Do growth monitoring and promotion programs answer the performance criteria of a screening program? A critical analysis based on a systematic review

Trop Med Int Health. 2005 Nov;10(11):1121-33.

Roberfroid D, Kolsteren P, Hoeree T, Maire B.Department of Public Health, Nutrition Unit, Institute of Tropical Medicine,Antwerp, Belgium.

OBJECTIVE: Growth Monitoring and Promotion programs (GMP) have been intensivelypromoted to improve children's health in developing countries. It has been hopedthat regularly weighing children would result in the early detection of growthfalterers, and that the growth chart would serve as an educational tool to makethat state apparent to both health workers and caretakers in order to triggerimproved caring practices. Our objective was to review whether GMP answers thetheoretical grounds of a screening and intervention program.

METHOD: Asystematic literature review was performed. The WHO framework developed byWilson and Jungner for planning and evaluating screening programs guided theanalysis.

RESULTS: Sixty-nine studies were retrieved. Overall, evidence is weakon the performance of GMP as a screening program for malnutrition through earlydetection of growth falterers. The main results are: (1) malnutrition remains apublic health problem, but its importance is context specific; (2) the value ofa low weight velocity to predict malnutrition is unknown and likely to vary indifferent contexts; (3) the performance of GMP for improving nutrition status ofchildren and in reducing mortality and morbidity is unknown; (4) the performanceof the screening is affected by the unreliability of weight measurements; (5)the promotional and educational effectiveness of GMP is low, in particular thegrowth chart is poorly understood by mothers; (6) the acceptability seems low inregards of low attendance rates; (7) evidence is lacking regardingcost-effectiveness.

CONCLUSIONS: We conclude that there is too little scientificevidence to indiscriminately support international promotion of GMP. However GMPcould constitute a valid strategy of public nutrition in specific situations. Weindicate paths for further research and how prevention programs could bedeveloped.

Interventions for preventing obesity in children.

Cochrane Database Syst Rev. 2005 Jul 20;(3):CD001871. Update of:Cochrane Database Syst Rev. 2002;(2):CD001871.

Summerbell CD, Waters E, Edmunds LD, Kelly S, Brown T, Campbell KJ.School of Health and Social Care, University of Teesside, Parkside West,Middlesbrough, Teesside, UK, TS1 3BA.

BACKGROUND: Obesity prevention is an international public health priority. Theprevalence of obesity and overweight is increasing in child populationsthroughout the world, impacting on short and long-term health. Obesityprevention strategies for children can change behaviour but efficacy in terms ofpreventing obesity remains poorly understood.

OBJECTIVES: To assess theeffectiveness of interventions designed to prevent obesity in childhood throughdiet, physical activity and/or lifestyle and social support.

SEARCH STRATEGY:MEDLINE, PsycINFO, EMBASE, CINAHL and CENTRAL were searched from 1990 toFebruary 2005. Non-English language papers were included and experts contacted.

SELECTION CRITERIA: Randomised controlled trials and controlled clinical trialswith minimum duration twelve weeks.

DATA COLLECTION AND ANALYSIS: Two reviewersindependently extracted data and assessed study quality.

MAIN RESULTS:Twenty-two studies were included; ten long-term (at least 12 months) and twelveshort-term (12 weeks to 12 months). Nineteen were school/preschool-basedinterventions, one was a community-based intervention targeting low-incomefamilies, and two were family-based interventions targeting non-obese childrenof obese or overweight parents.Six of the ten long-term studies combined dietaryeducation and physical activity interventions; five resulted in no difference inoverweight status between groups and one resulted in improvements for girlsreceiving the intervention, but not boys. Two studies focused on physicalactivity alone. Of these, a multi-media approach appeared to be effective inpreventing obesity. Two studies focused on nutrition education alone, butneither were effective in preventing obesity.Four of the twelve short-termstudies focused on interventions to increase physical activity levels, and twoof these studies resulted in minor reductions in overweight status in favour ofthe intervention. The other eight studies combined advice on diet and physicalactivity, but none had a significant impact.The studies were heterogeneous interms of study design, quality, target population, theoretical underpinning, andoutcome measures, making it impossible to combine study findings usingstatistical methods. There was an absence of cost-effectiveness data.

AUTHORS'CONCLUSIONS: The majority of studies were short-term. Studies that focused oncombining dietary and physical activity approaches did not significantly improveBMI, but some studies that focused on dietary or physical activity approachesshowed a small but positive impact on BMI status. Nearly all studies includedresulted in some improvement in diet or physical activity. Appropriateness ofdevelopment, design, duration and intensity of interventions to prevent obesityin childhood needs to be reconsidered alongside comprehensive reporting of theintervention scope and process.

Publication Types: Meta-Analysis, Review

Evaluación del programa de detección precoz universal de la hipoacusia del recién nacido

Evaluación del programa de detección precoz universal de la hipoacusia en el recién nacido
J González de Dios J Mollar Maseres M Rebagliato Russo
An Pediatr (Barc) 2005; 63: 230 - 237
Las repercusiones de la hipoacusia infantil y la incidencia de sordera, cuantificado en cifras, son datos suficientes para despertar alarma social. Nadie duda de la necesidad de llevar a cabo estrategias de detección precoz (cribado o screening ) de la hipoacusia en el recién nacido, cuyo objetivo es la detección y tratamiento precoz de las hipoacusias moderadas a profundas lo más precozmente posible en la etapa prelocutiva (primeros 2 años de vida) 1 .
Inicialmente se establecieron programas de cribado en grupos de riesgo, es decir, aquellos recién nacidos que presentaban una serie de antecedentes en donde el riesgo de hipoacusia era más frecuente que en la población general (tabla 1). La incidencia estimada de hipoacusia congénita moderada a profunda oscila entre 1:900 y 1:2.500 recién nacidos en la población general, pero es entre 10 y 20 veces superior en aquellos con factores de riesgo de hipoacusia. Entre el 50 y 75 % de los niños con hipoacusia bilateral moderada a profunda tienen uno o más factores de riesgo .
...¿Puede el cribado universal diagnosticar de forma válida las hipoacusias neurosensoriales moderadas a profundas?...
...¿Cuáles son los potenciales efectos adversos del cribado universal?...
...¿Produce el cribado una mejora en las habilidades de lenguaje y comunicación? ...
...¿Conlleva el tratamiento antes de los 6 meses una mejora en la capacidad de lenguaje y comunicación? ...
Disponemos de pruebas adecuadas para el cribado de hipoacusia neonatal, pero hemos de confirmar que el programa cumple los objetivos a todos los niveles (cribado, confirmación, diagnóstico, tratamiento y evaluación), con el fin de promover una asistencia sanitaria basada en las mejores pruebas científicas en la evaluación de actividades preventivas, máxime en un momento en el que este tipo de actividades se encuentran en debate.

Do Pacifiers Reduce the Risk of Sudden Infant Death Syndrome?

Do Pacifiers Reduce the Risk of Sudden Infant Death Syndrome?
A Meta-analysis
Fern R. Hauck, MD, MS*‡; Olanrewaju O. Omojokun, MD§; and Mir S. Siadaty, MD, MS‡
PEDIATRICS Vol. 116 No. 5 November 2005:e716-23
ABSTRACT. Objective. Pacifier use has been reported to be associated with a reduced risk of sudden infant death syndrome (SIDS), but most countries around the world, including the United States, have been reluctant to recommend the use of pacifiers because of concerns about possible adverse effects. This meta-analysis was undertaken to quantify and evaluate the protective effect of pacifiers against SIDS and to make a recommendation on the use of pacifiers to prevent SIDS.
Methods. We searched the Medline database (January 1966 to May 2004) to collect data on pacifier use and its association with SIDS, morbidity, or other adverse effects. The search strategy included published articles in English with the Medical Subject Headings terms “sudden infant death syndrome” and “pacifier” and the keywords “dummy” and “soother.” Combining searches resulted in 384 abstracts, which were all read and evaluated for inclusion. For the meta-analysis, articles with data on the relationship between pacifier use and SIDS risk were limited to published original case-control studies, because no prospective observational reports were found; 9 articles met these criteria. Two independent reviewers evaluated each study on the basis of the 6 criteria developed by the American Academy of Pediatrics Task Force on Infant Positioning and SIDS; in cases of disagreement, a third reviewer evaluated the study, and a consensus opinion was reached. We developed a script to calculate the summary odds ratio(SOR) by using the reported ORs and respective confidence intervals (CI) to weight the ORs.We then pooled them together to compute the SOR. We performed the Breslow-Day test for homogeneity of ORs, Cochran-Mantel-Haenszel test for the null hypothesis of no effect (OR
1), and the Mantel- Haenszel common OR estimate. The consistency of findings was evaluated and the overall potential benefits of pacifier use were weighed against the potential risks. Our recommendation is based on the taxonomy of the 5-point (A–E) scale adopted by the US Preventive Services Task Force.
Results. Seven studies were included in the metaanalysis. The SOR calculated for usual pacifier use (with univariate ORs) is 0.90 (95% confidence interval [CI]: 0.79 –1.03) and 0.71 (95% CI: 0.59–0.85) with multivariate ORs. For pacifier use during last sleep, the SORs calculated using univariate and multivariate ORs are 0.47 (95% CI: 0.40–0.55) and 0.39 (95% CI: 0.31– 0.50), respectively.
Conclusions. Published case-control studies demonstrate a significant reduced risk of SIDS with pacifier use, particularly when placed for sleep. Encouraging pacifier use is likely to be beneficial on a population-wide basis: 1 SIDS death could be prevented for every 2733 (95% CI: 2416–3334) infants who use a pacifier when placed for sleep (number needed to treat), based on the US SIDS rate and the last-sleep multivariate SOR resulting from this analysis. Therefore, we recommend that pacifiers be offered to infants as a potential method to reduce the risk of SIDS. The pacifier should be offered to the infant when being placed for all sleep episodes, including daytime naps and nighttime sleeps. This is a US Preventive Services Task Force level B strength of recommendation based on the consistency of findings and the likelihood that the beneficial effects will outweigh any potential negative effects. In consideration of potential adverse effects, we recommend pacifier use for infants up to 1 year of age, which includes the peak ages for SIDS risk and the period in which the infant’s need for sucking is highest. For breastfed infants, pacifiers should be introduced after breastfeeding has been well established.

The Changing Concept of Sudden Infant Death Syndrome: Diagnostic

The Changing Concept of Sudden Infant Death Syndrome: Diagnostic
Coding Shifts, Controversies Regarding the Sleeping Environment, and
New Variables to Consider in Reducing Risk
American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome.
PEDIATRICS Vol. 116 No. 5 November 2005 1245

ABSTRACT. There has been a major decrease in the incidence of sudden infant death syndrome (SIDS) since the American Academy of Pediatrics (AAP) released its recommendation in 1992 that infants be placed down for sleep in a nonprone position. Although the SIDS rate continues to fall, some of the recent decrease of the last several years may be a result of coding shifts to other causes of unexpected infant deaths. Since the AAP published its last statement on SIDS in 2000, several issues have become relevant, including the significant risk of side sleeping position; the AAP no longer recognizes side sleeping as a reasonable alternative to fully supine sleeping.
The AAP also stresses the need to avoid redundant soft bedding and soft objects in the infant’s sleeping environment, the hazards of adults sleeping with an infant in the same bed, the SIDS risk reduction associated with having infants sleep in the same room as adults and with using pacifiers at the time of sleep, the importance of educating secondary caregivers and neonatology practitioners on the importance of “back to sleep,” and strategies to reduce the incidence of positional plagiocephaly associated with supine positioning. This statement reviews the evidence associated with these and other SIDSrelated issues and proposes new recommendations for further reducing SIDS risk.

Pediatrics 2005;116:1245– 1255; SIDS, sudden infant death syndrome, sudden unexpected infant death, infant mortality, supine position, infant sleep, infant bedding.

The ICSI has updated guidelines

The Institute for Clinical Systems Improvement (ICSI) has updated guidelines on Preventive Services for Children and Adolescents. (11/29/2005).

Key additions and changes are: • The annotation and discussion section have been combined. Any duplicated statements have been removed.• Some of the annotations will have Key Points at the beginning. This informs the reader of key recommendations, highlights, or information pertinent to the content of the annotation. • References in support of recommendations or information are listed in the body of the annotation. A complete list of references is included in the Supporting Evidence section of the guideline.
Algorithm, Clinical Highlights, Annotations:

This guideline was merged with the ICSI Preventive Counseling and Education Guideline, and the Lipid Screening Guideline. Key changes in the guideline as a result of the merge were: • The scope was altered to address average rather than low-risk children and adolescents. • Services were prioritized into three categories: high ranking, evidence-based services; lower ranking, evidence-based services; and services that address important health issues, but with insufficient evidence of effectiveness to warrant recommendation or ranking. • The guideline is presented as a system delivery tool rather than a physician point-of-care tool. • Each preventive service includes 4 categories (as appropriate): Services, Efficacy, Counseling Messages, References/Related Guidelines. Content was updated to reflect the most current evidence for these categories.
Priority Aims & Suggested Measures, Measurement Specifications:

Aims, measures and measurement specifications were revised to reflect the focus on prioritization and system delivery.

Sun exposure and risk of melanoma

Susan A Oliveria, Mona Saraiya, Alan C Geller, Maureen K Heneghan and Cynthia Jorgensen.

Arch. Dis. Child. published online 2 Dec 2005.
Abstract
As skin cancer education programs directed to children and adolescents continue to expand, an epidemiologic basis for these programs is necessary to target efforts and plan for further evaluation. Here, we summarize the epidemiologic evidence on sun exposure during childhood and adolescence and melanoma risk. A literature review was conducted using MEDLINE® database (1966 - December 2004) to identify articles relating to sun exposure and melanoma. The review was restricted to studies that included sun exposure information on subjects 18 years of age or younger. Migrant studies generally indicate an increased melanoma risk in individuals who spent childhood in sunny geographic locations, and decreasing melanoma risk with older age at arrival. Individuals who resided in geographic locations close to the equator or close to the coast during childhood and/or adolescence have an elevated melanoma risk compared to those who lived at higher latitudes or never lived near the coast. The intermittent exposure hypothesis remains controversial; some studies indicate that children and adolescents who received intermittent sun exposure during vacation, recreation, or occupation are at increased melanoma risk as adults, but more recent studies suggest intermittent exposure to have a protective effect. The majority of sunburn studies suggest a positive association between early age sunburn and subsequent risk of melanoma. Future research efforts should focus on (1) clarifying the relationship between sun exposure and melanoma, (2) conducting prospective studies, (3) assessing sun exposure during different time periods of life using a reliable and quantitative method, (4) obtaining information on protective measures, and (5) examining the interrelationships between ability to tan, propensity to burn, skin type, history of sunburns, timing and pattern of sun exposure, number of nevi, and other host factors in the child and adolescent populations.

Gaps in the Evidence for Well-Child Care: A Challenge to Our Profession

Moyer VA, Butler M. Pediatrics. 2004 Dec;114(6):1511-21.
Abstract:
Background: Up to one third of visits to pediatricians involve health supervision (well-child care), and recommendations for office-based preventive interventions have dramatically expanded. We reviewed the evidence for the effectiveness of these interventions.
Methods: The well-child care recommendations of 7 major North American organizations were tabulated. Three types of health supervision interventions were recommended, ie, behavioral counseling, screening, and prophylaxis. For recommendations common to at least 2 of the 7 organizations, evidence of effectiveness was sought from systematic reviews and clinical trials. Immunizations were not considered for this review, because they have been reviewed elsewhere.
Results: Forty-two preventive interventions were recommended by 2 of the organizations. Limited clinical trials show that counseling can change some health risk behaviors; repeated intensive counseling is most likely to be effective. Harmful effects were shown for a few behavioral counseling interventions. Trials have been conducted for only 2 of the recommended screening interventions; therefore, rigorous evidence supporting screening is very limited. Trials support the use of folate to prevent neural tube defects, trials of iron supplementation do not address developmental outcomes, and trials were not found for the other recommended prophylactic interventions.
Conclusions: Limited direct evidence was found to support the recommended interventions. Because a large number of interventions are routinely recommended and often mandated and because the implementation of any recommendation may cause harm (including the displacement of other beneficial activities), these recommendations should be based on the strongest possible evidence. When recommendations are made, supporting evidence should be clearly stated.