14.4.20

Treatment of Depression in Children and Adolescents: A Systematic Review.

Viswanathan M, Kennedy SM, McKeeman J, Christian R, Coker-Schwimmer M, Cook Middleton J, Bann C, Lux L, Randolph C, Forman-Hoffman V. 

Background. Depressive disorders can affect long-term mental and physical health functioning among children and adolescents, including increased risk of suicide. Despite access to several nonpharmacological, pharmacological, and combined treatment options for childhood depression, clinicians contend with sparse evidence and are concerned about harms associated with treatment.

Methods. We conducted a systematic review to evaluate the efficacy, comparative effectiveness, and moderators of benefits and harms of available nonpharmacological and pharmacological treatments for children and adolescents with a confirmed diagnosis of a depressive disorder (DD)—major depressive disorder (MDD), persistent depressive disorder (previously termed dysthymia) or DD not otherwise specified. We searched five databases and other sources for evidence available from inception to May 29, 2019, dually screened the results, and analyzed eligible studies.

Results. We included in our analyses data from 60 studies (94 articles) that met our review eligibility criteria. For adolescents (study participants’ ages range from 12 to 18 years) with MDD, cognitive behavioral therapy (CBT), fluoxetine, escitalopram, and combined fluoxetine and CBT may improve depressive symptoms (1 randomized controlled trial [RCT] each, n ranges from 212 to 311); whether the magnitude of improvement is clinically significant is unclear. Among adolescents or children with MDD, CBT plus medications (8–17 years) may be associated with lower rates of relapse (1 RCT [n = 121]). In the same population (6–17 years), selective serotonin reuptake inhibitors (SSRIs) may be associated with improved response (7 RCTs [n = 1,525]; risk difference [RD], 72/1,000 [95% confidence interval (CI), 2 to 24], I2 = 9%) and functional status (5 RCTs [n = 941]; standardized mean difference, 0.16 [95% CI, 0.03 to 0.29]; I2 = 0%). For adolescents or children with any DD (7–18 years), CBT or family therapy may be associated with improvements in symptoms, response, or functional status (1 RCT each, n ranges from 64 to 99). Among children with any DD (7–12 years), family-based interpersonal therapy may be associated with improved symptoms (1 RCT, n = 38). Psychotherapy trials did not report harms. SSRIs may be associated with a higher risk of serious adverse events among adolescents or children with MDD (7–18 years; 9 RCTs [n = 2,206]; RD, 20/1,000 [95% CI, 1 to 440]; I2, 4%) and with a higher risk of withdrawal due to adverse events among adolescents with MDD (12–18 years; 4 RCTs [n = 1,296], RD, 26/1,000 [95% CI, 6 to 45]; I2, 0%). Paroxetine (1 RCT [n = 180]) may be associated with a higher risk of suicidal ideation or behaviors among adolescents with MDD (12–18 years). Evidence was insufficient to judge the risk of suicidal ideation or behavior for other SSRIs for adolescents and children with MDD or other DD (7–18 years) (10 RCTs [n = 2,368]; relative risk, 1.14 [95% CI, 0.89 to 1.45]; I2, 8%). However, this report excluded data on inpatients and those without depressive disorders, whom the Food and Drug Administration included in finding an increased risk of suicidality for all antidepressants across all indications.

Conclusion. Efficacious treatments exist for adolescents with MDD. SSRIs may be associated with increased withdrawal and serious adverse events. No evidence on harms of psychotherapy were identified.

3.12.19


Global Prevalence of Hypertension in ChildrenA Systematic Review and Meta-analysis


Song P, Zhang Y, Yu J, Zha M, Zhu Y, Rahimi K, Rudan I.
JAMA Pediatr. 2019;173(12):1154-1163. doi:10.1001/jamapediatrics.2019.3310

Key Points

Question: What is the prevalence of hypertension in the general pediatric population
Findings:  In this systematic review and meta-analysis of 47 articles, the prevalence of childhood hypertension increased from 1994 to 2018 and the increase was associated with higher body mass index, with the pooled estimate being 4.00% among individuals 19 years and younger. In 2015, the prevalence of childhood hypertension ranged from 4.32% among children aged 6 years to 3.28% among those aged 19 years and peaked at 7.89% among those aged 14 years.
Meaning: The findings suggest that childhood hypertension is becoming more common in the general pediatric population, representing a considerable public health challenge worldwide.

Abstract
Importance: Reliable estimates of the prevalence of childhood hypertension serve as the basis for adequate prevention and treatment. However, the prevalence of childhood hypertension has rarely been synthesized at the global level.
Objective: To conduct a systematic review and meta-analysis to assess the prevalence of hypertension in the general pediatric population.
Data Sources: PubMed, MEDLINE, Embase, Global Health, and Global Health Library were searched from inception until June 2018, using search terms related to hypertension (hypertension OR high blood pressure OR elevated blood pressure), children (children OR adolescents), and prevalence (prevalence OR epidemiology).
Study Selection: Studies that were conducted in the general pediatric population and quantified the prevalence of childhood hypertension were eligible. Included studies had blood pressure measurements from at least 3 separate occasions.
Data Extraction and Synthesis: Two authors independently extracted data. Random-effects meta-analysis was used to derive the pooled prevalence. Variations in the prevalence estimates in different subgroups, including age group, sex, setting, device, investigation period, BMI group, World Health Organization region and World Bank region, were examined by subgroup meta-analysis. Meta-regression was used to establish the age-specific prevalence of childhood hypertension and to assess its secular trend.
Main Outcomes and Measures: Prevalence of childhood hypertension overall and by subgroup.
Results: A total of 47 articles were included in the meta-analysis. The pooled prevalence was 4.00% (95% CI, 3.29%-4.78%) for hypertension, 9.67% (95% CI, 7.26%-12.38%) for prehypertension, 4.00% (95% CI, 2.10%-6.48%) for stage 1 hypertension, and 0.95% (95% CI, 0.48%-1.57%) for stage 2 hypertension in children 19 years and younger. In subgroup meta-analyses, the prevalence of childhood hypertension was higher when measured by aneroid sphygmomanometer (7.23% vs 4.59% by mercury sphygmomanometer vs 2.94% by oscillometric sphygmomanometer) and among overweight and obese children (15.27% and 4.99% vs 1.90% among normal-weight children). A trend of increasing prevalence of childhood hypertension was observed during the past 2 decades, with a relative increasing rate of 75% to 79% from 2000 to 2015. In 2015, the prevalence of hypertension ranged from 4.32% (95% CI, 2.79%-6.63%) among children aged 6 years to 3.28% (95% CI, 2.25%-4.77%) among those aged 19 years and peaked at 7.89% (95% CI, 5.75%-10.75%) among those aged 14 years.
Conclusions and Relevance: This study provides a global estimation of childhood hypertension prevalence based on blood pressure measurements in at least 3 separate visits. More high-quality epidemiologic investigations on childhood hypertension are still needed.


Editorial

Understanding the Global Prevalence of Hypertension in Children and Adolescents
Zwaigenbaum L, Brian JA, Ip A; Canadian Paediatric Society, Autism Spectrum Disorder Guidelines Task Force
Paediatr Child Health 2019 24(7):424–432.
Posted: Oct 24 2019

Abstract
Autism spectrum disorder (ASD) is a life-long neurodevelopmental disorder, characterized by impairments in social communication, repetitive, restricted patterns of behaviour, and unusual sensory sensitivities or interests. ASD significantly impacts the lives of children and their families. Currently, the estimated prevalence of ASD is 1 in 66 Canadians aged 5 to 17 years. General paediatricians, family physicians, and other health care professionals are, therefore, seeing more children with ASD in their practices. The timely diagnosis of ASD, and referral for intensive behavioural and educational interventions at the earliest age possible, may lead to better long-term outcomes by capitalizing on the brain’s neuroplasticity at younger ages. This statement provides clear, comprehensive, evidence-informed recommendations and tools to help community paediatricians and other primary care providers monitor for the earliest signs of ASD—an important step toward an accurate diagnosis and comprehensive needs assessment for intervention planning.

22.8.19

Adolescent Mental Health Program Components and Behavior Risk Reduction: A Meta-analysis.

Skeen S, Laurenzi CA, Gordon SL, du Toit S, Tomlinson M, Dua T, Fleischmann A, Kohl K, Ross D, Servili C, Brand AS, Dowdall N, Lund C, van der Westhuizen C, Carvajal-Aguirre L, Eriksson de
Carvalho C, Melendez-Torres GJ.

CONTEXT: Although adolescent mental health interventions are widely implemented, little consensus exists about elements comprising successful models.
OBJECTIVE: We aimed to identify effective program components of interventions to promote mental health and prevent mental disorders and risk behaviors during adolescence and to match these components across these key health outcomes to inform future multicomponent intervention development.
DATA SOURCES: A total of 14 600 records were identified, and 158 studies were
included.
STUDY SELECTION: Studies included universally delivered psychosocial interventions administered to adolescents ages 10 to 19. We included studies published between 2000 and 2018, using PubMed, Medline, PsycINFO, Scopus, Embase, and Applied Social Sciences Index Abstracts databases. We included randomized controlled, cluster randomized controlled, factorial, and crossover trials.
Outcomes included positive mental health, depressive and anxious symptomatology,  violence perpetration and bullying, and alcohol and other substance use.
DATA EXTRACTION: Data were extracted by 3 researchers who identified core components and relevant outcomes. Interventions were separated by modality; data  were analyzed by using a robust variance estimation meta-analysis model, and we estimated a series of single-predictor meta-regression models using random effects.
RESULTS: Universally delivered interventions can improve adolescent mental health and reduce risk behavior. Of 7 components with consistent signals of effectiveness, 3 had significant effects over multiple outcomes (interpersonal skills, emotional regulation, and alcohol and drug education).
LIMITATIONS: Most included studies were from high-income settings, limiting the applicability of these findings to low- and middle-income countries. Our sample included only trials.
CONCLUSIONS: Three program components emerged as consistently effective across different outcomes, providing a basis for developing future multioutcome intervention programs.

10.6.19

Defining certainty of net benefit: a GRADE concept paper.

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

3.5.19

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.



26.3.19

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.

Introduction
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.
Methods
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.
Results
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.
Discussion
Among these 37 adolescents, COPE provided effective PC-based behavioral treatment and a positive experience. Increased availability of COPE could improve care for adolescents.

20.2.19

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.