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Children, Volume 7, Issue 7 (July 2020) – 13 articles

Cover Story (view full-size image): Childhood obesity is associated with dyslipidemia, fatty liver disease and type 2 diabetes. These conditions are clinically silent and therefore expert guidelines recommend screening for these conditions. Multiple studies have demonstrated suboptimal rates of laboratory screening in children with obesity. We compared rates of screening for dyslipidemia, fatty liver disease and type 2 diabetes in children before and after implementation of a point of care decision support tool. We found no increase in the rates of screening following implementation of the tool. Further strategies are needed to improve rates of screening for obesity related comorbid conditions in children with obesity. View this paper.
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Article
Familial Factors Associating with Youth Physical Activity Using a National Sample
Children 2020, 7(7), 79; https://doi.org/10.3390/children7070079 - 15 Jul 2020
Cited by 2 | Viewed by 1498
Abstract
The purpose of this study was to examine the associations of familial and child-related factors with reported child physical activity using a representative sample of US children and adolescents. Data were analyzed from the combined 2017–2018 National Survey of Children’s Health. Household addresses [...] Read more.
The purpose of this study was to examine the associations of familial and child-related factors with reported child physical activity using a representative sample of US children and adolescents. Data were analyzed from the combined 2017–2018 National Survey of Children’s Health. Household addresses were randomly selected within each US state. One parent within each household answered health and wellness questions pertaining to one randomly selected child (n = 37,392; 48.8% female; 6–17 years old). Weighted logistic regression models examined the independent and joint associations between family-level and child-level factors with a child meeting the 60 min of physical activity per day guideline. After controlling for confounders, higher levels of family resilience (odds ratio (OR) = 2.17; 95% confidence interval (CI): 1.35–3.49, p = 0.001), high event attendance (OR = 1.65; 95%CI: 1.18–2.31, p = 0.004), and high family income (OR = 1.84, 95%CI: 1.34–2.52, p < 0.001) significantly associated with higher odds of a child meeting the 60 min of physical activity per day guideline. Family generational status and adult education significantly modified the association between family resilience and child physical activity. Programs that develop family resilience and encourage parental attendance for their child’s events or activities may positively influence a child’s physical activity behaviors. Expanded or enhanced programming may be needed for lower income families. Full article
(This article belongs to the Special Issue Parenting in Face of Health Challenges: Research and Interventions)
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Article
Poverty, Child Labor, and Hope: The Relationship between Hope and Perceived Social Support in Children Working in Street Markets in TRC2 Region of Turkey
Children 2020, 7(7), 78; https://0-doi-org.brum.beds.ac.uk/10.3390/children7070078 - 14 Jul 2020
Viewed by 1394
Abstract
Diyarbakır and Şanlıurfa (TRC2 Region) are the cities within the provinces of Turkey that have a high prevalence of poverty with an associated high child population. Due to the poverty in the cities of Diyarbakır and Şanlıurfa, this study investigated children working as [...] Read more.
Diyarbakır and Şanlıurfa (TRC2 Region) are the cities within the provinces of Turkey that have a high prevalence of poverty with an associated high child population. Due to the poverty in the cities of Diyarbakır and Şanlıurfa, this study investigated children working as a carrier in six purposefully selected districts, street markets, with the aim of providing social support for them to look forward to the future with hope. The research was conducted in 2019 by using questionnaires through face-to-face interviews, to cover all children in selected street markets within the scope of the full sampling volume. The data were analyzed using a structural equation modeling method. According to the results, 61.2% of working children are students, but most of them do not go to attend school; 8.7% of working children are the children of the Syrian refugees. Children work an average of 4.3 days a week and 8.6 h a day, with an average income of USD 1.6/day. As a result of the analysis, it was shown that the children received the most social support from their schoolmates (r = 0.428) to have hope in the future. This result shows that it is compulsory to include children in the education system. In this context, it is recommended that the financial contribution of children to their families should be paid by the state within the scope of social assistance and solidarity. Besides, strengthening social awareness and providing solidarity would contribute to the solution of the problem. The data obtained from this research could be used in studies and policies, to develop the concept of hope for combating poverty in regions with similar socio-economic characteristics. This research is the first of its type conducted on this issue in Turkey. Full article
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Article
Compressive Garments in Individuals with Autism and Severe Proprioceptive Dysfunction: A Retrospective Exploratory Case Series
Children 2020, 7(7), 77; https://0-doi-org.brum.beds.ac.uk/10.3390/children7070077 - 13 Jul 2020
Viewed by 2250
Abstract
(1) Background: Compression garments (CGs) are an adjuvant treatment for generalized joint hypermobility (GJH), including the Ehlers–Danlos syndrome/hypermobility types. The effects of CGs are likely to be related to better proprioceptive control. We aimed to explore the use of CGs in individuals with [...] Read more.
(1) Background: Compression garments (CGs) are an adjuvant treatment for generalized joint hypermobility (GJH), including the Ehlers–Danlos syndrome/hypermobility types. The effects of CGs are likely to be related to better proprioceptive control. We aimed to explore the use of CGs in individuals with autism and severe proprioceptive dysfunction (SPD), including individuals with GJH, to control posture and challenging behaviors. (2) Methods: We retrospectively described 14 patients with autism and SPD, including seven with comorbid GJH, who were hospitalized for major challenging behaviors with remaining behavioral symptomatology after the implementation of multidisciplinary approaches, including medication, treatment of organic comorbidities, and behavioral restructuring. Each patient received a CG to wear for at least 1 h (but most often longer) per day for six weeks. We assessed challenging behaviors in these participants with the Aberrant Behavior Checklist (ABC), sensory integration with the Dunn questionnaire, and postural sway and motor performance using a self-designed motricity path at baseline, two weeks, and six weeks. (3) Results: We observed a significant effect on most ABC rating scores at two weeks, which persisted at six weeks (total score, p = 0.004; irritability, p = 0.007; hyperactivity, p = 0.001; lethargy, p = 0.001). Postural control in dorsal and profile positions was significantly improved between before and after wearing the CGs (p = 0.006 and 0.007, respectively). Motor performance was also significantly improved. However, we did not observe a significant change in Dunn sensory scores. During the six-week duration, the treatment was generally well-tolerated. A comorbid GJH diagnosis was not associated with a better outcome. (4) Conclusions: CGs appear to be a promising adjuvant treatment for both behavioral and postural impairments in individuals with autism and SPD. Full article
(This article belongs to the Special Issue Motor Problems in Childhood Developmental Disorders)
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Article
“I Wasn’t Sure What It Meant to Be Honest”—Formative Research Towards a Physical Literacy Intervention for Preschoolers
Children 2020, 7(7), 76; https://0-doi-org.brum.beds.ac.uk/10.3390/children7070076 - 13 Jul 2020
Cited by 3 | Viewed by 1700
Abstract
Physical literacy (PL) as a concept is important in developing lifelong physical activity; however, there is little research exploring how PL can be developed during the preschool years. This two-phase qualitative study sought the insights of academics/expert practitioners and preschool staff towards PL [...] Read more.
Physical literacy (PL) as a concept is important in developing lifelong physical activity; however, there is little research exploring how PL can be developed during the preschool years. This two-phase qualitative study sought the insights of academics/expert practitioners and preschool staff towards PL in order to inform the design of future preschool PL interventions. Phase One comprised of nine semi-structured interviews with experts in the field of children’s physical activity and/or PL. Interview topics included perspectives on the concept of PL and recommendations for interventions targeted at improving preschool PL. Phase Two consisted of focus groups with practitioners from four local children’s centres. Focus groups explored perspectives on the feasibility and acceptability of proposed PL interventions. Interviews and focus groups were analysed by thematic analysis and means of representation, respectively. Findings revealed that whilst there was limited understanding about the concept of PL among preschool educators, knowledge of child development was evident and that all participants agreed that there was a need for further training for practitioners. Perceived barriers to promoting PL noted by practitioners included funding, policy, curricular priorities, parental opinions, and the preschool environment. It was recommended that interventions should be: (i) designed using a participatory approach including all key stakeholders, (ii) conducted over the long term, and (iii) incorporate opportunities for children to engage in free and outdoor play. Furthermore, any intervention should be flexible to allow for variation between children’s centres, aligned to current policy/children’s centre targets and provide training and resources in order to overcome perceived barriers. Full article
(This article belongs to the Section Global and Public Health)
Article
African American Children’s Diminished Returns of Subjective Family Socioeconomic Status on Fun Seeking
Children 2020, 7(7), 75; https://0-doi-org.brum.beds.ac.uk/10.3390/children7070075 - 09 Jul 2020
Cited by 9 | Viewed by 1376
Abstract
Background: Reward sensitivity (fun-seeking) is a risk factor for a wide range of high-risk behaviors. While high socioeconomic status (SES) is known to reduce reward sensitivity and associated high-risk behaviors, less is known about the differential effects of SES on reward sensitivity. It [...] Read more.
Background: Reward sensitivity (fun-seeking) is a risk factor for a wide range of high-risk behaviors. While high socioeconomic status (SES) is known to reduce reward sensitivity and associated high-risk behaviors, less is known about the differential effects of SES on reward sensitivity. It is plausible to expect weaker protective effects of family SES on reward sensitivity in racial minorities, a pattern called Minorities’ Diminished Returns (MDRs). Aim: We compared Caucasian and African American (AA) children for the effects of subjective family SES on children’s fun-seeking. Methods: This was a cross-sectional analysis of 7061 children from the Adolescent Brain Cognitive Development (ABCD) study. The independent variable was subjective family SES. The main outcome was children’s fun-seeking measured by the behavioral approach system (BAS) and behavioral avoidance system (BIS). Age, gender, marital status, and household size were the covariates. Results: In the overall sample, high subjective family SES was associated with lower levels of fun-seeking. We also found a statistically significant interaction between race and subjective family SES on children’s fun-seeking in the overall sample, suggesting that high subjective family SES is associated with a weaker effect on reducing fun-seeking among AA than Caucasian children. In race-stratified models, high subjective family SES was protective against fun-seeking of Caucasian but not AA children. Conclusion: Subjective family SES reduces the fun-seeking for Caucasian but not AA children. Full article
Article
Diminished Returns of Parental Education in Terms of Youth School Performance: Ruling out Regression toward the Mean
Children 2020, 7(7), 74; https://0-doi-org.brum.beds.ac.uk/10.3390/children7070074 - 07 Jul 2020
Cited by 11 | Viewed by 1575
Abstract
Background: Minorities’ Diminished Returns (MDRs) refer to systemically weaker effects of socioeconomic status (SES) indicators on various developmental, behavioral, and health outcomes of ethnic minorities compared to non-Hispanic (non-Latino) Whites. Similar MDRs also exist for the effects of parental education on the school [...] Read more.
Background: Minorities’ Diminished Returns (MDRs) refer to systemically weaker effects of socioeconomic status (SES) indicators on various developmental, behavioral, and health outcomes of ethnic minorities compared to non-Hispanic (non-Latino) Whites. Similar MDRs also exist for the effects of parental education on the school performance of ethnic minority youth. Aim: To assess whether regression toward the mean (RTM) has any role in explaining the diminished effects of parental education on the school performance of Black and Hispanic youth relative to non-Hispanic White youth. Materials and methods: Data for this cross-sectional study came from the Monitoring the Future survey (MTF, 2017), a nationally representative survey of American youth in 12th grade. The sample included 10,262 youth who were 12th graders (typically 17–18 years old). The independent variable was parental education with five categories: Some high school, High school graduate, Some college, College graduate, and Graduate school. The outcome was self-reported school performance measured as grade point average (GPA). Ethnicity was the effect modifier. Analysis of variance (ANOVA) and the Tukey Post Hoc test was used to analyze the data. Data visualization (line graphs) was used to visualize the shape of youth GPA as a function of parental education levels across ethnic groups. Results: While a perfect stepwise increase was seen in youth school performance as a result of parental education improvement, this pattern differed considerably across ethnic groups. Such a perfect stepwise increase in youth school performance as a result of the incremental increase in parental education was missing for Black and Hispanic youth. The shape of the association between parental education and youth school performance ruled out regression toward the mean (RTM) as an explanation for the observed diminished effects of parental education on the school performance of Black and Hispanic youth. Conclusion: Diminished returns of parental education on the school performance of Black and Hispanic youth cannot be explained by regression toward the mean. Other factors and contextual processes, such as segregation, discrimination, racism, and poor quality of schools in urban areas, should be investigated in future research. Full article
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Article
Children’s Drawing as a Projective Measure to Understand Their Experiences of Dental Treatment under General Anesthesia
Children 2020, 7(7), 73; https://0-doi-org.brum.beds.ac.uk/10.3390/children7070073 - 03 Jul 2020
Cited by 4 | Viewed by 2842
Abstract
Purpose: The overall aim of the study was to gain a deeper understanding of 3 to 10 year-old children’s experiences, main concerns, and how they manage attending hospital for dental treatment under general anesthesia (DTGA). Methods: Twelve children aged 3–10 who were scheduled [...] Read more.
Purpose: The overall aim of the study was to gain a deeper understanding of 3 to 10 year-old children’s experiences, main concerns, and how they manage attending hospital for dental treatment under general anesthesia (DTGA). Methods: Twelve children aged 3–10 who were scheduled for DTGA were interviewed. In addition to tape-recorded interviews, data were collected using video diaries, participant observations, and pre-, peri-, and postoperative drawings. The children’s drawings (n = 43) were analyzed using the Child Drawing: Hospital Manual (CD:H) and Vygotsky postulations for context readings, with the aim to explore what it means for children to undergo DTGA. Results: The analysis found that the main concern for children during the pre-operative period was that they were forced to prepare for an unknown experience, which elicited stress. This situation was handled during the peri-operative period by trying to recover control and to cooperate despite fear, stress, and anxiety. Drawings completed post-operatively showed the surgical mask, “stinky” smell of the anesthetic gas, and multiple extraction of teeth were the main troubling experiences for children. Several weeks after DTGA, children tried to regain normalcy in their lives again. Conclusion: This study contributed to a deeper understanding of how children as young as 3 years undergoing DTGA experience and express their lived experiences: emotional, psychological, physiological, or physical stress in the context of DTGA. Full article
(This article belongs to the Special Issue Advance in Pediatric Dentistry)
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Article
Simple Method for the Objective Activity Type Assessment with Preschoolers, Children and Adolescents
Children 2020, 7(7), 72; https://0-doi-org.brum.beds.ac.uk/10.3390/children7070072 - 02 Jul 2020
Cited by 1 | Viewed by 1525
Abstract
Background: The objective and accurate assessment of children’s sedentary and physical behavior is important for investigating their relation to health. The purpose of this study is to validate a simple and robust method for the identification of sitting, standing, walking, running and biking [...] Read more.
Background: The objective and accurate assessment of children’s sedentary and physical behavior is important for investigating their relation to health. The purpose of this study is to validate a simple and robust method for the identification of sitting, standing, walking, running and biking performed by preschool children, children and adolescents in the age from 3 to 16 years from a single thigh-worn accelerometer. Method: A total of 96 children were included in the study and all subjects followed a structured activity protocol performed in the subject’s normal kindergarten or school environment. Thigh acceleration was measured using the Axivity AX3 (Axivity, Newcastle, UK) device. Method development and accuracy was evaluated by equally dividing the subjects into a development and test group. Results: The sensitivity and specificity for identifying sitting and standing was above 99.3% and for walking and running above 82.6% for all age groups. The sensitivity and specificity for identifying biking was above 85.8% for children and adolescents and above 64.8% for the preschool group using running bikes. Conclusion: The accurate assessment of sitting, standing, walking, running and biking from thigh acceleration and with children in the age range of 3 to 16 is valid, although not with preschool children using running bikes. Full article
(This article belongs to the Section Global and Public Health)
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Article
Predicting Tobacco and Alcohol Consumption Based on Physical Activity Level and Demographic Characteristics in Romanian Students
Children 2020, 7(7), 71; https://0-doi-org.brum.beds.ac.uk/10.3390/children7070071 - 02 Jul 2020
Cited by 2 | Viewed by 1440
Abstract
Background: This study aims to assess the relationships between alcohol and tobacco consumption, physical activity (PA) and demographic characteristics in Romanian students. Methods: There were 253 participants in this study (112 male and 141 female, age 19.2 ± 0.70 yrs; BMI 22.4 ± [...] Read more.
Background: This study aims to assess the relationships between alcohol and tobacco consumption, physical activity (PA) and demographic characteristics in Romanian students. Methods: There were 253 participants in this study (112 male and 141 female, age 19.2 ± 0.70 yrs; BMI 22.4 ± 2.2 kg/m2), students of Transilvania University of Brasov. The International Physical Activity Questionnaire Short Form (IPAQ-SF), Alcohol Use Disorders Identification Test (AUDIT) and Fagerström Test for Nicotine Dependence (FTND) were employed for the data collection. Results: Results showed that moderate consumption of tobacco and harmful consumption of alcohol had high prevalence among age, gender, year of study and PA level categories. Although the correlation coefficient showed no significant relationship between tobacco and alcohol use, it was shown that a negative correlation between tobacco and PA level existed. Further, age, year of study and PA level had a negative significant relationship with alcohol use among students. In the end, the tobacco and alcohol consumption prediction model showed heterogeneous coefficients. Conclusion: Full models of tobacco and alcohol use were differently predicted by variables, so PAL (Physical Activity Level) could predict tobacco consumption but not alcohol. Full article
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Article
Drowning in Children: Retrospective Analysis of Incident Characteristics, Predicting Parameters, and Long-Term Outcome
Children 2020, 7(7), 70; https://0-doi-org.brum.beds.ac.uk/10.3390/children7070070 - 01 Jul 2020
Cited by 1 | Viewed by 1456
Abstract
Background: Drowning is the second leading cause of unnatural death in childhood worldwide. More than half of the drowned children, who were in need of cardiopulmonary resuscitation (CPR) at the scene suffered from lifelong neurological sequelae. There are few data about prognostic predictors [...] Read more.
Background: Drowning is the second leading cause of unnatural death in childhood worldwide. More than half of the drowned children, who were in need of cardiopulmonary resuscitation (CPR) at the scene suffered from lifelong neurological sequelae. There are few data about prognostic predictors in the pediatric population of drowning victims. The objective of the study was to assess incident characteristics, prognostic parameters, and long-term outcome of children recovering from a drowning incident. Methods: We carried out a retrospective analysis of data of the cohort of pediatric cases (age 0–18) of drowning victims admitted in the years 2000–2015 to the emergency room/intensive care unit/pediatric ward at the University Children’s Hospital of Zurich, Switzerland. Outcome was classified by the Pediatric Cerebral Performance Category Scale (PCPCS). New subcategories of severity for known prognostic parameters have been defined. A correlation analysis was performed between the subcategories of the prognostic parameters and the PCPCS. Results: A total of 80 patients were included in the analysis. Of these, 64% were male, most of the patients were at the age of 0–5 years. More than 80% of the patients were unattended at a public or private pool when the drowning incident happened. In all, 61% (n = 49) needed cardiopulmonary resuscitation (CPR). Of the resuscitated children, 63% showed good to mildly impaired long-term outcome (PCPCS 1–3). Furthermore, 15% (n = 12) were transferred to rehabilitation. Seven children died during the hospital stay and another four died due to complications in the ten years following the incident. The newly defined subcategories of the parameter submersion time, Glasgow Coma Scale (GCS) at time of admission, body temperature at time of admission, blood pH, blood glucose, and blood lactate level correlated significantly with the PCPCS. Conclusions: Supervision of children, especially boys of the age 0–5 years, next to public or private pools is most important for prevention of drowning incidents in Switzerland. Cardiopulmonary resuscitation done by trained staff leads to a better long-term outcome. Medical decision making in severe cases of drowning should consider submersion time, GCS at time of admission, body temperature at time of admission, blood pH, blood glucose, and blood lactate levels, as these parameters correlate with long-term outcome. Full article
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Review
Multi-System Inflammatory Syndrome in Children (MIS-C) Following SARS-CoV-2 Infection: Review of Clinical Presentation, Hypothetical Pathogenesis, and Proposed Management
Children 2020, 7(7), 69; https://0-doi-org.brum.beds.ac.uk/10.3390/children7070069 - 01 Jul 2020
Cited by 85 | Viewed by 14809
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection may result in the multisystem inflammatory syndrome in children (MIS-C). The clinical presentation of MIS-C includes fever, severe illness, and the involvement of two or more organ systems, in combination with laboratory evidence of inflammation [...] Read more.
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection may result in the multisystem inflammatory syndrome in children (MIS-C). The clinical presentation of MIS-C includes fever, severe illness, and the involvement of two or more organ systems, in combination with laboratory evidence of inflammation and laboratory or epidemiologic evidence of SARS-CoV-2 infection. Some features of MIS-C resemble Kawasaki Disease, toxic shock syndrome, and secondary hemophagocytic lymphohistiocytosis/macrophage activation syndrome. The relationship of MIS-C to SARS-CoV-2 infection suggests that the pathogenesis involves post-infectious immune dysregulation. Patients with MIS-C should ideally be managed in a pediatric intensive care environment since rapid clinical deterioration may occur. Specific immunomodulatory therapy depends on the clinical presentation. The relationship between the immune response to SARS-CoV-2 vaccines in development and MIS-C requires further study. Full article
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Brief Report
Dexmedetomidine as an Opioid-Sparing Agent in Pediatric Craniofacial Surgery
Children 2020, 7(7), 68; https://0-doi-org.brum.beds.ac.uk/10.3390/children7070068 - 01 Jul 2020
Cited by 3 | Viewed by 1477
Abstract
Pediatric craniofacial reconstruction surgery is associated with significant perioperative analgesic requirements. As dexmedetomidine mediates central nervous system sympathetic activity and pain modulation, its intraoperative use could be beneficial in craniofacial surgery. We hypothesized that intraoperative administration of dexmedetomidine in children undergoing craniofacial reconstructive [...] Read more.
Pediatric craniofacial reconstruction surgery is associated with significant perioperative analgesic requirements. As dexmedetomidine mediates central nervous system sympathetic activity and pain modulation, its intraoperative use could be beneficial in craniofacial surgery. We hypothesized that intraoperative administration of dexmedetomidine in children undergoing craniofacial reconstructive surgery would result in reduced opioid requirements, pain, sedation scores, and opioid-induced side effects compared to patients who did not receive dexmedetomidine. All patients who underwent craniofacial reconstructive surgery at our institution from July 2013 to June 2017 were retrospectively evaluated. The primary outcome measure was mean postoperative morphine equivalent requirements. Secondary outcome measures included incidence of opioid-related side effects, pain scores, and hospital length of stay. Thirty-nine patients received dexmedetomidine intraoperatively while 41 patients did not. There was no difference in postoperative opioid requirements or pain scores between the two cohorts. However, patients who received higher doses of dexmedetomidine (4.7 mcg/kg) intraoperatively exhibited significantly lower rescue medication requirements for nausea and vomiting postoperatively. Contrary to the hypothesis, dexmedetomidine was not associated with reduced postoperative opioid requirements or pain scores in children undergoing craniofacial reconstructive surgery. However, our findings do suggest that dexmedetomidine may be beneficial in reducing side effects such as postoperative nausea and vomiting. A randomized controlled trial would be necessary to verify these findings. Full article
(This article belongs to the Special Issue Pediatric Anesthesia)
Article
Impact of Point-of-Care Decision Support Tool on Laboratory Screening for Comorbidities in Children with Obesity
Children 2020, 7(7), 67; https://0-doi-org.brum.beds.ac.uk/10.3390/children7070067 - 27 Jun 2020
Viewed by 1309
Abstract
Background: Childhood obesity is associated with dyslipidemia, fatty liver disease, and type 2 diabetes. Expert guidelines recommend screening for these conditions in children with obesity. Aims and objectives: The objective of the study was to compare rates of laboratory screening for dyslipidemia, fatty [...] Read more.
Background: Childhood obesity is associated with dyslipidemia, fatty liver disease, and type 2 diabetes. Expert guidelines recommend screening for these conditions in children with obesity. Aims and objectives: The objective of the study was to compare rates of laboratory screening for dyslipidemia, fatty liver disease, and type 2 diabetes in children with obesity prior to and following implementation of a point-of-care decision support tool. Methods: We performed a retrospective record review of children with body mass index (BMI) ≥95th percentile for age and gender (age 7–18 years) undergoing well-child/sports examination visits. Multivariable logistic regression models were used to adjust for patient and provider confounders. Results: There was no increase in the rates of screening following implementation of the point-of-care decision support tool. Tests were more likely to be recommended in children with severe obesity and in females. Conclusions: The implementation of a point-of-care decision support tool was not associated with improvement in screening rates for dyslipidemia, fatty liver disease, and type 2 diabetes for children with obesity. Further strategies are needed to improve rates of screening for obesity-related comorbid conditions in children with obesity. Full article
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