Brief Primary Care Obesity Interventions: A Meta-analysis.

Leslie A. Sim, Jocelyn Lebow, Zhen Wang, Afton Koball, M. Hassan Murad.

CONTEXT: Although practice guidelines suggest that primary care providers working with children and adolescents incorporate BMI surveillance and counseling into routine practice, the evidence base for this practice is unclear.
OBJECTIVE: To determine the effect of brief, primary care interventions for pediatric weight management on BMI.
DATA SOURCES: Medline, CENTRAL, Embase, PsycInfo, and CINAHL were searched for relevant publications from January 1976 to March 2016 and cross-referenced with published studies.

STUDY SELECTION: Eligible studies were randomized controlled trials and quasi-experimental studies that compared the effect of office-based primary care weight management interventions to any control intervention on percent BMI or BMI z scores in children aged 2 to 18 years.
DATA EXTRACTION: Two reviewers independently screened sources, extracted data on participant, intervention, and study characteristics, z-BMI/percent BMI, harms, and study quality using the Cochrane and Newcastle-Ottawa risk of bias tools.

RESULTS: A random effects model was used to pool the effect size across eligible 10 randomized controlled trials and 2 quasi-experimental studies. Compared with usual care or control treatment, brief interventions feasible for primary care were associated with a significant but small reduction in BMI z score (–0.04, [95% confidence interval, –0.08 to –0.01]; P = .02) and a nonsignificant effect on body satisfaction (standardized mean difference 0.00, [95% confidence interval, –0.21 to 0.22]; P = .98).

LIMITATIONS: Studies had methodological limitations, follow-up was brief, and adverse effects were not commonly measured.

CONCLUSIONS: BMI surveillance and counseling has a marginal effect on BMI, highlighting the need for revised practice guidelines and the development of novel approaches for providers to address this problem.


Screening for Lipid Disorders in Children and Adolescents US Preventive Services Task Force Recommendation Statement.

US Preventive Services Task Force
JAMA. 2016;316(6):625-633. doi:10.1001/jama.2016.9852.

Importance  Elevations in levels of total, low-density lipoprotein, and non–high-density lipoprotein cholesterol; lower levels of high-density lipoprotein cholesterol; and, to a lesser extent, elevated triglyceride levels are associated with risk of cardiovascular disease in adults.

Objective  To update the 2007 US Preventive Services Task Force (USPSTF) recommendation on screening for lipid disorders in children, adolescents, and young adults.

Evidence Review  The USPSTF reviewed the evidence on screening for lipid disorders in children and adolescents 20 years or younger—1 review focused on screening for heterozygous familial hypercholesterolemia, and 1 review focused on screening for multifactorial dyslipidemia.

Findings  Evidence on the quantitative difference in diagnostic yield between universal and selective screening approaches, the effectiveness and harms of long-term treatment and the harms of screening, and the association between changes in intermediate outcomes and improvements in adult cardiovascular health outcomes are limited. Therefore, the USPSTF concludes that the balance of benefits and harms cannot be determined.

Conclusions and Recommendation  The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for lipid disorders in children and adolescents 20 years or younger. (I statement)


GRADE Evidence to Decision (EtD) frameworks: a systematic and transparent approach to making well informed healthcare choices. 1: Introduction.

Alonso-Coello P Schünemann HJ, Moberg J, Brignardello-Petersen R, Akl EA, Davoli M, Treweek S, Mustafa RA, Rada G, Rosenbaum S, Morelli A, Guyatt GH, Oxman AD; GRADE Working Group.

Summary points
-Clinicians, guideline developers, and policymakers sometimes neglect important criteria, give undue weight to criteria, and do not use the best available evidence to inform their judgments
-Explicit and transparent systems for decision making can help to ensure that all important criteria are considered and that decisions are informed by the best available research evidence
-The purpose of Evidence to Decision (EtD) frameworks is to help people use evidence in a structured and transparent way to inform decisions in the context of clinical recommendations, coverage decisions, and health system or public health recommendations and decisions
-EtD frameworks have a common structure that includes formulation of the question, an assessment of the evidence, and drawing conclusions, though there are some differences between frameworks for each type of decision
-EtD frameworks inform users about the judgments that were made and the evidence supporting those judgments by making the basis for decisions transparent to target audiences
-EtD frameworks also facilitate dissemination of recommendations and enable decision makers in other jurisdictions to adopt recommendations or decisions, or adapt them to their context


Swaddling and the Risk of Sudden Infant Death Syndrome: A Meta-analysis.

Pease AS, Fleming PJ, Hauck FR, Moon RY, Horne RS, L'Hoir MP, Ponsonby AL, Blair PS.
Pediatrics. 2016 Jun;137(6). pii: e20153275. doi: 10.1542/peds.2015-3275. Epub

CONTEXT: Swaddling is a traditional practice of wrapping infants to promote calming and sleep. Although the benefits and risks of swaddling in general have been studied, the practice in relation to sudden infant death syndrome remains unclear.
OBJECTIVE: The goal of this study was to conduct an individual-level meta-analysis of sudden infant death syndrome risk for infants swaddled for sleep.
DATA SOURCES: Additional data on sleeping position and age were provided by authors of included studies.
STUDY SELECTION: Observational studies that measured swaddling for the last or reference sleep were included.
DATA EXTRACTION: Of 283 articles screened, 4 studies met the inclusion criteria.
RESULTS: There was significant heterogeneity among studies (I(2) = 65.5%; P = .03), and a random effects model was therefore used for analysis. The overall age-adjusted pooled odds ratio (OR) for swaddling in all 4 studies was 1.58 (95%  confidence interval [CI], 0.97-2.58). Removing the most recent study conducted in the United Kingdom reduced the heterogeneity (I(2) = 28.2%; P = .25) and provided a pooled OR (using a fixed effects model) of 1.38 (95% CI, 1.05-1.80). Swaddling  risk varied according to position placed for sleep; the risk was highest for prone sleeping (OR, 12.99 [95% CI, 4.14-40.77]), followed by side sleeping (OR, 3.16 [95% CI, 2.08-4.81]) and supine sleeping (OR, 1.93 [95% CI, 1.27-2.93]).
Limited evidence suggested swaddling risk increased with infant age and was associated with a twofold risk for infants aged >6 months.
LIMITATIONS: Heterogeneity among the few studies available, imprecise definitions of swaddling, and difficulties controlling for further known risks make interpretation difficult.
CONCLUSIONS: Current advice to avoid front or side positions for sleep especially applies to infants who are swaddled. Consideration should be given to an age after which swaddling should be discouraged.


Primary Care Interventions to Support Breastfeeding: An Updated Systematic Review for the U.S. Preventive Services Task Force.

Agency for Healthcare Research and Quality U.S. Department of Health and Human Services.
Evidence Synthesis Number 143 . AHRQ Publication No. 15-05218-EF-1April 2016.

Objective: We conducted this systematic review to support the U.S. Preventive Services Task Force in updating its 2009 recommendation on counseling for breastfeeding. Our review addressed three questions: 1) What are the effects of prenatal, peripartum, and postpartum individual-and health care system-level interventions to promote and support breastfeeding on child and maternal health outcomes? 2) What are the effects of interventions on the initiation, duration, and exclusivity of breastfeeding? 3) Are there adverse events associated with interventions to promote and support breastfeeding?
Data Sources: We performed a search of MEDLINE, PubMed Publisher-Supplied, Cumulative Index for Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, and PsycInfo for studies published between January 1, 2008, and September 25, 2015. Studies included in the original U.S. Preventive Services Task Force review were re-evaluated. We supplemented searches by examining bibliographies from retrieved articles and consulting outside experts. We searched federal and international trial registries for ongoing trials.
Study Selection: Two researchers reviewed 2769 abstracts and 211 articles against the pre-specified inclusion criteria. Eligible studies included English-language studies conducted in a developed country that evaluated the effectiveness of an individual-or system-level breastfeeding intervention among pregnant women or mothers of full-or near-term infants. We included randomized or cluster randomized controlled trials for individual-level interventions and controlled before-and-after or prospective cohort studies for health system or policy interventions that reported health or breastfeeding outcomes. We conducted dual, independent critical appraisal of all provisionally included studies and abstracted all important study details and results from fair-and good-quality studies. Data were independently abstracted by one reviewer and confirmed by another.
Data Analysis: We qualitatively synthesized the results for health outcomes and adverse events. For breastfeeding outcomes, we synthesized the results by population (adults separately from adolescents or young adults) and intervention focus (individual-versus system-level approaches). Because of the small number of system-level interventions, we report those results narratively and do not pool the data. For individual-level interventions, we conducted random effects meta-analyses using the DerSimonian and Laird method and calculated pooled risk ratios for breastfeeding initiation and for any or exclusive breastfeeding at postpartum time points less than 3 months, 3 to 6 months, and 6 months. We explored potential effect modification by various population and intervention characteristics, such as intention to breastfeed and intervention type, and timing through stratified analyses and meta-regression. We generated funnel plots and conducted tests for small-study effects for all pooled analyses.
Results: We included 52 studies that were reported in 57 publications. The included studies were highly variable in terms of the country, study population, intervention and control conditions, specific outcome measures, and timing of measurements.
 on a range of infant health outcomes, such as gastrointestinal illness, otitis media, respiratory tract illness, and healthcare use. None of the studies reported maternal health outcomes.
Breastfeeding Outcomes. On the basis of 43 trials, breastfeeding support and education interventions targeting individuals were associated with a statistically significant higher likelihood of any and exclusive breastfeeding at less than 3 months and at 3 to 6 months compared with usual care among adults. Pooled estimates indicated beneficial associations for any breastfeeding at less than 3 months (risk ratio [RR], 1.07 [95% confidence interval {CI}, 1.03 to 1.11]; k=26) and at 3 to 6 months (RR, 1.11 [95% CI, 1.04 to 1.18]; k=23) and for exclusive breastfeeding at less than 3 months (RR, 1.21 [95% CI, 1.11 to 1.33]; k=22) and at 3 to 6 months (RR, 1.20 [95% CI, 1.05 to 1.38]; k=18). At 6 months, individual-level interventions with adults were associated with a 16 percent higher likelihood of exclusive breastfeeding (RR, 1.16 [95% CI, 1.02 to 1.32]; k=17) but not with any breastfeeding. The association between individual-level interventions and breastfeeding initiation was not statistically significant based on the pooled point estimate, but the confidence interval did not rule out potential benefit (RR, 1.00 [95% CI, 0.99 to 1.02]; k=14). There was some suggestion that interventions that took place during a combination of prenatal, peripartum, or postpartum time periods were more effective than those that took place only during one time period. There was no indication of effect modification by other intervention characteristics or by population subgroups. All four trials of individual-level interventions among adolescents or young adults reported higher rates of breastfeeding among intervention versus control group participants. For system-level interventions, there was limited, mixed evidence of an effect on rates of breastfeeding initiation or the duration of any or exclusive breastfeeding from well-controlled studies.
Adverse Events. Two trials among adults reported on adverse events related to a breastfeeding support intervention. One trial found no significant differences between groups in maternal anxiety at 2 weeks. The other reported that a few mothers expressed feelings of anxiety and decreased confidence in their breastfeeding abilities despite breastfeeding going well and therefore discontinued their participation in the peer counseling intervention.
Limitations: There were a number of threats to internal validity within the included studies. Detail regarding the measurement of breastfeeding outcomes, sociodemographic and breastfeeding-related population characteristics, and intervention and usual care characteristics were lacking. Our pooled analyses relied on unadjusted breastfeeding rates and did not control for potential confounding.
Conclusions: The body of fair-to-good quality evidence related to primary care interventions to support breastfeeding has nearly doubled since the release of the 2009 U.S. Preventive Services Task Force review and recommendation. The updated evidence confirms that breastfeeding support and education provided by professionals and peers to individual women, regardless of the mother’s age, is associated with an increase in the duration of any and exclusive breastfeeding. There are limited well-controlled studies examining the effectiveness of system-level policies and practices.


Screening for Celiac Disease: A Systematic Review for the U.S. Preventive Services Task Force Agency for Healthcare Research and Quality U.S. Department of Health and Human Services

Agency for Healthcare Research and Quality U.S. Department of Health and Human Services.
Evidence Synthesis Number 144. AHRQ Publication No. 14-05215-EF-1. May 2016.

Background: Unrecognized celiac disease (CD) may have adverse effects on morbidity and mortality. Purpose: To review the evidence on screening for CD in asymptomatic adults, adolescents, and children 3 years of age and older for the United States Preventive Services Task Force.
Data Sources: Ovid MEDLINE, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews (to February 2016).
Study Selection: Randomized clinical trials, cohort studies, and case-control studies of screening versus no screening, one screening strategy versus another, treatment versus no treatment, or immediate versus delayed treatment that evaluated clinical outcomes; and studies on diagnostic accuracy of serological tests for CD.
Data Extraction: One investigator abstracted data, a second checked data for accuracy, and two investigators independently assessed study quality using predefined criteria. Data Synthesis (Results): We identified no trials of screening for CD. One recent, good-quality systematic review found serological tests to be accurate for diagnosing CD, but two studies conducted in asymptomatic populations reported lower sensitivity than in studies not restricted to asymptomatic populations. One fair-quality, small (n=40), Finnish treatment trial of screendetected, asymptomatic adults with positive serological findings found initiation of a gluten-free diet associated with small improvement in gastrointestinal symptoms versus no gluten-free diet (less than 1 point on a 1 to 7 scale) at 1 year, with no differences on most measures of quality of life. No withdrawals due to adverse events occurred during the trial.
Limitations: Limited or no evidence for all key questions; limited to English language studies. Conclusions: More research is needed to understand the effectiveness of screening and treatment for CD in asymptomatic adults, adolescents, and children; accuracy of screening tests; and optimal screening strategies.


La detección precoz de Trastornos del Espectro Autista (TEA). El programa de cribado con M-CHAT en España y revisión de otros programas en Europa.

García Primo, P.

Los Trastornos del Espectro Autista (TEA) constituyen un conjunto de alteraciones graves del desarrollo neurológico que se caracterizan por la coocurrencia de dificultades en la interacción social y en la comunicación y por patrones restringidos y repetitivos de comportamiento, siendo una de las discapacidades del desarrollo más frecuentes en la infancia temprana.
El trabajo aquí presentado es una compilación de cuatro publicaciones (un capítulo de libro en español y 3 artículos, 2 de ellos publicados en revistas científicas internacionales en inglés y un artículo en español, publicado en una revista española). Todas y cada una de estas publicaciones están dirigidas, al avance del conocimiento y la puesta en práctica de de estrategias de cribado de TEA en edades tempranas, con el propósito de repercutir positivamente en el pronóstico de estos niños y en el mejor ajuste y calidad de vida de ellos y de sus familias. Los objetivos específicos  fueron alcanzados a través de cada uno de los estudios que forman parte de esta tesis y que son: 1) Desarrollar el proceso de traducción, adaptación cultural, análisis de validez y fiabilidad del cuestionario M-CHAT en España, 2) Pilotar y evaluar el funcionamiento y la estructura de un  programa de cribado con la versión validada en español del M-CHAT  a todos sus niveles (viabilidad, costes, nivel de participación...) dentro del Sistema Público de Salud en España y 3) Revisar y analizar de forma comparativa los diferentes procedimientos  utilizados en los estudios de cribado de autismo en Europa y describir su situación actual, así como identificar los posibles factores y aspectos metodológicos que se necesitan tener en cuenta para la interpretación de resultados en los estudios de cribado del autismo.  Se espera que los resultados de esta tesis sean especialmente útiles en lugares donde todavía no se ha puesto en marcha ningún programa de detección precoz del autismo, facilitando la toma de decisiones sobre qué herramienta puede funcionar mejor según las características del contexto.

Screening for Autism Spectrum Disorder in Young Children: A Systematic Evidence Review for the U.S. Preventive Services Task Force.

McPheeters M, PhD,Weitlauf A,  Vehorn A,  Taylor C,  Sathe NA,  Shanthi Krishnaswami M, Fonnesbeck C,  Warren ZE.
AHRQ Publication No. 13-05185-EF-1 February 2016

Context: The Centers for Disease Control and Prevention estimates that 1 in 68 children has an autism spectrum disorder (ASD) and the majority of children are not diagnosed until after 4 years of age. Current approaches rely on developmental surveillance, general developmental screening, and/or parental concerns. Systematic screening has been advocated for identifying ASD at earlier ages.

Objective: We systematically reviewed the evidence about benefits and harms of routine screening for ASD in primary care settings.
Methods: We explicitly focused on studies of screening instruments for use in young (≤36 months of age), unselected populations (e.g., universal screening approaches).

Results: We identified 17 unique screening studies reported in 22 papers. The most commonly studied tool was the Modified Checklist for Autism in Toddlers (M-CHAT), including the most recently available variant (M-CHAT-Revised with Followup [M-CHAT-R/F]), which has a positive predictive value of 48 percent in diverse populations of children ages 16 to 30 months. Forty-two studies of good and fair quality addressed interventions for young children. Among these, 17 involved direct provision of intervention to children. Fifteen of these 17 studies assessed cognitive outcomes, and outcomes were significantly more improved in the treatment versus comparison arm in 10 studies. Sixteen of these 17 studies assessed language outcomes, and outcomes were significantly improved in the treatment versus comparison group in 10 studies. Thirteen studies involved parent training. Five of these 13 studies addressed cognitive outcomes, and outcomes were significantly improved in the treatment versus comparison group in one study. Twelve of the 13 studies addressed language outcomes, and outcomes were significantly improved in the treatment versus comparison group in three studies. Thus, 20 studies overall measured cognitive outcomes and 11 reported greater benefit for the intervention group compared to the control group, and language outcomes were significantly improved in treatment versus comparison arms in 13 of 28 studies assessing language. Twelve studies focused on play and interaction and typically measured joint attention as the outcome. Nine out of 10 studies evaluating joint attention outcomes reported greater benefit in the treatment arm compared to the control arm. None of the studies focused on screen-detected children.

Conclusions: Both the M-CHAT and the M-CHAT-R/F, when including the followup interview procedure, have a positive predictive value of around 50 percent in community practices for children between 16 and 30 months of age. Screening tools are widely available. Multiple treatments are available to young children with ASD. Early intensive interventions demonstrate statistically significant improvements in cognitive and language outcomes in children compared to eclectic treatments obtained in the community or other comparison groups, although the studies are generally small, and, within the studies, some children benefit while others do not. We found no studies that directly compared long-term outcomes of screened versus non screened children. More research is needed to determine the benefits and harms of screening the general population.