% CI) of 0.77 (0.66-0.91), 0.60 (0.44-0.82), 0.32 (0.16-0.62), 0.26 (0.12-0.53), and 0.27 (0.14-0.52) at 4, 6, 12, 18, and 24 months, respectively. CONCLUSIONS: In this cluster-randomized trial with predominantly low-income, Hispanic, and non-Hispanic Black families, TIPP resulted in a significant reduction in parent-reported injuries. Our study provides evidence for implementing the American Academy of Pediatrics' TIPP in routine well-child care.