Defining certainty of net benefit: a GRADE concept paper.

Alper BS, Oettgen P, Kunnamo I on behalf of The GRADE Working Group, et al


WHO guidelines on physical activity, sedentary behaviour and sleep for children under 5 years of age.

World Health Organization: Geneva; 2019. Licence: CC BY-NC-SA 3.0 IGO.

La nueva guía de la OMS sobre recomendaciones en actividad física, sedentarismo y sueño para menores de 5 años completa la anteriormente publicada, dirigida a los grupos de edad de 5-17 años, 18-64 años y más de 65 años.

En la publicación se revisa la información disponible sobre el impacto del sueño inadecuado y los comportamientos sedentarios en los niños, así como el beneficio de una mayor actividad. 
Se desarrollan una serie de recomendaciones separadas para bebés, de 1 a 2 años y de 3 a 4 años que enfatizan la actividad física y el sueño de buena calidad. Además, subrayan la importancia de que los niños no pasen más de una hora al día restringidos en cochecitos y recomiendan que pasen el menor tiempo posible frente a una pantalla.

Estos consejos han generado críticas de algunos expertos que cuestionan la calidad de la evidencia utilizada para hacer las recomendaciones, así como la viabilidad y los beneficios de limitar el tiempo de pantallas.


Outcomes of a Brief Cognitive Skills-Based Intervention (COPE) for Adolescents in the Primary Care Setting.

Erlich, Kimberly J. et al. 
Journal of Pediatric Health Care , Volume 0 , Issue 0 , Articles in Press.

Approximately 25% of adolescents have behavioral disorders, yet few receive treatment. Primary care (PC) screening for depression and anxiety is recommended; however treatments, such as cognitive behavioral therapy (CBT), are rarely available in PC settings. Our aim was to determine whether the use of a CBT-based intervention (COPE for Teens) is associated with improved outcomes on measures of depression and anxiety, and to understand the patient experience.
Health record data were examined, including questionnaires on depression (PHQ-A), anxiety (GAD-7), and experience with COPE. Differences between pre- and post-intervention scores were evaluated by paired t-tests. Questionnaire data were analyzed via thematic coding.
Thirty-seven patients (73% female; ages 12-18) completed pre- and post-intervention measures. Comparison showed decrease in PHQ-A scores by 2.1 (p = 0.0067) and GAD-7 scores by 2.3 (p= 0.0081). Questionnaire data demonstrate satisfaction with COPE.
Among these 37 adolescents, COPE provided effective PC-based behavioral treatment and a positive experience. Increased availability of COPE could improve care for adolescents.


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.)