Priority setting in paediatric preventive care research.

Lavigne M, Birken CS, Maguire JL, Straus S, Laupacis A.

OBJECTIVES: To identify the unanswered research questions in paediatric preventive care that are most important to parents and clinicians, and to explore how questions from parents and clinicians may differ.
DESIGN: Iterative mixed methods research priority setting process.
SETTING: Toronto, Ontario, Canada.
PARTICIPANTS: Parents of children aged 0-5 years enrolled in a research network in Toronto, and clinicians practising in Toronto, Ontario, Canada.
INTERVENTIONS: Informed by the James Lind Alliance's methodology, an online questionnaire collected unanswered research questions in paediatric preventive care from study participants. Similar submissions were combined and ranked. A consensus workshop attended by 28 parents and clinicians considered the most highly ranked submissions and used the nominal group technique to select the 10 most important unanswered research questions.
RESULTS: Forty-two clinicians and 115 parents submitted 255 and 791 research questions, respectively, which were combined into 79 indicative questions. Most submissions were about nutrition, illness prevention, parenting and behavior management. Parents were more likely to ask questions about screen time (49 parents vs 8 clinicians, p<0.05) and environmental toxins (18 parents vs 0 clinicians, p<0.05). The top 10 unanswered questions identified at the workshop related to mental health, parental stress, physical activity, obesity, childhood development, behaviour management and screen time.
CONCLUSION: The top 10 most important unanswered research questions in paediatric preventive care from the perspective of parents and clinicians were identified. These research priorities may be important in advancing preventive healthcare for children.


Provider Perspectives on Adding Biomarker Screening for Tobacco Smoke Exposure to Lead Screening at Well-Child Visits.

Ghidei W, Brottman G, Lenne E, Quan T, Joseph A.

INTRODUCTION: Measurement of cotinine, a biomarker of tobacco smoke exposure, can accurately identify children at risk of health consequences from secondhand smoke. This study reports perspectives from pediatric health care providers on incorporating routine cotinine screening into well-child visits.
METHODS: Key informant interviews (N = 28) were conducted with pediatric primary  care providers: physicians, nurse practitioners, and registered nurses.
RESULTS: Themes identified in the interviews included the following: (a) Cotinine screening would assess children's exposure to tobacco smoke more reliably tan parental report; (b) Addressing positive cotinine screening results might require additional resources; (c) Wheezing and a history of emergency department visits increased the salience of cotinine screening; and (d) A better understanding of the significance of specific cotinine test values would improve utility.
DISCUSSION: Pediatric providers see advantages of biomarker screening for tobacco smoke exposure at well-child visits, especially for children with wheezing, but have concerns about limited capacity for follow-up with parents.

A Clinical Care Algorithmic Toolkit for Promoting Screening and Next-Level Assessment of Pediatric Depression and Anxiety in Primary Care.

Honigfeld L, Macary SJ, Grasso DJ.
With a documented shortage in youth mental health services, pediatric primary care (PPC) providers face increased pressure to enhance their capacity to identify and manage common mental health problems among youth, such as anxiety and depression. Because 90% of U.S. youth regularly see a PPC provider, the primary care setting is well positioned to serve as a key access point for early identification, service provision, and connection to mental health services. In to assist PPC providers in overcoming barriers to practice-wide mental health the context of task shifting, we evaluated a quality improvement project designed screening through implementing paper and computer-assisted clinical care family mental health histories, next-level actions, and referral options. Task algorithms. PPC providers were fairly successful at changing practice to better address mental health concerns when equipped with screening tools that included when guided by computer-assisted algorithms. shifting is a promising strategy to enhance mental health services, particularly when guided by computer-assisted algorithms.


Lifestyle Interventions in Preschool Children: A Meta-analysis of Effectiveness.

Ling J, Robbins LB, Wen F, Zhang N.

CONTEXT: With healthy behaviors becoming established in the preschool years, intervening with preschool children to assist them in establishing a healthy lifestyle and maintaining a long-term healthy weight is critical. To optimize future intervention designs, this meta-analysis aimed to estimate the effects of  lifestyle interventions on BMI among preschool children and explore potential
intervention moderators.
EVIDENCE ACQUISITION: In October 2015, a search of PubMed, CINAHL, EMBASE, PsycINFO, ERIC, and Cochrane library databases yielded 52 eligible articles with  42 randomized intervention-control comparisons (31 prevention and 11 treatment).  In 2016, weighted standardized mean differences for BMI were calculated using random-effects models to estimate effect sizes.
EVIDENCE SYNTHESIS: The effect sizes were -0.19 (95% CI= -0.28, -0.09) and -0.28  (95% CI= -0.48, -0.09) kg/m(2) for prevention and treatment interventions, with sustained effect sizes of -0.21 (95% CI= -0.35, -0.08) and -0.23 (95% CI= -0.43,  -0.04) kg/m(2), respectively. Child mean age, percentage Hispanic, and parental intervention sessions were common significant moderators. School-based or prevention interventions with active parental involvement did not yield better outcomes. Interventions targeting parents with parenting skill training and behavioral change strategies, and children with general health and nutrition education, resulted in greater effects.
CONCLUSIONS: Although publication bias limits the validity of the study findings, the meta-analysis results highlight the promising intervention approaches of parenting skill training and behavioral change strategies to target parents.
However, for children, general health and nutrition education should be employed.


The Identification of Psychosocial Risk Factors Associated With Child Neglect Using the WE-CARE Screening Tool in a High-Risk Population.

Zielinski, S., Paradis, H. A., Herendeen, P., & Barbel, P. 

Neglect accounts for over 70% of child maltreatment and carries significant sequelae. Identification of psychosocial determinants of health may allow pediatric providers to ameliorate precursors of child neglect.
Data were collected 1 month before and after implementation of the Well-Child Care Visit, Evaluation, Community Resources, Advocacy, Referral, Education (i.e., WE-CARE) screen at all well-child visits. Social workers recorded number and types of referrals, and providers completed surveys.
Analysis of 602 completed screens (75% capture rate) showed 377 families (63%) with at least one need and 198 (33% overall, 53% of those with positive results) indicating a desire to discuss. Of families requesting assistance, 122 (62%) connected with a social worker, and total referrals increased after implementation. Provider surveys supported an increased frequency of and comfort with assessing families for certain risk factors, and screening was not perceived to interrupt clinic flow.
Standardized screening identifies families at risk for neglect, improves provider comfort, and minimally affects flow. Identification of psychosocial needs should be part of routine preventive care.


Multilevel Correlates of Healthy BMI Maintenance and Return to a Healthy BMI among Children in Massachusetts.

Fiechtner L, Cheng ER, Lopez G, Sharifi M, Taveras EM. 

To examine predictors of healthy BMI maintenance (HBM) or return to a healthy BMI (RHB) among children.
We studied 33,272 children in Massachusetts between 2008 and 2012. We used multinomial logistic regression to examine associations of individual- and neighborhood-level factors with the odds of: (1) HBM: maintenance of a healthy BMI ≥5th to <85th percentile and (2) RHB: transition to a healthy BMI range from  an initial BMI ≥85th percentile between two clinic visits spanning an average of 
3.5 years.
Racial/ethnic minorities had lower odds of HBM and RHB than non-Hispanic white children. Higher neighborhood educational attainment was associated with an increased odds of HBM and RHB. Higher neighborhood median household income, proximity to a supermarket, and access to more open recreational space were associated with a higher odds of HBM. Children of ages 2-5 years at baseline had  higher odds of RHB and HBM than children 13 years and older.
Early childhood interventions and efforts to create health-promoting neighborhoods including improving access to supermarkets and open recreational space could have important effects on obesity prevention and management.


WITHDRAWN: Community-based population-level interventions for promoting child oral health.

de Silva AM, Hegde S, Akudo Nwagbara B, Calache H, Gussy MG, Nasser M, Morrice
HR, Riggs E, Leong PM, Meyenn LK, Yousefi-Nooraie R. 
Update of Cochrane Database Syst Rev. 2016 Sep 15;9:CD009837.

Dental caries and gingival and periodontal disease are commonly occurring, preventable chronic conditions. Even though much is known about how to treat oral disease, currently we do not know which community-based population-level interventions are most effective and equitable in preventing
poor oral health.
Primary • To determine the effectiveness of community-based population-level oral health promotion interventions in preventing dental caries  and gingival and periodontal disease among children from birth to 18 years of age. Secondary • To determine the most effective types of interventions (environmental, social, community and multi-component) and guiding theoretical frameworks.• To identify interventions that reduce inequality in oral health outcomes.• To examine the influence of context in the design, delivery and outcomes of interventions.
We searched the following databases from January 1996 to April 2014: MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Education Resource Information Center (ERIC), BIOSIS Previews, Web of Science, the Database of Abstracts of Reviews of Effects (DARE), ScienceDirect,
Sociological Abstracts, Social Science Citation Index, PsycINFO, SCOPUS, ProQuest Dissertations & Theses and Conference Proceedings Citation Index - Science.
Included studies were individual- and cluster-randomised controlled trials (RCTs), controlled before-and-after studies and quasi-experimental and interrupted time series. To be included, interventions had to target the primary outcomes: dental caries (measured as decayed, missing and filled deciduous teeth/surfaces, dmft/s; Decayed, Missing and Filled permanent teeth/surfaces, DMFT/S) and gingival or periodontal disease among children from birth to 18 years of age. Studies had to report on one or more of the primary outcomes at baseline and post intervention, or had to provide change scores for
both intervention and control groups. Interventions were excluded if they were solely of a chemical nature (e.g. chlorhexidine, fluoride varnish), were delivered primarily in a dental clinical setting or comprised solely fluoridation.
Two review authors independently performed screening, data extraction and assessment of risk of bias of included studies (a  team of six review authors - four review authors and two research assistants - assessed all studies). We calculated mean differences with 95% confidence intervals for continuous data. When data permitted, we undertook meta-analysis of primary outcome measures using a fixed-effect model to summarise results across studies. We used the I(2) statistic as a measure of statistical heterogeneity.
This review includes findings from 38 studies (total n = 119,789 children, including one national study of 99,071 children, which contributed 80% of total participants) on community-based oral health promotion interventions delivered in a variety of settings and incorporating a range of health promotion  strategies (e.g. policy, educational activities, professional oral health care, supervised toothbrushing programmes, motivational interviewing). We categorised interventions as dietary interventions (n = 3), oral health education (OHE) alone (n = 17), OHE in combination with supervised toothbrushing with fluoridated toothpaste (n = 8) and OHE in combination with a variety of other interventions (including professional preventive oral health care, n = 10). Interventions generally were implemented for less than one year (n = 26), and only 11 studies were RCTs. We graded the evidence as having moderate to very low quality.We conducted meta-analyses examining impact on dental caries of each intervention type, although not all studies provided sufficient data to allow pooling of effects across similar interventions. Meta-analyses of the effects of OHE alone on caries may show little or no effect on DMFT (two studies, mean difference (MD) 0.12, 95% confidence interval (CI) -0.11 to 0.36, low-quality evidence), dmft (three studies, MD -0.3, 95% CI -1.11 to 0.52, low-quality evidence) and DMFS (one study, MD -0.01, 95% CI -0.24 to 0.22, very low-quality evidence). Analysis  of studies testing OHE in combination with supervised toothbrushing with fluoridated toothpaste may show a beneficial effect on dmfs (three studies, MD -1.59, 95% CI -2.67 to -0.52, low-quality evidence) and dmft (two studies, MD -0.97, 95% CI -1.06 to -0.89, low-quality evidence) but may show little effect on DMFS (two studies, MD -0.02, 95% CI -0.13 to 0.10, low-quality evidence) and DMFT (three studies, MD -0.02, 95% CI -0.11 to 0.07, moderate-quality evidence).
Meta-analyses of two studies of OHE in an educational setting combined with professional preventive oral care in a dental clinic setting probably show a very small effect on DMFT (-0.09 weighted mean difference (WMD), 95% CI -0.1 to -0.08, moderate-quality evidence). Data were inadequate for meta-analyses on gingival health, although positive impact was reported.
This review provides evidence of low certainty suggesting that community-based oral health promotion interventions that combine oral health education with supervised toothbrushing or professional preventive oral care can  reduce dental caries in children. Other interventions, such as those that aim to  promote access to fluoride, improve children's diets or provide oral health education alone, show only limited impact. We found no clear indication of when is the most effective time to intervene during childhood. Cost-effectiveness, long-term sustainability and equity of impacts and adverse outcomes were not widely reported by study authors, limiting our ability to make inferences on these aspects. More rigorous measurement and reporting of study results would improve the quality of the evidence.

Updated Priorities Among Effective Clinical Preventive Services.

Michael V. Maciosek, Amy B. LaFrance, Steven P. Dehmer, Dana A. McGree, Thomas J. Flottemesch, Zack Xu, and Leif I. Solberg.

The Patient Protection and Affordable Care Act’s provisions for first-dollar coverage of evidence-based preventive services have reduced an important barrier to receipt of preventive care. Safety-net providers, however, still serve a substantial uninsured population, and clinician and patient time remain limited in all primary care settings. As a consequence, decision makers continue to set priorities to help focus their efforts. This report updates estimates of relative health impact and cost-effectiveness for evidence-based preventive services.
We assessed the potential impact of 28 evidence-based clinical preventive services in terms of their cost-effectiveness and clinically preventable burden, as measured by quality-adjusted life years (QALYs) saved. Each service received 1 to 5 points on each of the 2 measures—cost-effectiveness and clinically preventable burden—for a total score ranging from 2 to 10. New microsimulation models were used to provide updated estimates of 12 of these services. Priorities for improving delivery rates were established by comparing the ranking with what is known of current delivery rates nationally.
The 3 highest-ranking services, each with a total score of 10, are immunizing children, counseling to prevent tobacco initiation among youth, and tobacco-use screening and brief intervention to encourage cessation among adults. Greatest population health improvement could be obtained from increasing utilization of clinical preventive services that address tobacco use, obesity-related behaviors, and alcohol misuse, as well as colorectal cancer screening and influenza vaccinations.
This study identifies high-priority preventive services and should help decision makers select which services to emphasize in quality-improvement initiatives.


Infection: US Preventive Services Task Force Recommendation Statement.

Bibbins-Domingo K, Grossman DC, Curry SJ, et al. Serologic Screening for Genital Herpes

Genital herpes is a prevalent sexually transmitted infection in the United States, occurring in almost 1 in 6 persons aged 14 to 49 years. Infection is caused by 2 subtypes of the herpes simplex virus (HSV), HSV-1 and HSV-2. Antiviral medications may provide symptomatic relief from outbreaks but do not cure HSV infection. Neonatal herpes infection, while uncommon, can result in substantial morbidity and mortality.
Objective: To update the 2005 US Preventive Services Task Force (USPSTF) recommendation on screening for genital herpes.
Evidence Review: The USPSTF reviewed the evidence on the accuracy, benefits, and harms of serologic screening for HSV-2 infection in asymptomatic persons, including those who are pregnant, as well as the effectiveness and harms of preventive medications and behavioral counseling interventions to reduce future symptomatic episodes and transmission to others.
Findings: Based on the natural history of HSV infection, its epidemiology, and the available evidence on the accuracy of serologic screening tests, the USPSTF concluded that the harms outweigh the benefits of serologic screening for genital HSV infection in asymptomatic adolescents and adults, including those who are pregnant.
Conclusions and Recommendation: The USPSTF recommends against routine serologic screening for genital HSV infection in asymptomatic adolescents and adults, including those who are pregnant. (D recommendation).

School-Age Outcomes of Early Intervention for Preterm Infants and Their Parents: A Randomized Trial.

Spittle AJ, Barton S, Treyvaud K, et al.

OBJECTIVE: To examine the child and parental outcomes at school age of a randomized controlled trial of a home-based early preventative care program for infants born very preterm and their caregivers.

METHODS: At term-equivalent age, 120 infants born at a gestational age of <30 weeks were randomly allocated to intervention (n = 61) or standard care (n = 59) groups. The intervention included 9 home visits over the first year of life focusing on infant development, parental mental health, and the parent-infant relationship. At 8 years' corrected age, children's cognitive, behavioral, and motor functioning and parental mental health were assessed. Analysis was by intention to treat.

RESULTS: One hundred children, including 13 sets of twins, attended follow-up (85% follow-up of survivors). Children in the intervention group were less likely to have mathematics difficulties (odds ratio, 0.42; 95% confidence interval [CI], 0.18 to 0.98; P = .045) than children in the standard care group, but there was no evidence of an effect on other developmental outcomes. Parents in the intervention group reported fewer symptoms of depression (mean difference, -2.7; 95% CI, -4.0 to -1.4; P < .001) and had reduced odds for mild to severe depression (odds ratio, 0.14; 95% CI, 0.03 to 0.68; P = .0152) than parents in the standard care group.

CONCLUSIONS: An early preventive care program for very preterm infants and their parents had minimal long-term effects on child neurodevelopmental outcomes at the 8-year follow-up, whereas primary caregivers in the intervention group reported less depression.