Screening Accuracy of BMI for Adiposity Among 8- to 19-Year-Olds.

BACKGROUND AND OBJECTIVES: Although the limitations of BMI have long been recognized, there are recent concerns that it is not a good screening tool for adiposity. We therefore examined the cross-sectional relation of BMI to adiposity among 6923 8- to 19-year-olds in the National Health and Nutrition Survey from 2011 through 2018. METHODS: Participants were scanned with dual-energy x-ray absorptiometry. Adiposity was expressed as fat mass index (FMI, fat mass kg ÷ m2) and percentage of body fat (%fat). Lean mass was expressed as lean mass index (LMI, lean mass ÷ m2). Regression models and 2 × 2 tables were used to assess the relation of BMI to FMI, %fat, and LMI. RESULTS: Age and BMI accounted (R2) for 90% to 94% of the variability of FMI and LMI in each sex. Associations with %fat were weaker (R2s ∼0.70). We also examined the screening abilities of a BMI ≥ Centers for Disease Control and Prevention 95th percentile for high levels of adiposity and LMI. Cut points were chosen so that prevalences of high values of these variables would be similar to that for high BMI. Of participants with a high BMI, 88% had a high FMI, and 76% had a high %fat. Participants with a high BMI were 29 times more likely to have a high FMI than those with lower BMIs; comparable relative risks were 12 for high %fat and 14 for high LMI. CONCLUSIONS: Despite its limitations, a high BMI is a very good screening tool for identifying children and adolescents with elevated adiposity.

Differing prevalence of microcephaly and macrocephaly in male and female fetuses.

Objective: To compare the proportion of female and male fetuses classified as microcephalic (head circumference [HC] < 3rd percentile) and macrocephalic (>97th percentile) by commonly used sex-neutral growth curves. Methods: For fetuses evaluated at a single center, we retrospectively determined the percentile of the first fetal HC measurement between 16 and 0/7 and 21-6/7 weeks using the Hadlock, Intergrowth-21st, and NICHD growth curves. The association between sex and the likelihood of being classified as microcephalic or macrocephalic was evaluated with logistic regression. Results: Female fetuses (n = 3,006) were more likely than male fetuses (n = 3,186) to be classified as microcephalic using the Hadlock (0.4% male, 1.4% female; odds ratio female vs. male 3.7, 95% CI [1.9, 7.0], p < 0.001), Intergrowth-21st (0.5% male, 1.6% female; odds ratio female vs. male 3.4, 95% CI [1.9, 6.1], p < 0.001), and NICHD (0.3% male, 1.6% female; odds ratio female vs. male 5.6, 95% CI [2.7, 11.5], p < 0.001) curves. Male fetuses were more likely than female fetuses to be classified as macrocephalic using the Intergrowth-21st (6.0% male, 1.5% female; odds ratio male vs. female 4.3, 95% CI [3.1, 6.0], p < 0.001) and NICHD (4.7% male, 1.0% female; odds ratio male vs. female 5.1, 95% CI [3.4, 7.6], p < 0.001) curves. Very low proportions of fetuses were classified as macrocephalic using the Hadlock curves (0.2% male, < 0.1% female; odds ratio male vs. female 6.6, 95% CI [0.8, 52.6]). Conclusion: Female fetuses were more likely to be classified as microcephalic, and male fetuses were more likely to be classified as macrocephalic. Sex-specific fetal head circumference growth curves could improve interpretation of fetal head circumference measurements, potentially decreasing over- and under-diagnosis of microcephaly and macrocephaly based on sex, therefore improving guidance for clinical decisions. Additionally, the overall prevalence of atypical head size varied using three growth curves, with the NICHD and Intergrowth-21st curves fitting our population better than the Hadlock curves. The choice of fetal head circumference growth curves may substantially impact clinical care.

Provider Perspectives of Transitions of Care at a Tertiary Care Children's Hospital With a Hospitalist-Run Discharge Clinic.

Children's hospitals are discharging patients to home with increasingly complex outpatient needs, making safe transitions of care (ToCs) of vital importance. Our study involved a survey of both outpatient providers and pediatric hospitalists associated with our medical center to better describe providers' views on the ToC process. The survey included questions assessing views on patient care responsibilities, resource availability, our hospitalist-run postdischarge clinic (PDC), and comfort with telemedicine. Our hospitalists generally believed that primary care providers (PCPs) did not have adequate access to important ToC elements, whereas PCPs felt their access was adequate. Both provider types felt it was the inpatient team's responsibility to manage patient events between discharge and PCP follow-up and that a hospitalist-run PDC may reduce interim emergency room visits. This study challenges perceptions about the ToC process in children and describes a generalizable approach to assessing provider perceptions surrounding the ToC within individual health systems.

The past, present, and future of child growth monitoring: A review and primer for clinical genetics.

Child growth measurements are critical vital signs to track, with every individual child growth curve potentially revealing a story about a child's health and well-being. Simply put, every baby born requires basic building blocks to grow and thrive: proper nutrition, love and care, and medical health. To ensure that every child who is missing one of these vital aspects is identified, growth is traditionally measured at birth and each well-child visit. While the blue and pink growth curves appear omnipresent in pediatric clinics, it is surprising to realize that their use only became standard of care in 1977 when the National Center for Health Statistics (NCHS) adopted the growth curve as a clinical tool for health. Behind this practice lies a socioeconomically, culturally, and politically complex interplay of individuals and institutions around the world. In this review, we highlight the often forgotten past, current state of practice, and future potential of this powerful clinical tool: the growth reference chart, with a particular focus on clinical genetics practice. The goal of this article is to understand ongoing work in the field of anthropometry (the scientific study of human measurements) and its direct impact on modern pediatric and genetic patient care.

Evaluation of Income and Food Insecurity as Risk Factors for Failure to Thrive: An Analysis of National Survey Data.

Limited data exist regarding the relationship between socioeconomic risk factors and failure to thrive (FTT). Using data from the National Health and Nutrition Examination Survey (NHANES) from years 1999 to 2014, we sought to determine whether there was a higher prevalence of underweight (<5th percentile weight-for-age [WFA], weight-for-length [WFL], or body mass index-for-age [BFA]), and, therefore, likely a higher risk of FTT, in US children <3 years with low household income or food insecurity compared with children without these factors. Among 7356 evaluated children, there were no significant differences in the prevalence of underweight by adjusted household income quintile, food security, household Women, Infants, and Children (WIC) status, or federal poverty income ratio. These findings do not support a link between low income or food security and underweight in children and, therefore, do not provide support for an association between low income or food security and FTT.

Intraarticular steroids as DMARD-sparing agents for juvenile idiopathic arthritis flares: Analysis of the Childhood Arthritis and Rheumatology Research Alliance Registry

BACKGROUND: Children with juvenile idiopathic arthritis (JIA) who achieve a drug free remission often experience a flare of their disease requiring either intraarticular steroids (IAS) or systemic treatment with disease modifying anti-rheumatic drugs (DMARDs). IAS offer an opportunity to recapture disease control and avoid exposure to side effects from systemic immunosuppression. We examined a cohort of patients treated with IAS after drug free remission and report the probability of restarting systemic treatment within 12 months. METHODS: We analyzed a cohort of patients from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry who received IAS for a flare after a period of drug free remission. Historical factors and clinical characteristics and of the patients including data obtained at the time of treatment were analyzed. RESULTS: We identified 46 patients who met the inclusion criteria. Of those with follow up data available 49% had restarted systemic treatment 6 months after IAS injection and 70% had restarted systemic treatment at 12 months. The proportion of patients with prior use of a biologic DMARD was the only factor that differed between patients who restarted systemic treatment those who did not, both at 6 months (79% vs 35%, p < 0.01) and 12 months (81% vs 33%, p < 0.05). CONCLUSION: While IAS are an option for all patients who flare after drug free remission, it may not prevent the need to restart systemic treatment. Prior use of a biologic DMARD may predict lack of success for IAS. Those who previously received methotrexate only, on the other hand, are excellent candidates for IAS.

Weight gain among US adults during the COVID-19 pandemic through May 2021.

OBJECTIVE: There have been conflicting reports concerning weight gain among adults during the COVID-19 epidemic. Although early studies reported large weight increases, several of these analyses were based on convenience samples or self-reported information. The objective of the current study is to examine the pandemic-related weight increase associated with the pandemic through May 2021. METHODS: A total of 4.25 million adults (18 to 84 years) in an electronic health record database who had at least two weight measurements between January 2019 and February 2020 and one after June 2020 were selected. Weight changes before and after March 2020 were contrasted using mixed-effects regression models. RESULTS: Compared with the pre-pandemic weight trend, there was a small increase (0.1 kg) in weight in the first year of the pandemic (March 2020 through March 2021). Weight changes during the pandemic varied by sex, age, and initial BMI, but the largest mean increase across these characteristics was < 1.3 kg. Weight increases were generally greatest among women, adults with BMI of 30 or 35 kg/m2 , and younger adults. CONCLUSIONS: The results indicate that the mean weight gain among adults during the COVID-19 pandemic may be small.

Improving Hospital Infant Safe Sleep Compliance by Using Safety Prevention Bundle Methodology.

BACKGROUND AND OBJECTIVES: Sudden unexpected infant death often results from unsafe sleep environments and is the leading cause of postneonatal mortality in the United States. Standardization of infant sleep environment education has been revealed to impact such deaths. This standardized approach is similar to safety prevention bundles typically used to monitor and improve health outcomes, such as those related to hospital-acquired conditions (HACs). We sought to use the HAC model to measure and improve adherence to safe sleep guidelines in an entire children's hospital. METHODS: A hospital-wide safe sleep bundle was implemented on September 15, 2017. A safe sleep performance improvement team met monthly to review data and discuss ideas for improvement through the use of iterative plan-do-study-act cycles. Audits were performed monthly from March 2017 to October 2019 and monitored safe sleep parameters. Adherence was measured and reviewed through the use of statistical process control charts (p-charts). RESULTS: Overall compliance improved from 9% to 72%. Head of bed flat increased from 62% to 93%, sleep space free of extra items increased from 52% to 81%, and caregiver education completed increased from 10% to 84%. The centerline for infant in supine position remained stable at 81%. CONCLUSIONS: Using an HAC bundle safety prevention model to improve adherence to infant safe sleep guidelines is a feasible and effective method to improve the sleep environment for infants in all areas of a children's hospital.

The Relation of Adiposity Rebound to Subsequent BMI in a Large Electronic Health Record Database.

Objective: The beginning of postinfancy increase in BMI has been termed the adiposity rebound, and an early rebound increases the risk for obesity in adolescence and adulthood. We examined whether the relation of the age at BMI rebound (agerebound) to subsequent BMI is independent of childhood BMI. Design: From the electronic health records of 2.8 million children, we selected 17,077 children examined at least once each year between ages 2 and <8 years, and who were reexamined between age 10 and <16 years. The mean age at the last visit was 12 years (SD = 1). We identified agerebound for each child using lowess, a smoothing technique. Results: Children who had an agerebound <3 years were, on average, 6.8 kg/m2 heavier after age 10 years than were children with an agerebound >7 years. However, BMI after age 10 years was more strongly associated with BMI at the rebound (BMIrebound) than with agerebound (r = 0.63 vs. -0.49). Although the relation of agerebound to BMI at the last visit was mostly independent of the BMIrebound, adjustment for age-5 BMI reduced the association's magnitude by about 55%. Conclusions: Both agerebound and the BMIrebound are independently related to BMI and obesity after age 10 years. However, a child's BMIrebound and at ages 5 and 7 years accounts for more of the variability in BMI levels after age 10 years than does agerebound.

Elevated Heart Rate and Risk of Revisit With Admission in Pediatric Emergency Patients.

OBJECTIVE: The aim of this study was to identify emergency department (ED) heart rate (HR) values that identify children at elevated risk of ED revisit with admission. METHODS: We performed a retrospective cohort study of patients 0 to 18 years old discharged from a tertiary-care pediatric ED from January 2013 to December 2014. We created percentile curves for the last recorded HR for age using data from calendar year 2013 and used receiver operating characteristic (ROC) curves to characterize the performance of the percentiles for predicting ED revisit with admission within 72 hours. In a held-out validation data set (calendar year 2014 data), we evaluated test characteristics of last-recorded HR-for-age cut points identified as promising on the ROC curves, as well as those identifying the highest 5% and 1% of last recorded HRs for age. RESULTS: We evaluated 183,433 eligible ED visits. Last recorded HR for age had poor discrimination for predicting revisit with admission (area under the curve, 0.61; 95% confidence interval, 0.58-0.63). No promising cut points were identified on the ROC curves. Cut points identifying the highest 5% and 1% of last recorded HRs for age showed low sensitivity (10.1% and 2.5%) with numbers needed to evaluate of 62 and 50, respectively, to potentially prevent 1 revisit with admission. CONCLUSIONS: Last recorded ED HR discriminates poorly between children who are and are not at risk of revisit with admission in a pediatric ED. The use of single-parameter HR in isolation as an automated trigger for mandatory reevaluation prior to discharge may not improve revisit outcomes.

The Longitudinal Relation of Childhood Height to Subsequent Obesity in a Large Electronic Health Record Database.

OBJECTIVE: Several cross-sectional studies have shown that height in childhood is correlated with BMI and with body fatness, and two longitudinal studies have reported that childhood height is associated with adult BMI. This study explored this longitudinal association in an electronic health record database of 2.8 million children. METHODS: Children were initially examined between the ages of 2 and 13.9 years and, on average, were reexamined 4 years later. RESULTS: As expected, there was a cross-sectional correlation between height-for-age z score and BMI that increased from r = -0.06 (age of 2 years) to r = 0.37 (age of 9-10 years). In addition, height-for-age at the first visit was related to subsequent BMI and obesity, with the prevalence of subsequent obesity increasing about fourfold over six categories of height-for-age at the first visit. About 40% of this longitudinal association was independent of initial BMI, but its magnitude decreased with initial age. For example, the initial height-for-age of children who were 12 years of age or older was only weakly associated with subsequent BMI. CONCLUSIONS: Health professionals should recognize that greater childhood height-for-age before 12 years of age may be a marker for increased risk of subsequent obesity.

The association of body mass index and severe early childhood caries in young children in Winnipeg, Manitoba: A cross-sectional study.

BACKGROUND: Associations between body mass index (BMI) and caries have been reported. AIM: To evaluate the direction of the relationship between BMI and severe early childhood caries (S-ECC). DESIGN: Children were recruited as part of a larger prospective cohort study assessing changes in nutritional status following dental rehabilitation under general anaesthetic. Pre-operative anthropometric measurements were used to calculate BMI z-scores (BMIz). Operative reports were reviewed to calculate caries scores based on treatment rendered. Analysis included descriptive statistics, bivariate analyses, and simple and multiple linear regression. RESULTS: Overall, 150 children were recruited with a mean age of 47.7 ± 14.2 (SD) months; 52% female. Over 42% were at risk for overweight, overweight or obese. Although simple linear regression demonstrated a significant positive association between dmfs score and BMIz, adjusted multiple linear regression found no significant relationship between BMIz and dmfs, but highlighted a relationship between BMI z-score and family income, Registered First Nations Status and physical activity. CONCLUSIONS: Although a significant relationship between BMI and S-ECC was not found, poverty was a key confounding variable. As both S-ECC and obesity are known predictors of future disease, it is important for healthcare professionals to identify children at risk. Diet and behaviour modification may play a role in disease prevention.

Clinician Diagnoses of Failure to Thrive Before and After Switch to World Health Organization Growth Curves.

OBJECTIVE: To evaluate change in the incidence of failure to thrive (FTT) based on selected growth percentile criteria and diagnostic codes before and after a switch in growth curves. METHODS: We performed a retrospective cohort study of children 2 to 24 months of age in a large primary care network that switched its default growth curve from the Centers for Disease Control and Prevention (CDC) reference to the World Health Organization (WHO) standards in 2012. We compared the incidence of FTT defined by growth percentile criteria (using the default growth curve at the time of each measurement) and by International Classification of Diseases, Ninth Revision, codes in the 3 years before and after the CDC-WHO switch using an interrupted time series analysis. We performed these analyses stratified by age group (≤6 months and >6-24 months). RESULTS: We evaluated 83,299 children. Among those ≤6 months, increases in FTT incidence were found in both growth-percentile and clinician-diagnosis criteria at the CDC-WHO switch (P < .05). Among those >6 to 24 months, decreases in FTT incidence were found by growth-percentile criteria at the CDC-WHO switch (P < .05), but no significant changes were found in FTT incidence by diagnostic codes. CONCLUSIONS: When switching from the CDC to the WHO growth curves, changes in the incidence of FTT by growth-percentile and clinician-diagnosis criteria differed for younger versus older infants. Factors beyond growth likely influence the decision to diagnose a child as having FTT and may differ in younger compared to older infants.

Oral Health-Related Quality of Life of Canadian Preschoolers with Severe Caries After Dental Rehabilitation Under General Anesthesia.

Purpose: The purpose was to determine changes in the oral health-related quality-of-life (OHRQoL) of children with severe early childhood caries (S-ECC) following dental rehabilitation under general anesthesia (DRGA). Methods: This prospective cohort study involved caregivers completing questionnaires, including the Early Childhood Oral Health Impact Scale (ECOHIS). Data analysis included descriptive statistics, bivariate analyses, effect size, and multiple linear regression. Results: Initially, 150 children were enrolled, mean age of 47.7±14.2 (SD) months. The baseline mean total ECOHIS score was 6.3±5.3. Higher baseline ECOHIS scores were associated with single-parent families, low-income house-holds, higher decayed, missing, and filled primary teeth (dmft) scores, and having extractions (P ≤ 0.05). Multiple linear regression results showed low household income (P=0.01) and the child not having Registered First Nation status (a specific population of Indigenous Canadians; P=0.03) were significantly and independently associated with higher total baseline ECOHIS scores. At follow-up, 103 children had a mean total ECOHIS score of 3.5±2.9 versus a baseline score of 6.3±5.4. Change in total ECOHIS and three of four Child Impact Section domains showed significant improvement (P<0.001) post-DRGA. Worse follow-up ECOHIS scores were only associated with the child being male (P=0.02). Conclusions: Improvements in oral health-related quality of life were observed following DRGA. Consideration should be given for using the Early Childhood Oral Health Impact Scale to help prioritize children waiting for DRGA. (Pediatr Dent 2019;41(3):221-8) Received November 22, 2018 | Last Revision February 28, 2019 | Accepted April 1, 2019.

Failure to Thrive: An Expanded Differential Diagnosis.

The patient is a term 6-month-old male, who presented with failure to thrive since birth. History was remarkable for suspected milk and soy protein allergy, gastroesophageal reflux, constipation, and abdominal distension that was present since birth. He was losing weight despite oral intake of over 100 kcal/kg per day. Prior workup including laboratory studies, abdominal X-ray, upper gastrointestinal series with fluoroscopy, barium enema, and abdominal ultrasound were all within normal limits. The patient's history, diagnostic evaluation, and final diagnosis are revealed. This case highlights a rare condition presenting as failure to thrive, a common problem with a wide differential diagnosis.

Longitudinal growth in patients with single ventricle cardiac disease receiving tube-assisted feeds.

OBJECTIVE: Children with single ventricle cardiac disease (SVCD) have poor growth in early life. Tube-assisted feeding (TF) is used to improve weight gain, but its impact on long-term growth remains unknown. We sought to compare the longitudinal growth of SVCD patients receiving TF after initial cardiac surgery with those fed entirely by mouth. DESIGN: We conducted a retrospective cohort study of SVCD patients who underwent initial surgical palliation between 1999 and 2009. We defined TF as the use of nasogastric, gastrostomy, or jejunostomy TF. We compared maximal attained growth z-scores for each year of life between TF and non-TF patients. A secondary analysis compared surgical and clinical factors between groups. RESULTS: A total of 134 patients were included; 64% were male and 68% underwent the Norwood operation. One third of patients (44) received TF. Adjusting for age, TF patients had an average of 0.56 lower weight-for-age z-score (WAZ) than non-TF patients (P = 0.007) through the age of 6 years. Longitudinal height was not affected by TF status (P = 0.15). In a subanalysis of Norwood patients, TF patients had lower WAZ at initial hospital discharge despite longer LOS. TF patients had diminished WAZ after adjusting for complications, interstage hospitalizations, and timing of subsequent operations. CONCLUSIONS: In this single-center study, patients with SVCD requiring TF at discharge from initial surgical palliation had diminished WAZ at discharge and on long-term follow-up, despite controlling for other identifiable risk factors. Further investigation is needed to understand the mechanisms underlying this phenomenon and to risk stratify infants who go home on TF.