25.5.13

Effectiveness of Hormonal and Surgical Therapies for Cryptorchidism: A Systematic Review

Penson D, Krishnaswami S, Jules A, McPheeters ML.
Pediatrics. 2013 May 20. [Epub ahead of print]

BACKGROUND AND OBJECTIVE: Controversy remains concerning the optimal treatment approach for cryptorchidism. The objective of this study was to assess effectiveness of hormone therapy or surgery for cryptorchidism.
METHODS: We searched Medline and other databases from 1980 to February 2012. Two reviewers independently assessed studies against predetermined criteria. Two reviewers independently extracted data and assigned overall quality and strength of evidence ratings using predetermined criteria.
RESULTS: Fourteen studies addressed effectiveness of hormonal treatments, and 26 studies addressed surgical intervention outcomes. Hormonal treatment is associated with testicular descent in some children, but rates generally do not exceed those seen with placebo by >10%. Surgical treatment is associated with success rates of testicular descent ranging from 33% to 100%, depending on surgery. Weighted success averages were 78.7% for 1-stage Fowler-Stephens (FS), 86% for 2-stage FS, and 96.4% for primary orchiopexy. Descent rates were similar among studies comparing laparoscopic and open surgeries. Reported harms of hormonal treatments were mild and transient. Adverse effects specifically associated with surgical repair were rare.
CONCLUSIONS: The body of the reviewed literature comprises primarily fair- and poor-quality studies, limiting our ability to draw definitive conclusions. Hormonal treatment is marginally effective relative to placebo but is successful in some children and with minimal harms, suggesting that it may be an appropriate trial of care for some patients. Surgical options are effective, with high rates of testicular descent (moderate strength of evidence for FS procedures, high for primary orchiopexy). Comparable outcomes occur with laparoscopic and open approaches.

22.5.13

Health of Children Classified as Underweight by CDC Reference but Normal by WHO Standard


  1. on behalf of Children’s HealthWatch

Pediatrics. 2013 May 20. [Epub ahead of print]
OBJECTIVE: To ascertain measures of health status among 6- to 24-month-old children classified as below normal weight-for-age (underweight) by the Centers for Disease Control and Prevention (CDC) 2000 growth reference but as normal weight-for-age by the World Health Organization (WHO) 2006 standard.
METHODS: Data were gathered from children and primary caregivers at emergency departments and primary care clinics in 7 US cities. Outcome measures included caregiver rating of child health, parental evaluation of developmental status, history of hospitalizations, and admission to hospital at the time of visit. Children were classified as (1) not underweight by either CDC 2000 or WHO 2006 criteria, (2) underweight by CDC 2000 but not by WHO 2006 criteria, or (3) underweight by both criteria. http://pediatrics.aappublications.org/content/early/2013/05/15/peds.2012-2382.abstractAssociations between these categories and health outcome measures were assessed by using multiple logistic regression analysis.
RESULTS: Data were available for 18 420 children. For each health outcome measure, children classified as underweight by CDC 2000 but normal by WHO 2006 had higher adjusted odds ratios (aORs) of adverse health outcomes than children not classified as underweight by either; children classified as underweight by both had the highest aORs of adverse outcomes. For example, compared with children not underweight by either criteria, the aORs for fair/poor health rating were 2.54 (95% confidence interval: 2.20–2.93) among children underweight by CDC but not WHO and 3.76 (3.13–4.51) among children underweight by both.
CONCLUSIONS: Children who are reclassified from underweight to normal weight in changing from CDC 2000 to WHO 2006 growth charts may still be affected by morbidities associated with underweight.

21.5.13

Eating Frequency and Overweight and Obesity in Children and Adolescents: A Meta-analysis.


Pediatrics 2013;131:958–967

Panagiota Kaisari, MSc, Mary Yannakoulia, PhD, and Demosthenes B. Panagiotakos, PhD

Department of Nutrition and Dietetics, Harokopio University, Athens, Greece



OBJECTIVES: To determine the effect of eating frequency on body weight status in children and adolescents.



METHODS:In this meta-analysis, original observational studies published to October 2011 were selected through a literature search in the PubMed database. The reference list of the retrieved articles was also used to identify relevant articles; researchers were contacted when needed.

Selected studies were published in English, and they reported on the effect of eating frequency on overweight/obesity in children and adolescents. Pooled effect sizes were calculated using a random effects model.


RESULTS: Ten cross-sectional studies and 1 case-control study (21substudies in total), comprising 18 849 participants (aged 2–19 years),were included in the analysis. Their combined effect revealed that the highest category of eating frequency, as compared with the lowest,was associated with a beneficial effect regarding body weight status in children and adolescents (odds ratio [OR] = 0.78, log OR = –0.24,95% confidence interval [CI] –0.41 to –0.06). The observed beneficial effect remained significant in boys (OR = 0.76, log OR = –0.27, 95% CI–0.47 to –0.06), but not in girls (OR = 0.96, log OR = –0.04, 95% CI –0.40 to 0.32) (P for sex differences = 0.14).



CONCLUSIONS: Higher eating frequency was associated with lower body weight status in children and adolescents, mainly in boys. Clinical trials are warranted to confirm this inverse association, evaluate its clinical applicability, and support a public health recommendation; more studies are also needed to further investigate any sex-related differences, and most importantly, the biological mechanisms.



19.5.13

Association between total duration of breastfeeding and iron deficiency.




Maguire JL, Salehi L, Birken CS, Carsley S, Mamdani M, Thorpe KE, Lebovic G,
Khovratovich M, Parkin PC; TARGet Kids! collaboration.
MSc, FRCPC, Department of Pediatrics, St Michael's Hospital, 30 Bond St,
15CC-014, Toronto ON M5B 1W8 Canada. jonathon.maguire@utoronto.ca.

OBJECTIVE: To determine whether there is an association between the total breastfeeding duration and iron stores, iron deficiency, and iron deficiency anemia in healthy urban children.
METHODS: A cross-sectional study of healthy children, aged 1 to 6 years, seen for primary health care between December 2008 and July 2011 was conducted through the TARGet Kids! practice-based research network. Univariate and adjusted regression analyses were used to evaluate an association between total breastfeeding duration and serum ferritin, iron deficiency, and iron deficiency anemia.
RESULTS: Included were 1647 healthy children (median age 36 months) with survey, anthropometric, and laboratory data. An association was found between increasing duration of breastfeeding and lower serum ferritin (P = .0015). Adjusted logistic regression analysis revealed the odds of iron deficiency increased by 4.8% (95% confidence interval: 2%-8%) for each additional month of breastfeeding.
Exploratory analysis suggested an increasing cumulative probability of iron deficiency with longer total breastfeeding duration with an adjusted odds ratio of 1.71 (95% confidence interval: 1.05-2.79) for iron deficiency in children breastfed over versus under 12 months of age. The relationship between total breastfeeding duration and iron deficiency anemia did not meet statistical significance.
CONCLUSIONS: Increased total breastfeeding duration is associated with decreased iron stores, a clinically important association warranting additional investigation.

PMID:
 
23589818
 
[PubMed - in process]

7.5.13

Parenting interventions for the prevention of unintentional injuries in childhood.

Kendrick D, Mulvaney CA, Ye L, et al. Parenting interventions for the prevention of unintentional injuries in childhood. Cochrane Database Syst Rev. 2013 Mar 28;3:CD006020. doi: 10.1002/14651858.CD006020.pub3. (Review) PMID: 23543542

BACKGROUND: Parent education and training programmes can improve maternal psychosocial health, child behavioural problems and parenting practices. This review assesses the effects of parenting interventions for reducing child injury.
OBJECTIVES: To assess the effects of parenting interventions for preventing unintentional injury in children aged under 18 years and for increasing possession and use of safety equipment and safety practices by parents.  
SEARCH METHODS: We searched CENTRAL, MEDLINE, EMBASE, BIOSIS Preview, PsycINFO, Sociological Abstracts, Social Science Citation Index, CINAHL, ProQuest Dissertations and Theses, ERIC, DARE, ASSIA, Web of Science, SIGLE and ZETOC. We also handsearched abstracts from the World Conferences on Injury Prevention & Control and the journal Injury Prevention. The searches were conducted in January 2011.
SELECTION CRITERIA: We included randomised controlled trials (RCTs), non-randomised controlled trials (non-RCTs) and controlled before and after studies (CBAs), which evaluated parenting interventions administered to parents of children aged 18 years and under, and reported outcome data on injuries for children (unintentional or unspecified intent), possession and use of safety equipment or safety practices (including the Home Observation for Measurement of the Environment (HOME) scale which contained an assessment of home safety) by parents. Parenting interventions were defined as those with a specified protocol, manual or curriculum aimed at changing knowledge, attitudes or skills covering a range of parenting topics.
DATA COLLECTION AND ANALYSIS: Studies were selected, data were extracted and quality appraised independently by two authors. Pooled relative risks (RR) were estimated using random effect models.
MAIN RESULTS: Twenty two studies were included in the review: 16 RCTs, two non-RCTs, one partially randomised trial which contained two randomised intervention arms and one non-randomised control arm, two CBA studies and one quasi randomised controlled trial. Seventeen studies provided interventions comprising parenting education and other support services; 15 of which were home visiting programmes and two of which were paediatric practice-based interventions. Two provided solely educational interventions. Nineteen studies recruited families who were from socio-economically disadvantaged populations, were at risk of adverse child outcomes or people who may benefit from extra support, such as single mothers, teenage mothers, first time mothers and mothers with learning difficulties. Ten RCTs involving 5074 participants were included in the meta-analysis, which indicated that intervention families had a statistically significant lower risk of injury than control families (RR 0.83, 95% CI 0.73 to 0.94). Sensitivity analyses undertaken including only RCTs at low risk of various sources of bias found the findings to be robust to including only those studies at low risk of detection bias in terms of blinded outcome assessment and attrition bias in terms of follow up of fewer than 80% of participants in each arm. When analyses were restricted to studies at low risk of selection bias in terms of inadequate allocation concealment the effect size was no longer statistically significant. Several studies found statistically significant fewer home hazards or a greater number of safety practices in intervention families. Of ten studies reporting scores on the HOME scale, data from three RCTs were included in a meta-analysis which found no evidence of a difference in quality of the home environment between treatment arms (mean difference 0.57, 95% CI -0.59 to 1.72). Most of the studies reporting home safety practices, home hazards or composite home safety scores found statistically significant effects favouring intervention arm families. Overall, using GRADE, the quality of the evidence was rated as moderate.
AUTHORS' CONCLUSIONS: Parenting interventions, most commonly provided within the home using multi-faceted interventions are effective in reducing child injury. There is fairly consistent evidence that they also improve home safety. The evidence relates mainly to interventions provided to families from disadvantaged populations, who are at risk of adverse child health outcomes or whose families may benefit from extra support. Further research is required to explore mechanisms by which these interventions may reduce injury, the features of parenting interventions that are necessary or sufficient to reduce injury and the generalisability to different population groups.

6.5.13

Screening for and Treatment of Suicide Risk Relevant to Primary Care: A Systematic Review for the U.S. Preventive Services Task Force

O`Connor E, Gaynes BN, Burda BU, et al. Screening for and Treatment of Suicide Risk Relevant to Primary Care: A Systematic Review for the U.S. Preventive Services Task Force. Ann Intern Med. 2013 Apr 23. doi: 10.7326/0003-4819-158-10-201305210-00642. (Review) PMID: 23609101

BACKGROUND: In 2009, suicide accounted for 36 897 deaths in the United States.
PURPOSE: To review the accuracy of screening instruments and the efficacy and safety of screening for and treatment of suicide risk in populations and settings relevant to primary care.
DATA SOURCES: Citations from MEDLINE, PsycINFO, the Cochrane Central Register of Controlled Trials, and CINAHL (2002 to 17 July 2012); gray literature; and a surveillance search of MEDLINE for additional screening trials (July to December 2012).
STUDY SELECTION: Fair- or good-quality English-language studies that assessed the accuracy of screening instruments in primary care or similar populations and trials of suicide prevention interventions in primary or mental health care settings.
DATA EXTRACTION: One investigator abstracted data; a second checked the abstraction. Two investigators rated study quality.
DATA SYNTHESIS: Evidence was insufficient to determine the benefits of screening in primary care populations; very limited evidence identified no serious harms. Minimal evidence suggested that screening tools can identify some adults at increased risk for suicide in primary care, but accuracy was lower in studies of older adults. Minimal evidence limited to high-risk populations suggested poor performance of screening instruments in adolescents. Trial evidence showed that psychotherapy reduced suicide attempts in high-risk adults but not adolescents. Most trials were insufficiently powered to detect effects on deaths.
LIMITATIONS: Treatment evidence was derived from high-risk rather than screen-detected populations. Evidence relevant to adolescents, older adults, and racial or ethnic minorities was limited.
CONCLUSION: Primary care-feasible screening tools might help to identify some adults at increased risk for suicide but have limited ability to detect suicide risk in adolescents. Psychotherapy may reduce suicide attempts in some high-risk adults, but effective interventions for high-risk adolescents are not yet proven. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.

3.5.13


Screening women for intimate partner violence in healthcare settings


Taft A, O'Doherty L, Hegarty K, Ramsay J, Davidson L, Feder G. Screening women for intimate partner violence in healthcare settings. Cochrane Database of Systematic Reviews 2013, Issue 4. Art. No.: CD007007. DOI: 10.1002/14651858.CD007007.pub2.


Abstract

Background

Intimate partner violence (IPV) damages individuals, their children, communities, and the wider economic and social fabric of society. Some governments and professional organisations recommend screening all women for intimate partner violence rather than asking only women with symptoms (case-finding); however, what is the evidence that screening interventions will increase identification, and referral to support agencies, or improve women's subsequent wellbeing and not cause harm?

Objectives

To assess the effectiveness of screening for intimate partner violence conducted within healthcare settings for identification, referral to support agencies and health outcomes for women.

Search methods

We searched the following databases in July 2012: CENTRAL (2012, Issue 6), MEDLINE (1948 to September Week June Week 3 2012), EMBASE (1980 to Week 28 2012), MEDLINE In–Process (3 July 2012), DARE (2012, Issue 2), CINAHL (1937 to current), PsycINFO (1806 to June Week 4 2012), Sociological Abstracts (1952 to current) and ASSIA (1987 to October 2010). In addition we searched the following trials registers: metaRegister of Controlled Trials (mRCT) (to July 2012), and International Clinical Trials Registry Platform (ICTRP), ClinicalTrials.gov, Australian New Zealand Clinical Trials Registry and the International Standard Randomised Controlled Trial Number Register to August 2010. We also searched the reference lists of articles and websites of relevant organisations.

Selection criteria

Randomised or quasi-randomised trials assessing the effectiveness of IPV screening where healthcare professionals screened women face-to-face or were informed of results of screening questionnaires, compared with usual care ( which included screening for other purposes).

Data collection and analysis

Two review authors independently assessed the risk of bias in the trials and undertook data extraction. For binary outcomes, we calculated a standardised estimation of the risk ratio (RR) and for continuous data, either a mean difference (MD) or standardised mean difference (SMD). All are presented with a 95% confidence interval (CI).

Main results

We included 11 trials that recruited 13,027 women overall. Six of 10 studies were assessed as being at high risk of bias.
When data from six comparable studies were combined (n = 3564), screening increased identification of victims/survivors (RR 2.33; 95% CI 1.40 to 3.89), particularly in antenatal settings (RR 4.26; 95% CI 1.76 to 10.31).
Only three studies measured referrals to support agencies (n = 1400). There is no evidence that screening increases such referrals, as although referral numbers increased in the screened group, actual numbers were very small and crossed the line of no effect (RR 2.67; 95% CI 0.99 to 7.20).
Only two studies measured women's experience of violence after screening (one at three months, the other at six, 12 and 18 months after screening) and found no significant reduction of abuse.
Only one study measured adverse effects and data from this study suggested that screening may not cause harm. This same study showed a trend towards mental health benefit, but the results did not reach statistical significance.
There was insufficient evidence on which to judge whether screening increases take up of specialist services, and no studies included economic evaluation.

Authors' conclusions

Screening is likely to increase identification rates but rates of referral to support agencies are low and as yet we know little about the proportions of false measurement (negatives or positives). Screening does not appear to cause harm, but only one study examined this outcome. As there is an absence of evidence of long-term benefit for women, there is insufficient evidence to justify universal screening in healthcare settings. Studies comparing screening versus case finding (with or without advocacy or therapeutic interventions) for women's long-term wellbeing would better inform future policies in healthcare settings.

Plain language su


mmary

Screening women for intimate partner violence in healthcare settings

Women who have experienced physical, psychological or sexual violence from an intimate partner (for example, husband, boyfriend, ex-husband or ex-boyfriend) can suffer poor physical and mental health, poor pregnancy outcomes and premature death. Their children and families can also suffer. The effects of violence often result in women attending healthcare settings. Some people have argued that healthcare professionals should routinely ask all women attending a healthcare setting whether they have experienced violence from their partner or ex-partner. They argue that this approach (known as universal screening) might encourage women who would not otherwise do so, to disclose abuse, or to recognise their experience as ‘abuse’. In turn, this would enable the healthcare professional to provide immediate support or refer them to specialist help, or both. Some governments and health organisations recommend universal screening for intimate partner violence (IPV). Others argue that such screening should be targeted to high risk groups, such as pregnant women attending antenatal clinics (targeted screening is known as ‘selective screening’).
We carried out this review to find out two things. First, whether there was any evidence that IPV screening increases the number of women identified and the number referred on to specialist services. Second, whether screening results in health benefits to women or causes any harm.
We found 11 studies that assessed the effectiveness of IPV screening where healthcare professionals screened women face-to-face or were informed of results of screening questionnaires, compared with usual care. No study compared the benefit of universal screening versus selective screening. All the studies were conducted in high income countries. The studies looked at screening in hospitals and in community settings. Screening methods included questionnaires (paper and computer based) completed by women themselves or face-to-face screening. No study took into account differences in how much abuse women were experiencing, or whether they were able or ready to take action – something that might affect the likelihood of disclosing abuse. Further, none looked at the sustainability of screening by healthcare professionals.
Screening doubled the likelihood that abused women were identified, but did not increase the numbers referred for specialist help. Both the numbers identified and referred for support were low. Screening did not reduce the level of violence experienced by women or improve women’s health and wellbeing at any time point from three to 18 months after the screening. One study reported no evidence of harm. The remaining ten studies did not address the issue of harmful consequences. We do not know if screening increases take up of specialist services. None of the studies measured how much it costs to deliver screening.
We conclude that there is insufficient evidence to justify universal screening for intimate partner violence in healthcare settings.

School-based programmes for preventing smoking


Thomas RE, McLellan J, Perera R. School-based programmes for preventing smoking. Cochrane Database of Systematic Reviews 2013, Issue 4. Art. No.: CD001293. DOI: 10.1002/14651858.CD001293.pub3.

Abstract

Background

Helping young people to avoid starting smoking is a widely endorsed public health goal, and schools provide a route to communicate with nearly all young people. School-based interventions have been delivered for close to 40 years.

Objectives

The primary aim of this review was to determine whether school smoking interventions prevent youth from starting smoking. Our secondary objective was to determine which interventions were most effective. This included evaluating the effects of theoretical approaches; additional booster sessions; programme deliverers; gender effects; and multifocal interventions versus those focused solely on smoking.

Search methods

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Tobacco Addiction Group's Specialised Register, MEDLINE, EMBASE, PsyclNFO, ERIC, CINAHL, Health Star, and Dissertation Abstracts for terms relating to school-based smoking cessation programmes. In addition, we screened the bibliographies of articles and ran individual MEDLINE searches for 133 authors who had undertaken randomised controlled trials in this area. The most recent searches were conducted in October 2012.

Selection criteria

We selected randomised controlled trials (RCTs) where students, classes, schools, or school districts were randomised to intervention arm(s) versus a control group, and followed for at least six months. Participants had to be youth (aged 5 to 18). Interventions could be any curricula used in a school setting to deter tobacco use, and outcome measures could be never smoking, frequency of smoking, number of cigarettes smoked, or smoking indices.

Data collection and analysis

Two reviewers independently assessed studies for inclusion, extracted data and assessed risk of bias. Based on the type of outcome, we placed studies into three groups for analysis: Pure Prevention cohorts (Group 1), Change in Smoking Behaviour over time (Group 2) and Point Prevalence of Smoking (Group 3).

Main results

One hundred and thirty-four studies involving 428,293 participants met the inclusion criteria. Some studies provided data for more than one group.
Pure Prevention cohorts (Group 1) included 49 studies (N = 142,447). Pooled results at follow-up at one year or less found no overall effect of intervention curricula versus control (odds ratio (OR) 0.94, 95% confidence interval (CI) 0.85 to 1.05). In a subgroup analysis, the combined social competence and social influences curricula (six RCTs) showed a statistically significant effect in preventing the onset of smoking (OR 0.49, 95% CI 0.28 to 0.87; seven arms); whereas significant effects were not detected in programmes involving information only (OR 0.12, 95% CI 0.00 to 14.87; one study), social influences only (OR 1.00, 95% CI 0.88 to 1.13; 25 studies), or multimodal interventions (OR 0.89, 95% CI 0.73 to 1.08; five studies). In contrast, pooled results at longest follow-up showed an overall significant effect favouring the intervention (OR 0.88, 95% CI 0.82 to 0.96). Subgroup analyses detected significant effects in programmes with social competence curricula (OR 0.52, 95% CI 0.30 to 0.88), and the combined social competence and social influences curricula (OR 0.50, 95% CI 0.28 to 0.87), but not in those programmes with information only, social influence only, and multimodal programmes.
Change in Smoking Behaviour over time (Group 2) included 15 studies (N = 45,555). At one year or less there was a small but statistically significant effect favouring controls (standardised mean difference (SMD) 0.04, 95% CI 0.02 to 0.06). For follow-up longer than one year there was a statistically nonsignificant effect (SMD 0.02, 95% CI -0.00 to 0.02).
Twenty-five studies reported data on the Point Prevalence of Smoking (Group 3), though heterogeneity in this group was too high for data to be pooled.
We were unable to analyse data for 49 studies (N = 152,544).
Subgroup analyses (Pure Prevention cohorts only) demonstrated that at longest follow-up for all curricula combined, there was a significant effect favouring adult presenters (OR 0.88, 95% CI 0.81 to 0.96). There were no differences between tobacco-only and multifocal interventions. For curricula with booster sessions there was a significant effect only for combined social competence and social influences interventions with follow-up of one year or less (OR 0.50, 95% CI 0.26 to 0.96) and at longest follow-up (OR 0.51, 95% CI 0.27 to 0.96). Limited data on gender differences suggested no overall effect, although one study found an effect of multimodal intervention at one year for male students. Sensitivity analyses for Pure Prevention cohorts and Change in Smoking Behaviour over time outcomes suggested that neither selection nor attrition bias affected the results.

Authors' conclusions

Pure Prevention cohorts showed a significant effect at longest follow-up, with an average 12% reduction in starting smoking compared to the control groups. However, no overall effect was detected at one year or less. The combined social competence and social influences interventions showed a significant effect at one year and at longest follow-up. Studies that deployed a social influences programme showed no overall effect at any time point; multimodal interventions and those with an information-only approach were similarly ineffective.
Studies reporting Change in Smoking Behaviour over time did not show an overall effect, but at an intervention level there were positive findings for social competence and combined social competence and social influences interventions.