21.11.16

Strategies to improve the implementation of healthy eating, physical activity and obesity prevention policies, practices or programmes within childcare services.

Wolfenden L1, Jones J, Williams CM, Finch M, Wyse RJ, Kingsland M, Tzelepis F, Wiggers J, Williams AJ, Seward K, Small T, Welch V, Booth D, Yoong SL.

BACKGROUND:
Despite the existence of effective interventions and best-practice guideline recommendations for childcare services to implement policies, practices and programmes to promote child healthy eating, physical activity and prevent unhealthy weight gain, many services fail to do so.
OBJECTIVES:
The primary aim of the review was to examine the effectiveness of strategies aimed at improving the implementation of policies, practices or programmes by childcare services that promote child healthy eating, physical activity and/or obesity prevention. The secondary aims of the review were to:1. describe the impact of such strategies on childcare service staff knowledge, skills or attitudes;2. describe the cost or cost-effectiveness of such strategies;3. describe any adverse effects of such strategies on childcare services, service staff or children;4. examine the effect of such strategies on child diet, physical activity or weight status.
SEARCH METHODS:
We searched the following electronic databases on 3 August 2015: the Cochrane Central Register of Controlled trials (CENTRAL), MEDLINE, MEDLINE In Process, EMBASE, PsycINFO, ERIC, CINAHL and SCOPUS. We also searched reference lists of included trials, handsearched two international implementation science journals and searched the World Health Organization International Clinical Trials Registry Platform (www.who.int/ictrp/) and ClinicalTrials.gov (www.clinicaltrials.gov).
SELECTION CRITERIA:
We included any study (randomised or non-randomised) with a parallel control group that compared any strategy to improve the implementation of a healthy eating, physical activity or obesity prevention policy, practice or programme by staff of centre-based childcare services to no intervention, 'usual' practice or an alternative strategy.
DATA COLLECTION AND ANALYSIS:
The review authors independently screened abstracts and titles, extracted trial data and assessed risk of bias in pairs; we resolved discrepancies via consensus. Heterogeneity across studies precluded pooling of data and undertaking quantitative assessment via meta-analysis. However, we narratively synthesised the trial findings by describing the effect size of the primary outcome measure for policy or practice implementation (or the median of such measures where a single primary outcome was not stated).
MAIN RESULTS:
We identified 10 trials as eligible and included them in the review. The trials sought to improve the implementation of policies and practices targeting healthy eating (two trials), physical activity (two trials) or both healthy eating and physical activity (six trials). Collectively the implementation strategies tested in the 10 trials included educational materials, educational meetings, audit and feedback, opinion leaders, small incentives or grants, educational outreach visits or academic detailing. A total of 1053 childcare services participated across all trials. Of the 10 trials, eight examined implementation strategies versus a usual practice control and two compared alternative implementation strategies. There was considerable study heterogeneity. We judged all studies as having high risk of bias for at least one domain.It is uncertain whether the strategies tested improved the implementation of policies, practices or programmes that promote child healthy eating, physical activity and/or obesity prevention. No intervention improved the implementation of all policies and practices targeted by the implementation strategies relative to a comparison group. Of the eight trials that compared an implementation strategy to usual practice or a no intervention control, however, seven reported improvements in the implementation of at least one of the targeted policies or practices relative to control. For these trials the effect on the primary implementation outcome was as follows: among the three trials that reported score-based measures of implementation the scores ranged from 1 to 5.1; across four trials reporting the proportion of staff or services implementing a specific policy or practice this ranged from 0% to 9.5%; and in three trials reporting the time (per day or week) staff or services spent implementing a policy or practice this ranged from 4.3 minutes to 7.7 minutes. The review findings also indicate that is it uncertain whether such interventions improve childcare service staff knowledge or attitudes (two trials), child physical activity (two trials), child weight status (two trials) or child diet (one trial). None of the included trials reported on the cost or cost-effectiveness of the intervention. One trial assessed the adverse effects of a physical activity intervention and found no difference in rates of child injury between groups. For all review outcomes, we rated the quality of the evidence as very low. The primary limitation of the review was the lack of conventional terminology in implementation science, which may have resulted in potentially relevant studies failing to be identified based on the search terms used in this review.
AUTHORS' CONCLUSIONS:
Current research provides weak and inconsistent evidence of the effectiveness of such strategies in improving the implementation of policies and practices, childcare service staff knowledge or attitudes, or child diet, physical activity or weight status. Further research in the field is required.

3.11.16

Brief Primary Care Obesity Interventions: A Meta-analysis.

Sim LA, Lebow J, Wang Z, Koball A, Murad MH.

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.

1.11.16

Public Comment on Draft Recommendation Statement and Draft Evidence Review: Screening for Obesity in Children and Adolescents

The U.S. Preventive Services Task Force seeks comments on a draft recommendation statement and draft evidence review on screening for obesity in children and adolescents. Based on its review of the evidence, the Task Force recommends screening for obesity in children and adolescents age 6 years and older and offering or referring them to comprehensive, intensive behavioral interventions to promote improvements in weight status. This is a B recommendation. 
The draft recommendation statement and draft evidence review are available for review and public comment from November 1 through November 28, 2016.

Motor Development Interventions for Preterm Infants: A Systematic Review and Meta-analysis.

Hughes AJ, Redsell SA, Glazebrook C.

CONTEXTS:
Preterm infants are at an increased risk of neurodevelopmental delay. Some studies report positive intervention effects on motor outcomes, but it is currently unclear which motor activities are most effective in the short and longer term.
OBJECTIVE:
The aim of the study was to identify interventions that improve the motor development of preterm infants.
DATA SOURCES:
An a priori protocol was agreed upon. Seventeen electronic databases from 1980 to April 2015 and gray literature sources were searched.
STUDY SELECTION:
Three reviewers screened the articles.
DATA EXTRACTION:
The outcome of interest was motor skills assessment scores. All data collection and risk of bias assessments were agreed upon by the 3 reviewers.
RESULTS:
Forty-two publications, which reported results from 36 trials (25 randomized controlled trials and 11 nonrandomized studies) with a total of 3484 infants, met the inclusion criteria. A meta-analysis was conducted by using standardized mean differences on 21 studies, with positive effects found at 3 months (mean 1.37; confidence interval 0.48-2.27), 6 months (0.34; 0.11-0.57), 12 months (0.73; 0.20-1.26), and 24 months (0.28; 0.07-0.49). At 3 months, there was a large and significant effect size for motor-specific interventions (2.00; 0.28-3.72) but not generic interventions (0.33; -0.03 to -0.69). Studies were not excluded on the basis of quality; therefore, heterogeneity was significant and the random-effects model was used.
LIMITATIONS:
Incomplete or inconsistent reporting of outcome measures limited the data available for meta-analysis beyond 24 months.
CONCLUSIONS:
A positive intervention effect on motor skills appears to be present up to 24 months' corrected age. There is some evidence at 3 months that interventions with specific motor components are most effective.
PMID: 27638931 DOI: 10.1542/peds.2016-0147

30.10.16

Primary Care Interventions to Support Breastfeeding. Updated Evidence Report and Systematic Review for the US Preventive Services Task Force.


Carrie D. Patnode, PhD; Michelle L. Henninger, PhD; Caitlyn A. Senger, MPH1; et al Leslie A. Perdue, MPH; Evelyn P. Whitlock, MD.

Importance  Although 80% of infants in the United States start breastfeeding, only 22% are exclusively breastfed up to around 6 months as recommended by a number of professional organizations.
Objective  To systematically review the evidence on the benefits and harms of breastfeeding interventions to support the US Preventive Services Task Force in updating its 2008 recommendation.
Data Sources  MEDLINE, PubMed, Cumulative Index for Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, and PsycINFO for studies published in the English language between January 1, 2008, and September 25, 2015. Studies included in the previous review were re-evaluated for inclusion. Surveillance for new evidence in targeted publications was conducted through January 26, 2016.
Study Selection  Review of randomized clinical trials and before-and-after studies with concurrent controls conducted in a developed country that evaluated a primary care–relevant breastfeeding intervention among mothers of full- or near-term infants. Of 211 full-text articles reviewed, 52 studies met inclusion criteria. Thirty-one studies were newly identified, and 21 studies were carried forward from the previous review.
Data Extraction and Synthesis  Independent critical appraisal of all provisionally included studies. Data were independently abstracted by one reviewer and confirmed by another.
Main Outcomes and Measures  Child and maternal health outcomes, rates and duration of breastfeeding, and harms related to interventions as prespecified before data collection.
Results  Fifty-two studies (n = 66 757) in 57 publications were included. Six trials (n = 2219) reported inconsistent effects of the interventions on infant health outcomes; no studies reported maternal health outcomes. Pooled estimates based on random-effects meta-analyses using the DerSimonian and Laird method indicated beneficial associations between individual-level breastfeeding interventions and any breastfeeding for less than 3 months (risk ratio [RR], 1.07 [95% CI, 1.03-1.11]; 26 studies [n = 11 588]), at 3 to less than 6 months (RR, 1.11 [95% CI, 1.04-1.18]; 23 studies [n = 8942]), and for exclusive breastfeeding for less than 3 months (RR, 1.21 [95% CI, 1.11-1.33]; 22 studies [n = 8246]), 3 to less than 6 months (RR, 1.20 [95% CI, 1.05-1.38]; 18 studies [n = 7027]), and at 6 months (RR, 1.16 [95% CI, 1.02-1.32]; 17 studies [n = 7690]). Absolute differences in the rates of any breastfeeding ranged from 14.1% in favor of the control group to 18.4% in favor of the intervention group. There was no significant association between interventions and breastfeeding initiation (RR, 1.00 [95% CI, 0.99-1.02]; 14 studies [n = 9428]). There was limited mixed evidence of an association between system-level interventions and rates of breastfeeding from well-controlled studies as well as for harms related to breastfeeding interventions, including maternal anxiety scores, decreased confidence, and concerns about confidentiality.
Conclusions and Relevance  The updated evidence confirms that breastfeeding support interventions are associated with an increase in the rates of any and exclusive breastfeeding. There are limited well-controlled studies examining the effectiveness of system-level policies and practices on rates of breastfeeding or child health and none for maternal health.

Primary Care Interventions to Support Breastfeeding. US Preventive Services Task Force Recommendation Statement.


US Preventive Services Task Force

Importance  There is convincing evidence that breastfeeding provides substantial health benefits for children. However, nearly half of all US mothers who initially breastfeed stop doing so by 6 months, and there are significant disparities in breastfeeding rates among younger mothers and in disadvantaged communities.
Objective  To update the 2008 US Preventive Services Task Force (USPSTF) recommendation on primary care interventions to promote breastfeeding.
Evidence Review  The USPSTF reviewed the evidence on the effectiveness of interventions to support breastfeeding on breastfeeding initiation, duration, and exclusivity. The USPSTF also briefly reviewed the literature on the effects of these interventions on child and maternal health outcomes.
Findings  The USPSTF found adequate evidence that interventions to support breastfeeding, including professional support, peer support, and formal education, change behavior and that the harms of these interventions are no greater than small. The USPSTF concludes with moderate certainty that interventions to support breastfeeding have a moderate net benefit.
Conclusions and Recommendation  The USPSTF recommends providing interventions during pregnancy and after birth to support breastfeeding. (B recommendation)

26.10.16

Predictive Validity of the Modified Checklist for Autism in Toddlers (M-CHAT) Born Very Preterm.

Kim SH, Joseph RM, Frazier JA, O'Shea TM, Chawarska K, Allred EN(6), Leviton A(6), Kuban KK; Extremely Low Gestational Age Newborn (ELGAN) Study Investigators.

Objective
To examine the predictive validity of the Modified Checklist for Autism in Toddlers (M-CHAT) administered at age 24 months for autism spectrum disorder (ASD) diagnosed at 10 years of age in a US cohort of 827 extremely low gestational age newborns (ELGANs) followed from birth.

Study design
We examined the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the M-CHAT in predicting an ASD diagnosis at age 10 years based on gold standard diagnostic instruments. We then assessed how these predictive parameters were affected by sensorimotor and cognitive impairments, socioeconomic status (SES), and emotional/behavioral dysregulation at age 2 years.

Results
Using standard criteria, the M-CHAT had a sensitivity of 52%, a specificity of 84%, a PPV of 20%, and an NPV of 96%. False-positive and false-negative rates were high among children with hearing and vision impairments. High false-positive rates also were associated with lower SES, motor and cognitive impairments, and emotional/behavioral dysregulation at age 2 years.

Conclusions
Among extremely preterm children with ASD, almost one-half were not correctly screened by the M-CHAT at age 2 years. Sensorimotor and cognitive impairments, SES, and emotional/behavioral dysregulation contributed significantly to M-CHAT misclassifications. Clinicians are advised to consider these factors when screening very preterm toddlers for ASD.

23.10.16

Brief Primary Care Obesity Interventions: A Meta-analysis.

Sim LA(1), Lebow J(2), Wang Z(3), Koball A(4), Murad MH(3).

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.

10.10.16

Data Linkage Strategies To Advance Youth Suicide Prevention.

Holly C. Wilcox, PhD; Hadi Kharrazi, MHI, MD, PhD; Renee F. Wilson, MS; Rashelle J. Musci, PhD; Ryoko Susukida, PhD; Fardad Gharghabi, MD; Allen Zhang, BS; Lawrence Wissow, MD, MPH; and Karen A. Robinson, PhD

Background: Linking national, state, and community data systems to data from prevention programs could allow for longer-term assessment of outcomes and evaluation of interventions to prevent suicide.
Purpose: To identify and describe data systems that can be linked to data from prevention studies to advance youth suicide prevention research.
Data Sources: A systematic review, an environmental scan, and a targeted search were conducted to identify prevention studies and potentially linkable external data systems with suicide outcomes from January 1990 through December 2015.
Study Selection: Studies and data systems had to be U.S.-based and include persons aged 25 years or younger. Data systems also had to include data on suicide, suicide attempt, or suicidal ideation.
Data Extraction: Information about participants, intervention type, suicide outcomes, primary analytic method used for linkage, statistical approach, analyses performed, and characteristics of data systems was abstracted by 2 reviewers.
Data Synthesis: Of 47 studies (described in 59 articles) identified in the systematic review, only 6 were already linked to data systems. A total of 153 unique and potentially linkable data systems were identified, but only 66 were classified as “fairly accessible” and had data dictionaries available. Of the data systems identified, 19% were established primarily for research, 11% for clinical care or operations, 29% for administrative services (such as billing), and 52% for surveillance. About one third (37%) provided national data, 12% provided regional data, 63% provided state data, and 41% provided data below the state level (some provided coverage for >1 geographic unit).
Limitation: Only U.S.-based studies published in English were included.
Conclusion: There is untapped potential to evaluate and enhance suicide prevention efforts by linking suicide prevention data with existing data systems. However, sparse availability of data dictionaries and lack of adherence to standard data elements limit this potential.
 Primary Funding Source: Agency for Healthcare Research and Quality.