Diagnosing Jaundice by Eye-Outpatient Assessment of Conjunctival Icterus in the Newborn.

In pediatric office practices, we compared transcutaneous bilirubin levels in 689 newborns, age 3-10 days, with and without conjunctival icterus. In this age range, and in the absence of other clinical or laboratory indications, the presence of conjunctival icterus does not imply the need to measure the transcutaneous bilirubin or serum bilirubin level, but the absence of conjunctival icterus helps to rule out significant hyperbilirubinemia.

Associations of home food availability, dietary intake, screen time and physical activity with BMI in young American-Indian children.

OBJECTIVE: To evaluate associations between home environmental factors and BMI of young American-Indian children. DESIGN: Cross-sectional and prospective study. SETTING: School-based obesity prevention trial (Bright Start) on a Northern Plains Indian reservation in South Dakota. Mixed model multivariable analysis was used to examine associations between child BMI categories (normal, overweight and obese) and home food availability, children's dietary intake and physical activity. Analyses were adjusted for age, gender, socio-economic status, parent BMI and school; prospective analyses also adjusted for study condition and baseline predictor and outcome variables. SUBJECTS: Kindergarten children (n = 424, 51 % male; mean age = 5.8 years, 30 % overweight/obese) and parents/caregivers (89 % female; 86 % overweight/obese) had their height and weight measured and parents/caregivers completed surveys on home environmental factors (baseline and 2 years later). RESULTS: Higher fast-food intake and parent-perceived barriers to physical activity were marginally associated with higher probabilities of a child being overweight and obese. Vegetable availability was marginally associated with lower probabilities of being overweight and obese. The associations between home environmental factors and child weight status at follow-up were not significant. CONCLUSIONS: Findings indicate that selected aspects of the home environment are associated with weight status of American-Indian children. Obesity interventions with this population should consider helping parents to engage and model healthful behaviours and to increase availability of healthful foods at home.

Food responsiveness, parental food control and anthropometric outcomes among young American Indian children: cross-sectional and prospective findings.

OBJECTIVE: Assess cross-sectional and prospective associations between food responsiveness and parental food control and anthropometric outcomes among American Indian children. DESIGN: Parents/caregivers completed psychosocial surveys and trained staff measured children's anthropometry at baseline (kindergarten) and at follow-up (1st grade) as part of a school-based obesity prevention trial (Bright Start). SETTING: On/near the Pine Ridge Indian reservation. PARTICIPANTS: 422 child (51% female, mean age=5.8 years, 30% overweight/obese) and parent/caregiver (89% mothers) dyads. MAIN OUTCOME MEASURES: Two independent variables (child's Food Responsiveness and Parental Control scales) and six child anthropometric dependent variables (overweight status, body mass index z-score, % body fat, waist circumference, triceps skinfold, subscapular skinfold). Linear regression analyses, stratified by sex and adjusted for age and treatment condition. RESULTS: Baseline Food Responsiveness scale scores were positively associated with all six baseline anthropometric outcomes among boys (P's all <.01), but not girls. Parental Control scale scores were not significantly associated with outcomes and no prospective associations were statistically significant. CONCLUSIONS: Responsiveness to food may be associated with excess adiposity in young American Indian boys, however, the effects are not detectable over time. Obesity prevention programs for American Indian children may benefit by addressing eating without hunger among boys.

Understanding medical professionalism using express team-based learning; a qualitative case-based study.

Medical Professionalism (MP) defined as values, behaviours and attitudes that promote professional relationships, public trust and patient safety is a vital competency in health profession education. MP has a distinctive uniqueness due to cultural, contextual, conceptual, and generational variations. There is no standard instructional strategy to probe the understanding of MP in a cohesive, structured, interactive manner. This study aimed to investigate undergraduate medical students' understanding of MP using express team-based learning (e-TBL) at both campuses of Royal College of Surgeons Ireland (RCSI). Using the key principles of a sociocultural theoretical lens in adult learning theory, we designed e-TBL as a context-learning-based educational strategy. We conducted three e-TBL sessions on cross-cultural communication and health disparities, a reflective report on clinical encounters, and professionalism in practice. We collected, collated, and analyzed the student experiences qualitatively using data gathered from team-based case discussions during e-TBL sessions. A dedicated working group developed very short-answer questions for the individual readiness assurance test (IRAT) and MP-based case scenarios for team discussions. In this adapted 4-step e-TBL session, pre-class material was administered, IRAT was undertaken, and team-based discussions were facilitated, followed by facilitator feedback. A qualitative inductive thematic analysis was performed, which generated subthemes and themes illustrated in excerpts. Our thematic analysis of data from 172 students (101 from Bahrain and 71 from Dublin) yielded four unique themes: incoming professional attitudes, transformative experiences, sociological understanding of professionalism, and new professional identity formation. This qualitative study provides a deeper understanding of medical students' perceptions of medical professionalism. The generated themes resonated with divergent and evolving elements of MP in an era of socioeconomic and cultural diversity, transformative experiences, and professional identity formation. The core elements of these themes can be integrated into the teaching of MP to prepare fit-to-practice future doctors.

High food insecurity and its correlates among families living on a rural American Indian Reservation.

OBJECTIVES: We sought to better understand the prevalence and consequences of food insecurity among American Indian families with young children. METHODS: Parents or caregivers of kindergarten-age children enrolled in the Bright Start study (dyad n=432) living on the Pine Ridge Reservation in South Dakota completed a questionnaire on their child's dietary intake, the home food environment, and food security. We assessed food security with a standard 6-item scale and examined associations of food insecurity with family sociodemographic characteristics, parents' and children's weight, children's dietary patterns, and the home food environment. RESULTS: Almost 40% of families reported experiencing food insecurity. Children from food-insecure households were more likely to eat some less healthful types of foods, including items purchased at convenience stores (P= .002), and food-insecure parents reported experiencing many barriers to accessing healthful food. Food security status was not associated with differences in home food availability or children's or parents' weight status. CONCLUSIONS: Food insecurity is prevalent among families living on the Pine Ridge Reservation. Increasing reservation access to food that is high quality, reasonably priced, and healthful should be a public health goal.

American Indian parents' assessment of and concern about their kindergarten child's weight status, South Dakota, 2005-2006.

INTRODUCTION: Obesity is highly prevalent among American Indians, and effective prevention efforts require caregiver involvement. We examined American Indian (AI) parents' assessment of and level of concern about their kindergarten child's weight status. METHODS: We collected baseline data (fall of 2005 and fall of 2006) on children and their parents or caregivers for a school-based obesity prevention trial (Bright Start) on an AI reservation in South Dakota. The current study uses 413 parent-child pairs. Age- and sex-adjusted body mass index percentiles were categorized as very underweight (<5th percentile), slightly underweight (5th to <15th percentile), normal weight (15th to <85th percentile), overweight (85th to <95th percentile), and obese (≥ 95th percentile). Parents or caregivers reported their assessment of and concerns about their child's weight status as well as sociodemographic characteristics. We used mixed-model multivariable analysis to examine associations between sociodemographic characteristics and the probability of parents underclassifying or overclassifying their child's weight status; analyses were adjusted for school as a random effect. RESULTS: Children were evenly divided by sex and had a mean age of 5.8 years. Twenty-nine percent of children and 86% of parents were overweight or obese. Approximately 33% (n = 138) of parents underclassified and 7% (n = 29) of parents overclassified their child's weight status. Higher parental weight status and higher concern about their child's weight status increased the probability of underclassification (P for trend = .02 for both). CONCLUSION: In this sample of at-risk children, one-third of parents underclassified their child's weight status. Childhood obesity prevention programs need to increase awareness and recognition of childhood obesity and address parental weight issues.

Summer effects on body mass index (BMI) gain and growth patterns of American Indian children from kindergarten to first grade: a prospective study.

BACKGROUND: Overweight and obesity are highly prevalent among American Indian children, especially those living on reservations. There is little scientific evidence about the effects of summer vacation on obesity development in children. The purpose of this study was to investigate the effects of summer vacation between kindergarten and first grade on growth in height, weight, and body mass index (BMI) for a sample of American Indian children. METHODS: Children had their height and weight measured in four rounds of data collection (yielded three intervals: kindergarten, summer vacation, and first grade) as part of a school-based obesity prevention trial (Bright Start) in a Northern Plains Indian Reservation. Demographic variables were collected at baseline from parent surveys. Growth velocities (Z-score units/year) for BMI, weight, and height were estimated and compared for each interval using generalized linear mixed models. RESULTS: The children were taller and heavier than median of same age counterparts. Height Z-scores were positively associated with increasing weight status category. The mean weight velocity during summer was significantly less than during the school year. More rapid growth velocity in height during summer than during school year was observed. Obese children gained less adjusted-BMI in the first grade after gaining more than their counterparts during the previous two intervals. No statistically significant interval effects were found for height and BMI velocities. CONCLUSIONS: There was no indication of a significant summer effect on children's BMI. Rather than seasonal or school-related patterns, the predominant pattern indicated by weight-Z and BMI-Z velocities might be related to age or maturation. TRIAL REGISTRATION: Bright Start: Obesity Prevention in American Indian Children Clinical Trial Govt ID# NCT00123032.

Associations of American Indian children's screen-time behavior with parental television behavior, parental perceptions of children's screen time, and media-related resources in the home.

INTRODUCTION: American Indian children have high rates of overweight and obesity, which may be partially attributable to screen-time behavior. Young children's screen-time behavior is strongly influenced by their environment and their parents' behavior. We explored whether parental television watching time, parental perceptions of children's screen time, and media-related resources in the home are related to screen time (ie, television, DVD/video, video game, and computer use) among Oglala Lakota youth residing on or near the Pine Ridge Reservation in South Dakota. METHODS: We collected baseline data from 431 child and parent/caregiver pairs who participated in Bright Start, a group-randomized, controlled, school-based obesity prevention trial to reduce excess weight gain. Controlling for demographic characteristics, we used linear regression analysis to assess associations between children's screen time and parental television watching time, parental perceptions of children's screen time, and availability of media-related household resources. RESULTS: The most parsimonious model for explaining child screen time included the children's sex, parental body mass index, parental television watching time, how often the child watched television after school or in the evening, parental perception that the child spent too much time playing video games, how often the parent limited the child's television time, and the presence of a VCR/DVD player or video game player in the home (F(7,367) = 14.67; P < .001; adjusted R(2) = .37). The presence of a television in the bedroom did not contribute significantly to the model. CONCLUSION: Changes in parental television watching time, parental influence over children's screen-time behavior, and availability of media-related resources in the home could decrease screen time and may be used as a strategy for reducing overweight and obesity in American Indian children.

Factors influencing choice of medical vs. surgical treatment of pediatric appendicitis.

PURPOSE: To examine what proportion of caregivers, if given a choice, would choose medical versus surgical treatment of appendicitis and what factors would be important in their decision. METHODS: A survey was devised and given to the caregivers of children presenting to the pediatrician for a routine visit in community and academic pediatric clinics. The survey presented a summary of outcomes after medical (non-operative) and surgical treatment of uncomplicated appendicitis. Participants were then asked to choose medical versus surgical treatment if their child were to develop appendicitis. They were also asked to rate the importance of certain factors in their decision -1 being "not important" and 5 being "very important". RESULTS: Four hundred surveys were distributed with an 86.2% (345/400) response rate. Six percent (21/342) of respondents reported a history of appendicitis and 49.4% (168/340) reported having known someone who had appendicitis. The majority of respondents, 85.3% (284/333), were mothers. A minority of respondents, 41.7% (95% CI: 36.7, 47.0), chose medical treatment over surgery for appendicitis. There was no statistical difference in the proportion of mothers (41.6%) versus fathers who chose medical treatment (41.3%). Caregivers who chose medical treatment were more likely to rate time in hospital (p = .008) and time out of school (p = 05) as important in decision making when compared with those who chose surgery. Those who chose surgical treatment were more likely to rate risk of recurrent appendicitis (p < .001) as important to decision making. In the multivariate analysis, those who rated time in hospital as very important had more than twice the odds of choosing medical therapy (OR 2.20, p = 0.02) when compared with those who rated it as less important. Not knowing someone who has had appendicitis was significantly associated with choosing medical therapy when compared with those who do know someone who has had appendicitis, OR 2.3, p = .002. Rating pain as very important was also significantly associated with choosing medical therapy, when compared to those rating pain 1-3, OR 3.38, p = .03. CONCLUSIONS: In this survey of caregivers of children presenting for routine care, 41.7% would choose medical, or non-operative, therapy for their children with acute appendicitis. The risk of recurrence, time in hospital, and time out of school, pain, and knowing someone who has had appendicitis were all important factors that families may consider when making a decision. These data may be useful for surgeons counseling patients on which treatment to pursue.

Verbal coding and the storage of form-position associations in visual-spatial short-term memory.

Short-term memory for form-position associations was assessed using an object relocation task. Participants attempted to remember the positions of either three or five Japanese Kanji characters, presented on a computer monitor. Following a short blank interval, participants were presented with 2 alternative Kanji, only 1 of which was present in the initial stimulus, and the set of locations occupied in the initial stimulus. They attempted to select the correct item and relocate it back to its original position. The proportion of correct item selections showed effects of both articulatory suppression and memory load. In contrast, the conditional probability of location given a correct item selection showed an effect of load but no effect of suppression. These results are consistent with the proposal that access to visual memory is aided by verbal recoding, but that there is no verbal contribution to memory for the association between form and position.

Maintenance of the classroom health education curricula: results from the CATCH-ON study.

Maintenance of the interactive Child and Adolescent Trial for Cardiovascular Health (CATCH) third- to fifth-grade curricula was studied in the 56 original intervention schools and 20 of the original control schools 5 years postintervention in four regions of the United States. Target grade teachers completed a self-administered survey that included questions regarding use of the CATCH materials, training in CATCH or other health education, barriers and perceived support for health education, and amount of health education currently taught. Percentage of teachers who continued to teach CATCH in the classroom was low; however, percentages were significantly higher in former intervention compared with control schools, even though control schools received training and materials following the main field trial. The results of this study can provide useful information for future development of classroom health promotion materials with a higher level of sustainability.

Developmental coordination impairments in adulthood.

The aim of this study was to extend the understanding of Developmental Coordination Disorder (DCD) into adulthood. We recruited 19 adults aged between 18 and 65 who had received diagnoses of DCD or dyspraxia or who self-reported as having motor impairments consistent with a history of DCD, together with age- and gender-matched controls. Participants were given tests of manual dexterity, handwriting, construction, obstacle avoidance, dynamic balance, static balance, dual task performance, ball skills, reaction time, movement time and sequencing. As a group, adults with DCD performed more poorly than controls across all tasks. Slowness and variability of movement was a pervasive feature of their performance and many individuals had considerable problems with sequencing and with dual task performance. A discriminant function analysis conducted using six performance measures correctly classified participants as car drivers or non-drivers. Adults do retain motor difficulties and these can exclude them from important activities of daily living.

Two distinct pathways for developmental coordination disorder: persistence and resolution.

This article describes the perceptual motor, educational and social outcome of early motor delay in a group of 17-18 year old Finnish adolescents who were originally evaluated at age 5. The study group consisted of 65 adolescents: 22 with significant motor problems (or developmental coordination disorder, DCD), 23 with minor motor problems (intermediate group) and 20 controls. The goal of this study was to reassess the results obtained when they were age 15 and to determine whether the variables used earlier could still discriminate the adolescents at age 17. The results showed that at age 17 all perceptual motor tasks differentiated the three groups. The DCD group performed less well than the control group on all tasks, with the intermediate group situated between these two. Discriminant function analyses showed that more classification errors occurred between the control and intermediate groups at age 17 than at age 15, suggesting that the distinction between these groups becomes more difficult with age. In the educational domain, similar to the findings at age 15, the adolescents with DCD had the lowest WAIS scores and shortest school careers of the three groups. In the social domain, as found two years earlier, the DCD group had the lowest perceptions of athletic and scholastic competence while the intermediate and control groups did not differ. In addition, the interview results indicated that the three groups were in different stages of identity development. In sum, the outcome at age 17 was a replication of the results obtained at age 15 and suggests two developmental paths for those with early perceptual motor problems: 'persistence' and 'catching up'.

An after-school obesity prevention program for African-American girls: the Minnesota GEMS pilot study.

OBJECTIVE: This paper describes the development of an after-school obesity-prevention program for African-American girls, and presents findings from a 12-week pilot trial conducted by the University of Minnesota. This study was part of the GEMS project, created to test interventions designed to reduce excess weight gain in African-American girls. DESIGN: Two-arm parallel group, randomized controlled trial. Measures were taken at baseline and at 12 weeks follow up. SETTING: An after-school community program. PARTICIPANTS: Fifty-four African-American girls, 8- to 10-years of age, and their parents/caregivers. INTERVENTION: The after-school intervention was conducted twice a week for 12 weeks, and focused on increasing physical activity and healthy eating. A family component was also included. Girls in the control group received a program over 12 weeks unrelated to nutrition and physical activity. OUTCOMES: Measures included height and weight (body mass index), percent body fat (DEXA), physical activity, assessed using a CSA accelerometer and self-report, two 24-hour dietary recalls, and psycho-social and demographic variables. Parental data included demographic and psycho-social characteristics, and dietary measures. Additionally, process evaluation data on the intervention were collected. RESULTS: Recruitment goals were met. After adjustment for baseline level, follow-up BMI did not differ between the treatment groups, an expected finding, given that this was a pilot study. At 12 weeks follow up, differences between the intervention and control groups were in the hypothesized direction of change for most variables, among both the girls and their parents. Process evaluation results demonstrated that the program was well attended, and well received, by girls and parents. CONCLUSIONS: An after-school obesity prevention program for low-income African-American girls is a promising model for future efforts.

Development of prehension between 5 and 10 years of age: distance scaling, grip aperture, and sight of the hand.

The authors investigated whether 5- to 10-year-old children (N = 75) differ from adults (N = 12) in the developmental course of distance scaling and the adaptations to the inability to see the hand during prehension movements. The children reached under a surface and grasped and lifted an object suspended through it. All children scaled velocity appropriately for movement distance, both with and without sight of the hand. However, 5- to 6-year-old children did not increase grip aperture with increased distance, whereas older children and adults did. The older children and adults spent longer after peak deceleration when they could not see the hand, and maximum grip aperture (MGA) was larger, providing an increased safety margin. Children aged 5 to 6 spent the same amount of time between peak deceleration and grasp, whether or not they could see the hand, and they failed to increase MGA when they could not see the hand. Prehension in the younger children differed from that of older children in two ways: The younger children did not integrate reach and grasp over different distances and did not use visual information about hand position to optimize accuracy.

The natural history of jaundice in predominantly breastfed infants.

BACKGROUND AND OBJECTIVES: Breastfed newborns are more likely to develop prolonged hyperbilirubinemia than those fed formula, but the prevalence of prolonged hyperbilirubinemia in a largely white, North American breastfed population is unknown. In this population, we documented the natural history of jaundice and the prevalence of prolonged hyperbilirubinemia, and we evaluated the utility of assessing the cephalocaudal progression of jaundice in office-based practices. METHODS: We measured transcutaneous bilirubin (TcB) levels during the first month in 1044 predominantly breastfed infants ≥35 weeks of gestation and assigned a cephalocaudal zone score to each infant at the time of the TcB measurement. RESULTS: TcB level was ≥5 mg/dL in 43% of infants at age 21 ± 3 days and 34% were clinically jaundiced. At 28 ± 3 days, the TcB was ≥5 mg/dL in 34% and 21% were jaundiced. There was a strong correlation between the TcB level and the jaundice zone score, but there was a wide range of TcB levels associated with each score. CONCLUSIONS: Practitioners can be reassured that it is normal for 20% to 30% of predominantly breastfed newborns to be jaundiced at age 3 to 4 weeks and for 30% to 40% of these infants to have bilirubin levels ≥5 mg/dL. The jaundice zone score does not provide an accurate assessment of the bilirubin level, but a score of zero (complete absence of jaundice) suggests that the level is unlikely to be >12.9 mg/dL, whereas a score of ≥4 usually predicts a level of ≥10 mg/dL.

Intervention effects on kindergarten and first-grade teachers' classroom food practices and food-related beliefs in American Indian reservation schools.

Prevalence of obesity among American Indian children is higher than the general US population. The school environment and teachers play important roles in helping students develop healthy eating habits. The aim of this prospective study was to examine teachers' classroom and school food practices and beliefs and the effect of teacher training on these practices and beliefs. Data were used from the Bright Start study, a group-randomized, school-based trial that took place on the Pine Ridge American Indian reservation (fall 2005 to spring 2008). Kindergarten and first-grade teachers (n=75) from 14 schools completed a survey at the beginning and end of the school year. Thirty-seven survey items were evaluated using mixed-model analysis of variance to examine the intervention effect for each teacher-practice and belief item (adjusting for teacher type and school as random effect). At baseline, some teachers reported classroom and school food practices and beliefs that supported health and some that did not. The intervention was significantly associated with lower classroom use of candy as a treat (P=0.0005) and fast-food rewards (P=0.008); more intervention teachers disagreed that fast food should be offered as school lunch alternatives (P=0.019), that it would be acceptable to sell unhealthy foods as part of school fundraising (P=0.006), and that it would not make sense to limit students' food choices in school (P=0.035). School-based interventions involving teacher training can result in positive changes in teachers' classroom food practices and beliefs about the influence of the school food environment in schools serving American Indian children on reservations.

Asynchrony in discrete bimanual aiming: evidence for visual strategies of coordination.

The bimanual coupling literature supposes an inherent drive for synchrony between the upper limbs when making discrete bimanual movements. The level of synchrony is argued to be task dependent, reliant on the visual demands of the two targets, and the result of a complex pattern of hand and eye movements (Bingham, Hughes, & Mon-Williams, 2008 ; Riek, Tresilian, Mon-Williams, Coppard, & Carson, 2003). However, recent work by Bruyn and Mason (2009) suggests that temporal coordination is not solely influenced by visual saccades. In this experimental series, a total of 8 participants performed congruent movements to targets either near or far from the midline. Targets far from the midline, requiring a visual saccade, resulted in greater terminal asynchrony. Initial and terminal asynchrony were not consistent, but linked to the task demands at that stage of the movement. If the asynchrony evident at the end of a bimanual movement is due to a complex pattern of hand and eye movements then the removal of visual feedback should result in an increase in synchrony. Sixteen participants then completed congruent and incongruent bimanual aiming movements to near and/or far targets. Movements were made with or without visual feedback of hands and targets. Analyses revealed that movements made without visual feedback showed increased synchrony between the limbs, yet movements to incongruent targets still showed greater asynchrony. We suggest that visual constraints are not the sole cause of asynchrony in discrete bimanual movements.

Bright Start: Description and main outcomes from a group-randomized obesity prevention trial in American Indian children.

The aim of the Bright Start study was to develop and test the effectiveness of a school environment intervention, supplemented with family involvement, to reduce excessive weight gain by increasing physical activity and healthy eating practices among kindergarten and first-grade American Indian children. Bright Start was a group-randomized, school-based trial involving 454 children attending 14 schools on the Pine Ridge Reservation in South Dakota. Children were followed from the beginning of their kindergarten year through the end of first grade. Main outcome variables were mean BMI, mean percent body fat, and prevalence of overweight/obese children. The goals of the intervention were to: increase physical activity at school to at least 60 min/day; modify school meals and snacks; and involve families in making behavioral and environmental changes at home. At baseline, 32% of boys and 25% of girls were overweight/obese. Although the intervention was not associated with statistically significant change in mean levels of BMI, BMI-Z, skinfolds or percentage body fat, the intervention was associated with a statistically significant net decrease of 10% in the prevalence of overweight. Intervention children experienced a 13.4% incidence of overweight, whereas the control children experienced a corresponding incidence of 24.8%; a difference of -11.4% (P = 0.033). The intervention significantly reduced parent-reported mean child intakes of sugar-sweetened beverages, whole milk, and chocolate milk. Changes in duration of school physical activity were not significant. Because obesity is the most daunting health challenge facing American Indian children today, more intervention research is needed to identify effective approaches.

Hebb repetition effects in visual memory: the roles of verbal rehearsal and distinctiveness.

A version of the Hebb repetition task was used with faces to explore the generality of the effect in a nonverbal domain. In the baseline condition, a series of upright faces was presented, and participants were asked to reconstruct the original order. Performance in this condition was compared to another in which the same stimuli were accompanied by concurrent verbal rehearsal to examine whether Hebb learning is dependent on verbal processing. Baseline performance was also compared to a condition in which the same faces were presented inverted. This comparison was used to determine the importance in Hebb learning of being able to visually distinguish between the list items. The results produced classic serial position curves that were equivalent over conditions with Hebb repetition effects being in evidence only for upright faces and verbal suppression as having no effect. These findings are interpreted as posing a challenge to current models derived from verbal-domain data.