Estimated Change in Prevalence and Trends of Childhood Blood Pressure Levels in the United States After Application of the 2017 AAP Guideline.

Al Kibria GM, Swasey K, Sharmeen A, Day B.

INTRODUCTION: Childhood hypertension is associated with higher risks of cardiovascular disease during adulthood. This study estimated the prevalence of hypertension and high blood pressure among children aged 8 to 17 years in the United States per the 2017 American Academy of Pediatrics (AAP) guideline and compared that with the 2004 National Institutes of Health/National Heart, Lung,
and Blood Institute (NIH/NHLBI) guideline's prevalence estimate during 2005-2008  and 2013-2016.

METHODS: This cross-sectional study analyzed the National Health and Nutrition Examination Survey data. High blood pressure included hypertension and elevated blood pressure (per the 2017 AAP guideline)/prehypertension (per the 2004 NIH/NHLBI guideline).

RESULTS: The analysis included 3,633 children in 2005-2008 and 3,471 children in  2013-2016. Per the 2004 NIH/NHLBI guideline, 3.1% (95% confidence interval [CI],  2.3%-4.3%) had hypertension in 2005-2008 and 1.9% (95% CI, 1.4%-2.6%) had hypertension in 2013-2016. Per the 2017 AAP guideline, prevalence was 5.7% (95% CI, 4.6%-7.1%) in 2005-2008 and 3.5% (95% CI, 2.7%-4.5%) in 2013-2016. About 2.5% (95% CI, 2.0%-3.1%) children in 2005-2008 and 1.5% (95% CI, 0.9%-2.0%) children in 2013-2016 were reclassified as hypertensive. We observed a similar change in prevalence for high blood pressure after application of the new guideline. The prevalence of high blood pressure also declined from 2005-2008 to 2013-2016 per both guidelines.

CONCLUSION: Although the new guideline would reclassify a small proportion of children as having hypertension or high blood pressure, the prevalence declined from 2005-2008 to 2013-2016.


Primary Care Interventions to Prevent Child Maltreatment Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

Viswanathan M, Fraser JG, Pan H, et al. Primary Care Interventions to Prevent Child Maltreatment Updated Evidence Report and Systematic Review for the US Preventive Services Task ForceJAMA.2018;320(20):2129–2140. doi:10.1001/jama.2018.17647
Importance  Child maltreatment, also referred to as child abuse and neglect, can result in lifelong negative consequences.
Objective  To update the evidence on interventions provided in or referable from primary care to prevent child maltreatment for the US Preventive Services Task Force.
Data Sources  PubMed, Cochrane Library, EMBASE, and trial registries through December 18, 2017; references; experts; literature surveillance through July 17, 2018.
Study Selection  English-language fair- and good-quality randomized clinical trials that (1) included children with no known exposure to maltreatment and no signs or symptoms of current or past maltreatment, (2) evaluated interventions feasible in a primary care setting or that could result from a referral from primary care, and (3) reported abuse or neglect outcomes or proxies for abuse or neglect (eg, injury with a specificity for abuse, visits to the emergency department, hospitalization).
Data Extraction and Synthesis  Two reviewers independently assessed titles/abstracts, full-text articles, and study quality; a third resolved conflicts when needed. When at least 3 similar trials were available, random-effects meta-analyses were conducted.
Main Outcomes and Measures  Direct measures (including reports to child protective services and removal of the child from the home) or proxy measures of abuse or neglect; behavioral, emotional, mental, or physical well-being; and harms.
Results  Twenty-two trials (33 publications) were included (N = 11 132). No significant association was found between interventions and reports to child protective services within 1 year of intervention completion (10.6% vs 11.9%; pooled odds ratio [OR], 0.94 [95% CI, 0.72-1.23]; 10 trials [n = 2444]) or removal of the child from the home within 1 to 3 years of follow-up (3.5% vs 3.7%; pooled OR, 1.09 [95% CI, 0.16-7.28]; 4 trials [n = 609]). No statistically significant associations were observed between interventions and outcomes for emergency department visits in the short term (<2 years), hospitalizations, child development, school performance, and prevention of death. Nonsignificant results from single trials led to a conclusion of insufficient evidence for injuries, failure to thrive, failure to immunize, school attendance, and other measures of abuse or neglect. Inconsistent results led to a conclusion of insufficient evidence for long-term (≥2 years) outcomes for reports to child protective services (ORs range from 0.48 to 1.13; 3 trials [n = 1690]), emergency department visits (1 of 2 trials reported significant differences) and internalizing and externalizing behavior symptoms (3 of 6 trials reported reductions in behavior difficulties). No eligible trials on harms of interventions were identified.
Conclusions and Relevance  Interventions provided in or referable from primary care did not consistently prevent child maltreatment. No evidence on harms is available.

Interventions to Prevent Child Maltreatment US Preventive Services Task Force Recommendation Statement.

In 2016, approximately 676 000 children in the United States experienced maltreatment (abuse, neglect, or both), with 75% of these children experiencing neglect, 18% experiencing physical abuse, and 8% experiencing sexual abuse. Approximately 14% of abused children experienced multiple forms of maltreatment, and more than 1700 children died as a result of maltreatment.

To update the US Preventive Services Task Force (USPSTF) 2013 recommendation on primary care interventions to prevent child maltreatment.

Evidence Review 
The USPSTF commissioned a review of the evidence on primary care interventions to prevent maltreatment in children and adolescents without signs or symptoms of maltreatment.

The USPSTF found limited and inconsistent evidence on the benefits of primary care interventions, including home visitation programs, to prevent child maltreatment and found no evidence related to the harms of such interventions. The USPSTF concludes that the evidence is insufficient to assess the balance of benefits and harms of primary care interventions to prevent child maltreatment. The level of certainty of the magnitude of the benefits and harms of these interventions is low.

Conclusions and Recommendation 
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of primary care interventions to prevent child maltreatment. (I statement)


Interventions for treating children and adolescents with overweight and obesity: an overview of Cochrane reviews

Ells LJ, Rees K, Brown T, Mead E, Al-Khudairy L, Azevedo L, McGeechan GJ, Baur L, Loveman E, Clements H, Rayco-Solon P, Farpour-Lambert N, Demaio A.

Children and adolescents with overweight and obesity are a global health concern.
This is an integrative overview of six Cochrane systematic reviews, providing an 
up-to-date synthesis of the evidence examining interventions for the treatment of
children and adolescents with overweight or obesity. The data extraction and
quality assessments for each review were conducted by one author and checked by a
second. The six high quality reviews provide evidence on the effectiveness of
behaviour changing interventions conducted in children <6 years (7 trials),
6-11 years (70 trials), adolescents 12-17 years (44 trials) and interventions
that target only parents of children aged 5-11 years (20 trials); in addition to 
interventions examining surgery (1 trial) and drugs (21 trials). Most of the
evidence was derived from high-income countries and published in the last two
decades. Collectively, the evidence suggests that multi-component behaviour
changing interventions may be beneficial in achieving small reductions in body
weight status in children of all ages, with low adverse event occurrence were
reported. More research is required to understand which specific intervention
components are most effective and in whom, and how best to maintain intervention 
effects. Evidence from surgical and drug interventions was too limited to make
inferences about use and safety, and adverse events were a serious consideration.


Estimating the Risk of Attempted Suicide Among Sexual Minority Youths A Systematic Review and Meta-analysis

Giacomo E, Krausz M, Colmegna F et al

Importance  Suicide is the second-leading cause of death among adolescents. Sexual minority individuals are at a higher risk of suicide and attempted suicide, but a precise and systematic evaluation of this risk among sexual minority youths has not been documented to our knowledge.
Objective  To examine the risk of attempted suicide among sexual minority adolescents, differentiating for each sexual minority group.
Data Sources  Electronic databases (PubMed, Embase, and PsycINFO) were searched for articles published through April 30, 2017, with the following search terms: heterosexualhomosexualbisexualtransgenderadolescentsteens, and attempted suicide.
Study Selection  Studies that reported attempted suicide in sexual minority adolescents compared with heterosexual peers were included. Thirty-five studies satisfied criteria for inclusion of 764 records identified.
Data Extraction and Synthesis  Pooled analyses were based on odds ratios (ORs), with relevant 95% CIs, weighting each study with inverse variance models with random effects. Risk of publication bias and analysis of heterogeneity through univariable and multivariable meta-regressions were also rated.
Main Outcomes and Measures  The evaluation of increased odds of attempted suicide among sexual minority youths compared with heterosexual peers.
Results  Thirty-five studies reported in 22 articles that involved a total of 2 378 987 heterosexual and 113 468 sexual minority adolescents (age range, 12-20 years) were included in the analysis. Sexual minority youths were generally at higher risk of attempted suicide (OR, 3.50; 95% CI, 2.98-4.12; c2 = 3074.01; P < .001; I2 = 99%). If estimated in each sexual minority group, the OR was 3.71 in the homosexual group (95% CI, 3.15-4.37; c2 = 825.20; P < .001; I2 = 97%) and 4.87 in the bisexual group (95% CI, 4.76-4.98; c2 = 980.02; P < .001; I2 = 98%); transgender youths were described as an individual group in only 1 study, which reported an OR of 5.87 (95% CI, 3.51-9.82). Meta-regressions weighted for the study weight highlighted that the presence of young participants (12 years old) was associated with heterogeneity in the bisexual group, whereas the year of sampling was associated with heterogeneity in the whole group when combined with other covariates.
Conclusions and Relevance  Our findings suggest that youths with nonheterosexual identity have a significantly higher risk of life-threatening behavior compared with their heterosexual peers. Public awareness is important, and a careful evaluation of supportive strategies (eg, support programs, counseling, and destigmatizing efforts) should be part of education and public health planning.

Acceleration of BMI in Early Childhood and Risk of Sustained Obesity

Geserick M Vogel M Gausche R et. al.

The dynamics of body-mass index (BMI) in children from birth to adolescence are unclear, and whether susceptibility for the development of sustained obesity occurs at a specific age in children is important to determine.
METHODSTo assess the age at onset of obesity, we performed prospective and retrospective analyses of the course of BMI over time in a population-based sample of 51,505 children for whom sequential anthropometric data were available during childhood (0 to 14 years of age) and adolescence (15 to 18 years of age). In addition, we assessed the dynamics of annual BMI increments, defined as the change in BMI standard-deviation score per year, during childhood in 34,196 children.
RESULTSIn retrospective analyses, we found that most of the adolescents with normal weight had always had a normal weight throughout childhood. Approximately half (53%) of the obese adolescents had been overweight or obese from 5 years of age onward, and the BMI standard-deviation score further increased with age. In prospective analyses, we found that almost 90% of the children who were obese at 3 years of age were overweight or obese in adolescence. Among the adolescents who were obese, the greatest acceleration in annual BMI increments had occurred between 2 and 6 years of age, with a further rise in BMI percentile thereafter. High acceleration in annual BMI increments during the preschool years (but not during the school years) was associated with a risk of overweight or obesity in adolescence that was 1.4 times as high as the risk among children who had had stable BMI. The rate of overweight or obesity in adolescence was higher among children who had been large for gestational age at birth (43.7%) than among those who had been at an appropriate weight for gestational age (28.4%) or small for gestational age (27.2%), which corresponded to a risk of adolescent obesity that was 1.55 times as high among those who had been large for gestational age as among the other groups.
CONCLUSIONSAmong obese adolescents, the most rapid weight gain had occurred between 2 and 6 years of age; most children who were obese at that age were obese in adolescence. (Funded by the German Research Council for the Clinical Research Center “Obesity Mechanisms” and others; ClinicalTrials.gov number, NCT03072537.)


AAP Policy Statement. Child passenger safety

This Policy Is A Revision Of The Policy In

  • PediatricsAugust 2018
    From the American Academy of PediatricsPolicy Statement


    Child Passenger Safety



    Child passenger safety has dramatically evolved over the past decade; however, motor vehicle crashes continue to be the leading cause of death for children 4 years and older. This policy statement provides 4 evidence-based recommendations for best practices in the choice of a child restraint system to optimize safety in passenger vehicles for children from birth through adolescence: (1) rear-facing car safety seats as long as possible; (2) forward-facing car safety seats from the time they outgrow rear-facing seats for most children through at least 4 years of age; (3) belt-positioning booster seats from the time they outgrow forward-facing seats for most children through at least 8 years of age; and (4) lap and shoulder seat belts for all who have outgrown booster seats. In addition, a fifth evidence-based recommendation is for all children younger than 13 years to ride in the rear seats of vehicles. It is important to note that every transition is associated with some decrease in protection; therefore, parents should be encouraged to delay these transitions for as long as possible. These recommendations are presented in the form of an algorithm that is intended to facilitate implementation of the recommendations by pediatricians to their patients and families and should cover most situations that pediatricians will encounter in practice. The American Academy of Pediatrics urges all pediatricians to know and promote these recommendations as part of child passenger safety anticipatory guidance at every health supervision visit.
  • Abbreviations:
    AAP — 
    American Academy of Pediatrics
    CSS — 
    car safety seat
  • 4.10.18

    Escoliosis idiopática del adolescente. ¿Algo nuevo sobre el cribado?

    AVC | Artículos Valorados Críticamente

    Dunn J, Henrikson NB, Morrison CC, Blasi PR, Nguyen M, Lin JS. Screening for adolescent idiopathic scoliosis: evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2018;319:173-87.
    Revisores: Orejón de Luna G1, Puebla Molina SF2.
    1CS General Ricardos. Madrid. España. 
    2Intensivista Pediátrico. Magíster en Epidemiología Clínica. Hospital San Juan de Dios de La Serena. Chile. 
    Correspondencia: Gloria Orejón de Luna. Correo electrónico: gloriaglo04@gmail.com
    Fecha de recepción: 03/09/2018
    Fecha de aceptación: 17/09/2018
    Fecha de publicación: 03/10/2018

    Resumen Estructurado

    Objetivo: evaluar los beneficios del cribado en la detección precoz de la escoliosis idiopática del adolescente (EIA).
    Diseño: revisión sistemática basada en 6 preguntas: si el cribado de la escoliosis idiopática del adolescente (EIA) mejora los resultados en salud del niño o el adulto o en el grado de gravedad de la EIA, cuán preciso es el cribado en la detección de la EIA, si el tratamiento de la EIA cuyo ángulo de Cobb es menor de 50° mejora los resultados en salud en la edad infantil o adulta o en la gravedad de la EIA, si existe asociación entre la gravedad de la EIA y los resultados de salud en la edad adulta, si existe daño con el cribado de la EIA y si existe daño en el tratamiento de la IEA en adolescentes que tienen un ángulo de Cobb de menos de 50°.
    Fuente de datos: se realizó una búsqueda sistemática de artículos publicados entre enero de 1966 y el 20 de octubre de 2016 en las bases de datos de los registros de ensayos clínicos controlados de Cochrane, OVID Medline, ERIC (Eric.ed.gov), PubMed y Cumulative Index to Nursing and Allied Health Literature (CINAHL). La búsqueda fue complementada en la plataforma de la Organización Mundial de la Salud (OMS) y en ClinicalTrial.gov.
    Selección de estudios: dos revisores evaluaron de forma independiente 8230 títulos y resúmenes y 1088 artículos según los criterios de inclusión preestablecidos. Las discrepancias se resolvieron por consenso. Para la pregunta de detección, la población de interés fueron niños asintomáticos entre 10 y 18 años, utilizando cualquier medición objetiva, siendo la más comúnmente usada el test de Adams. Para la pregunta de tratamiento los criterios de inclusión fueron niños y adolescentes de 10 a 18 años con el diagnóstico de EIA con un ángulo de Cobb de entre 10° y 50° al momento del diagnóstico. Se excluyeron niños con curvas con ángulos mayores a 50° porque estos pacientes son susceptibles de ser detectados clínicamente. Dependiendo de la pregunta, se incluyeron los diseños adecuados para contestar cada pregunta.
    Extracción de datos: se extrajeron los datos pertinentes de cada estudio y se construyeron tablas de evidencias estandarizadas adaptadas para cada pregunta y diseño de estudio. Se realiza una síntesis narrativa de los resultados. Por la heterogeneidad en los estudios no fue posible realizar un metanálisis.
    Resultados: no se encontraron estudios para responder la primera pregunta. La precisión del cribado aumentó con el número de test usados. Sensibilidad del 93,8% y especificidad del 92,2%, con un valor predictivo positivo del 81%, usando test de Adams, escoliómetro y topografía de Moiré. En un estudio usando test de Adams y escoliómetro, la precisión fue más baja. Sensibilidad del 71,1% y especificidad del 97,1%. El tratamiento ortopédico mostró beneficio respecto a los controles en un estudio prospectivo controlado, mejorando en 5-6° la progresión de la escoliosis. No hubo diferencias en los resultados de calidad de vida entre diferentes tratamientos ortopédicos. Dos ensayos clínicos aleatorizados evaluaron los ejercicios, demostrando mejoría significativa a los 12 meses de vida, comparando ejercicios específicos con ejercicios generales. Hubo una reducción en el ángulo de Cobb de 4,9° respecto al grupo control, que fue de 2,8°; estas diferencias son estadísticamente significativas. Se observó mejoría significativa en el ángulo de la curva de la escoliosis, 0,67° frente a 1,38° (p <0,05) a los 12 meses de observación como en la percepción de calidad de vida. Hubo diferencias no significativas en la asociación de la gravedad de la EIA y los resultados de salud en la edad adulta. No se encontraron estudios para evaluar daño al realizar el cribado. Un estudio de buena calidad metodológica de 242 adolescentes reportó dolores y molestias derivados de la terapia ortopédica. Las tasas de ansiedad y depresión fueron bajas y similares en ambos grupos.
    Conclusión: no hay suficiente evidencia para hacer una recomendación sobre la realización del cribado sistemático y universal de la escoliosis idiopática del adolescente.
    Conflicto de intereses: no existe.
    Fuente de financiación: Agency for Healthcare Research and Quality (AHRQ), US Department of Health and Human Services.

    Comentario Crítico

    Justificación: la escoliosis idiopática del adolescente es la desviación tridimensional de la columna vertebral en pacientes de más de 10 años, no causada por ninguna patología subyacente, de más de 10° de ángulo de Cobb y que generalmente se asocia a rotación vertebral1-4. Desde hace tiempo, existe una importante controversia sobre la eficacia e indicación de realizar cribado de la EIA1,5. Por una parte, se ha visto que el tratamiento precoz de la EIA, sobre todo antes de completar la maduración ósea, previene la progresión de la misma, evitando deformidades permanentes de la columna. Pero, por otra, no se ha encontrado una clara evidencia para recomendar un cribado sistemático y universal de la EIA3-5. Por todo ello y teniendo en cuenta que la escoliosis genera una gran ansiedad en los adolescentes y sus familias, parece interesante actualizar la posible indicación de dicho cribado.
    Validez o rigor científico: es una revisión sistemática realizada bajo los criterios de GRADE. Sus objetivos están bien definidos. Se ha realizado una búsqueda bibliográfica exhaustiva, especificando claramente los criterios de inclusión y exclusión, que fueron adecuados para los objetivos del estudio. La evaluación de la calidad también fue adecuada.
    Importancia clínica: el cribado es una intervención que se realiza en población sana y su principal objetivo debe ser mejorar los resultados de salud de la población a la que va dirigido, por lo que es importante que en el estudio se haya valorado la eficacia del tratamiento de la EIA. Si tomamos en cuenta que la prevalencia de la EIA es de 5,2%, probabilidad preprueba, y el valor predictivo positivo es de 86,54% (probabilidad posprueba)*, la información ganada es de 81 puntos porcentuales y si la prueba es negativa se descarta prácticamente el diagnóstico, fundamentalmente en los estudios de cohorte donde el cribado se realizó usando el test de Adams, escoliómetro y topografía de Moiré. En estas variables, los resultados no fueron tan alentadores, encontrando diferencias poco significativas entre el grupo de intervención y el grupo control, aunque el tratamiento con corsé o ejercicio parece disminuir la evolución de la curvatura en los adolescentes. No hubo evidencia de que el cribado de la EIA mejorase el pronóstico en la edad adulta. Otros estudios coinciden con estos mismos resultados, incluso asegurando que los riesgos de un cribado universal de la EIA son superiores a los beneficios, ya que al tener un VPP bajo, aumentaría el diagnóstico de falsos positivos, la realización de pruebas innecesarias y la ansiedad por la enfermedad en los adolescentes y sus familias1,2,5. Otros autores, aunque reconocen que no hay evidencia de que sea eficaz, recomiendan realizar el cribado de rutina sobre todo para detectar los pacientes con factores de riesgo (adolescentes que no han completado maduración ósea con curvas de más de 20° de ángulo de Cobb) para poder realizar un seguimiento y tratamiento adecuado3.
    Aplicabilidad en la práctica clínica: a la vista de los resultados, podemos decir que la controversia en cuanto a la realización del cribado de EIA no se ha solucionado. Sin embargo, esta revisión aporta más argumentos para no indicar la realización del cribado sistemático y universal en la población adolescente. Lo que sí parece estar indicado es realizar un seguimiento y tratamiento adecuado en los adolescentes con curvas escolióticas moderadas o graves. El hecho de que en la revisión sistemática se excluyeran los estudios no realizados en la población general o en centros de Atención Primaria, hace que los resultados sean más concluyentes para su aplicabilidad en este ámbito.
    Conflicto de intereses de los autores del comentario: no existe.


    1. Esparza Olcina MJ. Cribado de la escoliosis idiopática del adolescente. En: Recomendaciones PrevInfad/PAPPS [en línea] [actualizado en junio de 2014, consultado el 27/09/2018]. Disponible en: http://previnfad.aepap.org/monografia/escoliosis
    2. Plaszewski M, Bettany-Saltikov J. Are current scoliosis school screening recommendations evidence-based and up to date? A best evidence synthesis uymbrella review. Eur Spine J. 2014;23:2572-85.
    3. Burton MS. Diagnosis and treatment of adolescent idiopathic scoliosis. Pediatr Ann. 2013;42:224-8.
    4. El-Hawary R, Chukwunyerenwa CH. Update on evaluation and treatment of scoliosis. Pediatr Clin N Am. 2014;61:1223-41.
    5. Duerloo JA, Verkek PH. To screen or not to screen for adolescent idiopathic scoliosis? A review of the literature. Public Health. 2015;129:1267-72.

    Cómo citar este artículo

    Orejón de Luna G, Puebla Molina SG. Escoliosis idiopática del adolescente. ¿Algo nuevo sobre el cribado? Evid Pediatr. 2018;14:17.