Influence of obesity on clinical outcomes in hospitalized children: a systematic review

An In-Depth Look at Nutrition Support and Adequacy for Critically Ill Children with Organ Dysfunction

Patients admitted to a pediatric intensive care unit (PICU) need individualized nutrition support that is tailored to their particular disease severity, nutritional status, and therapeutic interventions. We aim to evaluate how calories and proteins are provided during the first seven days of hospitalization for children in critical condition with organ dysfunction (OD). A single-center retrospective cohort study of children aged 2-18 years, mechanically ventilated > 48 h, and admitted > 7 days to a PICU from 2016 to 2017 was carried out. Nutrition support included enteral and parenteral nutrition. We calculated scores for the Pediatric Sequential Organ Failure Assessment (pSOFA) on days 1 and 3 of admission, with OD defined as a score > 5. Of 4199 patient admissions, 164 children were included. The prevalence of OD for days 1 and 3 was 79.3% and 78.7%, respectively. On day 3, when pSOFA scores trended upward, decreased, or remained unchanged, median (IQR) caloric intake was 0 (0-15), 9.2 (0-25), and 22 (1-43) kcal/kg/day, respectively (p = 0.0032); when pSOFA scores trended upward, decreased, or remained unchanged, protein intake was 0 (0-0.64), 0.44 (0-1.25), and 0.66 (0.04-1.67) g/kg/day, respectively (p = 0.0023). Organ dysfunction was prevalent through the first 72 h of a PICU stay. When the pSOFA scores trended downward or remained unchanged, caloric and protein intakes were higher than those that trended upward.

Association between weight-for-length percentile and ICU length of stay in patients with a single ventricle undergoing bidirectional Glenn repair: A retrospective cohort study

BACKGROUND

Poor weight gain has been identified as an independent risk factor for increased surgical morbidity and mortality for patients with single-ventricle physiology undergoing staged surgical palliation. Conversely, excessive weight gain has also emerged as an independent risk factor predicting increased morbidity and mortality in a single-center study. Given this novel single-center concept, we investigated the impact of excessive weight on patients with single-ventricle physiology undergoing bidirectional Glenn palliation in a multicenter study model.

METHODS

Patients from the Pediatric Heart Network Single Ventricle Reconstruction Trial (n = 387) were analyzed in a retrospective cohort study examining the independent effect of weight percentile on intensive care unit (ICU) length of stay (LOS) and ventilator days. Locally estimated scatterplot smoothing (LOESS) regression was used to plot weight-for-length (WFL) percentiles by ICU LOS and ventilator days. Unadjusted and adjusted ordinal regression was used to model ICU LOS and ventilator days.

RESULTS

Scatterplots and LOESS regression curves demonstrated increasing ICU LOS and ventilator days for increasing WFL percentiles. Unadjusted ordinal regression analysis of ICU LOS demonstrated a trend of increasing ICU LOS for increasing WFL percentiles that was not statistically significant (P = 0.11). A similar trend was demonstrated in adjusted ordinal regression that was not statistically significant (P = 0.48). Unadjusted and adjusted ordinal regression analysis of ventilator days did not reach statistical significance (P = 0.07).

CONCLUSION

Excessive weight gain has a clinically relevant but not statistically significant association with increased ICU LOS and ventilator days for those patients in the >90th WFL percentile for age.

Clinical characteristics and influence of postoperative Hirschsprung-associated enterocolitis: retrospective study at a tertiary children's hospital

PURPOSE

To explore the influence of postoperative Hirschsprung-associated enterocolitis (post-HAEC) on long-term outcomes and to identify risk factors of post-HAEC.

METHODS

The medical records of 304 eligible patients diagnosed with Hirschsprung's disease (HSCR) were reviewed. We analyzed the clinical characteristics of post-HAEC and its influence on long-term outcomes. Furthermore, risk factors for early and recurrent HAEC were identified separately.

RESULTS

The overall incidence of post-HAEC was 29.9% (91/304). We categorized early HAEC as occurring within postoperative 3 months (n = 39) and recurrent HAEC as occurring ≥ 3 episodes within postoperative 6 months (n = 25). Patients with early HAEC were more likely to experience worse nutritional status, defecation function, and quality of life compared to those with late or no episodes (P < 0.05). Similarly, the adverse influences of recurrent HAEC on these outcomes were also significant (P < 0.05). The risk factors for early HAEC included preoperative undernutrition, long-segment HSCR, and postoperative Grade 3-4 complications within 30 days. For recurrent HAEC, risk factors were preoperative malnutrition, non-parental caregivers, long-segment HSCR, and postoperative Grade 3-4 complications within 30 days.

CONCLUSION

Classification of post-HAEC based on the first episode time and frequency was necessary. The earlier or more frequent episodes of post-HAEC have detrimental influences on long-term outcomes. Furthermore, risk factors for early and recurrent HAEC were different.

Gut dysbiosis in patients with chronic pain: a systematic review and meta-analysis

Introduction

Recent evidence supports the contribution of gut microbiota dysbiosis to the pathophysiology of rheumatic diseases, neuropathic pain, and neurodegenerative disorders. The bidirectional gut-brain communication network and the occurrence of chronic pain both involve contributions of the autonomic nervous system and the hypothalamic pituitary adrenal axis. Nevertheless, the current understanding of the association between gut microbiota and chronic pain is still not clear. Therefore, the aim of this study is to systematically evaluate the existing knowledge about gut microbiota alterations in chronic pain conditions.

Methods

Four databases were consulted for this systematic literature review: PubMed, Web of Science, Scopus, and Embase. The Newcastle-Ottawa Scale was used to assess the risk of bias. The study protocol was prospectively registered at the International prospective register of systematic reviews (PROSPERO, CRD42023430115). Alpha-diversity, β-diversity, and relative abundance at different taxonomic levels were summarized qualitatively, and quantitatively if possible.

Results

The initial database search identified a total of 3544 unique studies, of which 21 studies were eventually included in the systematic review and 11 in the meta-analysis. Decreases in alpha-diversity were revealed in chronic pain patients compared to controls for several metrics: observed species (SMD= -0.201, 95% CI from -0.04 to -0.36, p=0.01), Shannon index (SMD= -0.27, 95% CI from -0.11 to -0.43, p<0.001), and faith phylogenetic diversity (SMD -0.35, 95% CI from -0.08 to -0.61, p=0.01). Inconsistent results were revealed for beta-diversity. A decrease in the relative abundance of the Lachnospiraceae family, genus Faecalibacterium and Roseburia, and species of Faecalibacterium prausnitzii and Odoribacter splanchnicus, as well as an increase in Eggerthella spp., was revealed in chronic pain patients compared to controls.

Discussion

Indications for gut microbiota dysbiosis were revealed in chronic pain patients, with non-specific disease alterations of microbes.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42023430115.

Malnutrition and Nutrition Support in Latin American PICUs: The Nutrition in PICU (NutriPIC) Study

OBJECTIVES

To characterize the nutritional status of children admitted to Latin American (LA) PICUs and to describe the adequacy of nutrition support in reference to contemporary international recommendations.

DESIGN

The Nutrition in PICU (NutriPIC) study was a combined point-prevalence study of malnutrition carried out on 1 day in 2021 (Monday 8 November) and a retrospective cohort study of adequacy of nutritional support in the week preceding.

SETTING

Four-one PICUs in 13 LA countries.

PATIENTS

Patients already admitted to the PICU of 1 month to 18 years old on the study day were included in the point-prevalence study. For the retrospective arm, we included patients receiving nutritional support on the study day and with a PICU length of stay (LOS) greater than or equal to 72 hours. Exclusion criteria were being a neonate, conditions that precluded accurate anthropometric measurements, and PICU LOS greater than 14 days.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 316 patients screened, 5 did not meet age criteria. There were 191 of 311 patients who were included in the point-prevalence study and underwent anthropometric evaluation. Underweight and length for age less than -2 z scores were present in 42 of 88 children (47.7%) and 41 of 88 children (46.6%) less than 24 months old, and 14 of 103 (13.6%) and (23/103) 22.3% of 103 children greater than or equal to 24 months, respectively. Evidence of obesity (body mass index > 2 z score) was present in 7 of 88 children (5.7%) less than 24 months old and 13 of 103 children (12.6%) greater than or equal to 24 months. In the 115 of 311 patients meeting criteria for the retrospective arm, a total of 98 patients reported complete nutritional data. The 7-day median (interquartile range) adequacy for delivered versus recommended enteral energy and protein requirement was 114% (75, 154) and 99% (60, 133), respectively.

CONCLUSIONS

The NutriPIC study found that in 2021 malnutrition was highly prevalent especially in PICU admissions of less than 24 months old. Retrospectively, the 7-day median nutritional support appears to meet both energy and protein requirements.

Tests and Indices Predicting Extubation Failure in Children: A Systematic Review and Meta-analysis

INTRODUCTION

There is lack of consensus on what constitutes best practice when assessing extubation readiness in children. This systematic review aims to synthesize data from existing literature on pre-extubation assessments and evaluate their diagnostic accuracies in predicting extubation failure (EF) in children.

METHODS

A systematic search in PubMed, EMBASE, Web of Science, CINAHL, and Cochrane was performed from inception of each database to 15 July 2021. Randomized controlled trials or observational studies that studied the association between pre-extubation assessments and extubation outcome in the pediatric intensive care unit population were included. Meta-analysis was performed for studies that report diagnostic tests results of a combination of parameters.

RESULTS

In total, 41 of 11,663 publications screened were included (total patients, n = 8111). Definition of EF across studies was heterogeneous. Fifty-five unique pre-extubation assessments were identified. Parameters most studied were: respiratory rate (RR) (13/41, n = 1945), partial pressure of arterial carbon dioxide (10/41, n = 1379), tidal volume (13/41, n = 1945), rapid shallow breathing index (RBSI) (9/41, n = 1400), and spontaneous breathing trials (SBT) (13/41, n = 5652). Meta-analysis shows that RSBI, compliance rate oxygenation pressure (CROP) index, and SBT had sensitivities ranging from 0.14 to 0.57. CROP index had the highest sensitivity [0.57, 95% confidence interval (CI) 0.4-0.73] and area under curve (AUC, 0.98). SBT had the highest specificity (0.93, 95% CI 0.92-0.94).

CONCLUSIONS

Pre-extubation assessments studied thus far remain poor predictors of EF. CROP index, having the highest AUC, should be further explored as a predictor of EF. Standardizing the EF definition will allow better comparison of pre-extubation assessments.

Inpatient medical management of severe pediatric obesity: Literature review and case reports

Pediatric obesity rates continue to rise steeply with significant adverse effects on health outcomes across the lifespan. Significant obesity can affect the efficacy, side effects, and ability to use certain treatment, medication, or imaging modalities needed in the evaluation and management of acute pediatric conditions. Inpatient settings are rarely used as an opportunity for weight counseling and thus there is a paucity of clinical guidelines on how to manage severe obesity in the inpatient setting. We present a literature review and three patient cases with single-center protocol for non-surgical management of severe obesity in children admitted for other acute medical reasons. We performed a PubMed review from January 2002 to February 2022 utilizing keywords: "inpatient," "obesity," and "intervention." For our cases, we identified three patients with severe obesity acutely impacting their health while admitted for medical treatment who concurrently underwent acute, inpatient, weight loss regimens at a single children's hospital. The literature search yielded 33 articles describing inpatient weight loss treatments. Three patients met case criteria, all three of which demonstrated a decrease in their weight in excess percent of the 95th percentile after inpatient weight-management protocol implementation (% reduction BMI_p95: 16%-30%). This highlights obesity acutely limits or impacts specific medical care required during inpatient admissions in pediatric patients. It also suggests that implementation of an inpatient weight-management protocol during admission may provide an opportune setting to support acute weight loss and overall improved health outcomes in this high-risk cohort.

Body Mass Index Category and Adverse Events in Hospitalized Children

OBJECTIVE

To identify associations between patient body mass index (BMI) category and adverse event (AE) rate, severity, and preventability in a cohort of children discharged from an academic children's hospital.

METHODS

We identified patients 2 to 17 years old consecutively discharged between June and October 2018. Patient age, sex, height, and weight were used to categorize patients as having underweight, normal weight, overweight, or obesity. We used the Global Assessment of Pediatrics Patient Safety trigger tool to identify AEs, which were scored for harm and preventability. The primary outcome was the rate of AEs; these were compared with Poisson regression. We used multivariable logistic regression to model event preventability.

RESULTS

We reviewed 834 encounters in 680 subjects; 51 (7.5%) had underweight, 367 (54.0%) had normal weight, 112 (16.5%) had overweight, and 150 (22.1%) had obesity. Our cohort experienced 270 AEs, with an overall rate of 69.7 (61.8-78.5) AEs per 1000 patient-days: 67.7 (46.4-98.7) in underweight, 70.0 (59.4-82.4) in normal weight, 58.6 (42.5-79.7) in overweight, and 80.4 (62.5-103.6) in obesity, P = .46. No associations were seen between BMI category and AE severity. Children with obesity had an increased rate of preventable AEs (P < .01), but this association did not persist in the multivariable model.

CONCLUSIONS

In this single-center study, we did not find associations between BMI category and rate, severity, or preventability of AEs.

Gut dysbiosis in rheumatic diseases: A systematic review and meta-analysis of 92 observational studies

Background

Emerging evidence suggests that dysbiosis in gut microbiota may contribute to the occurrence or development of several rheumatic diseases. Since gut microbiota dysbiosis is potentially modifiable, it has been postulated to be a promising preventive or therapeutic target for rheumatic diseases. However, the current understanding on the potential associations between gut microbiota and rheumatic diseases is still inadequate. Therefore, we aimed to synthesise the accumulating evidence for the relation of gut microbiota to rheumatic diseases.

Methods

The PubMed, Embase and Cochrane Library were searched from inception to March 11, 2022 to include observational studies evaluating the associations between gut microbiota and rheumatic diseases. Standardised mean difference (SMD) of α-diversity indices between rheumatic diseases and controls were estimated using random-effects model. β-diversity indices and relative abundance of gut microbes were summarised qualitatively.

Findings

Of the included 92 studies (11,998 participants), 68 provided data for α-diversity. Taken together as a whole, decreases in α-diversity indices were consistently found in rheumatic diseases (observed species: SMD = −0.36, [95%CI = −0.63, −0.09]; Chao1: SMD = −0.57, [95%CI = −0.88, −0.26]; Shannon index: SMD = −0.33, [95%CI = −0.48, −0.17]; Simpson index: SMD = −0.32, [95%CI = −0.49, −0.14]). However, when specific rheumatic diseases were examined, decreases were only observed in rheumatoid arthritis (observed species: SMD = −0.51, [95%CI = −0.78, −0.24]; Shannon index: SMD = −0.31, [95%CI = −0.49, −0.13]; Simpson index: SMD = −0.31, [95%CI = −0.54, −0.08]), systemic lupus erythematosus (Chao1: SMD = −1.60, [95%CI = −2.54, −0.66]; Shannon index: SMD = −0.63, [95%CI = −1.08, −0.18]), gout (Simpson index: SMD = −0.64, [95%CI = −1.07, −0.22]) and fibromyalgia (Simpson index: SMD = −0.28, [95%CI = −0.44, −0.11]), whereas an increase was observed in systemic sclerosis (Shannon index: SMD = 1.25, [95%CI = 0.09, 2.41]). Differences with statistical significance in β-diversity were consistently reported in ankylosing spondylitis and IgG4-related diseases. Although little evidence of disease specificity of gut microbes was found, shared alterations of the depletion of anti-inflammatory butyrate-producing microbe (i.e., Faecalibacterium) and the enrichment of pro-inflammatory microbe (i.e., Streptococcus) were observed in rheumatoid arthritis, Sjögren's syndrome and systemic lupus erythematosus.

Interpretation

Gut microbiota dysbiosis was associated with rheumatic diseases, principally with potentially non-specific, shared alterations of microbes.

Funding

National Natural Science Foundation of China (81930071, 81902265, 82072502 and U21A20352).

Clinical Outcome and Antibiotic Dosing Differences by Weight in Children With Acute Osteomyelitis

OBJECTIVES

To evaluate for weight-based differences in clinical outcomes and antibiotic dosing variability for children hospitalized with acute hematogenous osteomyelitis (AHO).

METHODS

We performed a retrospective cohort study of children aged 2 to 17 years and hospitalized with a primary AHO International Classification of Diseases, Ninth Revision or International Classification of Diseases, 10th Revision diagnosis code between 2010 and 2017 using the Cerner Health Facts database. Weight categories (healthy, overweight, obesity) were determined by using Centers for Disease Control and Prevention age- and sex-specific BMI percentiles. Rates of procedures, complications, and length of stay (LOS) were compared between groups. Dosing variability between groups was assessed by comparing the initial milligrams per kilogram per day of prescribed antibiotics.

RESULTS

We identified 755 children with AHO for inclusion. Children with overweight and obesity were more likely to undergo surgical procedures (19% and 17%, respectively) compared with children with a healthy weight (10%; P = .009). They also had a longer LOS (5.7 and 5.8 days) than children with a healthy weight (4.9 days; P = .03). There were no differences in complication rates between weight categories. Mean weight-adjusted daily dose for the most frequently prescribed antibiotics was different by weight category, with children in higher weight categories more likely to receive lower weight-based doses.

CONCLUSIONS

Children with overweight and obesity hospitalized for AHO were more likely to undergo procedures, have longer LOS, and receive lower weight-based antibiotic dosing compared with children with a healthy weight. Our findings suggest that weight should be carefully considered when treating children with AHO.

Impact of Body Mass Index and Initial Respiratory Support on Pediatric Subjects in Acute Respiratory Failure

BACKGROUND

It is unknown how the initial choice of respiratory support by pediatric ICU providers contributes to outcomes of nonintubated obese children with respiratory failure. We hypothesized that body mass index and the type of initial respiratory support applied are associated with poor clinical outcomes in patients who carry respiratory failure-associated diagnoses.

METHODS

This is a retrospective analysis of de-identified patient data obtained from the Virtual PICU System database (2009-2018). We included subjects 2-18 y old who received bi-level positive airway pressure/CPAP or high-flow nasal cannula as the initial respiratory support and were assigned respiratory failure-associated diagnoses (ie, acute hypoxic respiratory failure). The study population was divided into 2 body mass index percentile groups, underweight/healthy weight (< 85th percentile) and overweight/obese (≥ 85th percentile), and subjects were evaluated for the following outcomes: endotracheal intubation requirement, medical and physical PICU length of stay, and mortality scores.

RESULTS

A total of 1,721 subjects were included: 1,091 (63.4%) underweight/healthy weight and 630 (36.6%) overweight/obese. Body mass index percentile was not associated with the initial respiratory support utilized (odds ratio 0.961 [95% CI 0.79-1.17], P = .73). Multivariable logistic regression analysis demonstrated that the odds of requiring endotracheal intubation (odds ratio 1.60 [95% CI 1.10-2.35], P = .02) were significantly higher in overweight/obese subjects initially placed on high-flow nasal cannula. Body mass index and bi-level positive airway pressure/CPAP therapy were both positively associated with medical and physical PICU length of stay, Pediatric Risk of Mortality Score 3 (PRISM3) scores, and Pediatric Index of Mortality 2 (PIM2) scores when separate multivariable models were fit for these 4 response variables.

CONCLUSIONS

The selection of respiratory support may place overweight/obese pediatric patients at higher risk for endotracheal intubation. Due to methodological limitations, we were unable to draw conclusions about the initial approach to the respiratory management of overweight/obese pediatric patients. Further investigation may be warranted.

Impact of overweight/obesity on clinical outcomes after reduction for intussusception in children

PURPOSE

Childhood obesity is a worsening epidemic. Little is known about the impact of overweight and obesity (OV-OB) on clinical outcomes after reduction for intussusception in children. The aim of this study was to compare clinical outcomes after primarily air enema reduction for intussusception in grouped OV-OB (body mass index-for-age percentile ≥ 85) pediatric patients compared with no OV-OB patients.

METHODS

A retrospective study of 564 children who had undergone intussusception reduction via pneumatic reduction (PR) from April 2018 to January 2020 was conducted with assessments of demographic data, clinical symptoms, pre-reduction examination, and reduction results. One-to-one propensity score matching (PSM) was performed to compare clinical outcomes between patients with and without OV-OB, and the risk factors affecting recurrence and surgical reduction were analyzed in the PSM population.

RESULTS

Of the 564 patients, 132 cases (23.4%) were OV-OB (overweight: 95 cases; obesity: 37 cases). In the propensity-matched analysis, the OV-OB group showed a significant increase in surgical reduction (10.2% versus 0.9%, P = 0.005) and recurrence (47.2% versus 10.2%, P < 0.001), excretion time of carbon powder after PR (median: 11.2 h versus 8.4 h, P < 0.001), higher maximum pressure of PR (median: 10.2 kPa versus 7.8 kPa, P < 0.001), and number of PR attempts (mean: 2.0 versus 1.4, P < 0.001). There were no significant differences in the reasons for surgery (PR failure or bowel perforation), time to recurrence (early or late), and the times of recurrences ≥ 2. After applying the multivariate logistic regression analysis, we found that OV-OB and white blood cell count ≥ 20 × 10⁹/L were risk factors for both surgical reduction and the recurrence of intussusception.

CONCLUSION

This study suggested that childhood OV-OB was associated with the failure of PR and recurrence of intussusception after reduction, which should be paid more attention in clinical practice.

Identifying factors associated with overweight and obesity among intermediate school students aged 12-15 years in school settings: mixed-methodology protocol

INTRODUCTION

Childhood obesity is a public health concern globally. In Arab countries, the prevalence of overweight and obesity has increased significantly over the last three decades. The level of childhood overweight and obesity in the Kingdom of Saudi Arabia (KSA) is high and continues to increase. This study will explore factors associated with overweight and obesity among adolescents and identify barriers and enablers to the implementation of comprehensive school-based obesity prevention interventions.

METHODS AND ANALYSIS

Socioecological model will inform this mixed-methods study. The study will include three phases: (1) a scoping review of the literature; (2) the development of a student survey instrument and (3) a mixed-method study comprising a cross-sectional survey targeting students aged 12-15 years with the collection of the students' height and weight measurements; one-on-one interviews with physical education teachers and school principals; and the administration of school climate audits using the Health Promoting School framework. Reliability and validity of the survey instrument will be examined during survey development. Descriptive, inferential and thematic analysis will be employed using appropriate statistical software.

ETHICS AND DISSEMINATION

Ethical approval has been granted from the Curtin University of Human Research Ethics Committee (HR2020-0337) and from the KSA Ministry of Education (4181827686). School principals will provide permission to conduct the study in individual schools. Individual consent/assent will be obtained from students and their parents, and teachers. Study findings will be disseminated via peer-review publications, reports and conferences.

Parenteral Provision of Micronutrients to Pediatric Patients: An International Expert Consensus Paper

INTRODUCTION

Micronutrients (vitamins and trace elements) are essential to all nutrition. For children and neonates who are dependent upon nutrition support therapies for growth and development, the prescribed regimen must supply all essential components. This paper aims to facilitate interpretation of existing clinical guidelines into practical approaches for the provision of micronutrients in pediatric parenteral nutrition.

METHODS

An international, interdisciplinary expert panel was convened to review recent evidence-based guidelines and published literature to develop consensus-based recommendations on practical micronutrient provision in pediatric parenteral nutrition.

RESULTS

The guidelines and evidence have been interpreted as answers to 10 commonly asked questions around the practical principles for provision and monitoring of micronutrients in pediatric patients.

CONCLUSION

Micronutrients are an essential part of all parenteral nutrition and should be included in the pediatric nutrition therapy care plan.

Association between admission body mass index and outcomes in critically ill children: A systematic review and meta-analysis

BACKGROUND & AIMS

The association between nutritional status at pediatric intensive care unit (PICU) admission with clinical outcomes remains unclear. We conducted this systematic review to summarize the overall impact of PICU admission body mass index (BMI) on clinical outcomes.

METHODS

We searched the following medical databases from inception through May 2020: PubMed, Excerpta Medica database (Embase), Cumulative Index of Nursing and Allied Health Literature (CINAHL), Cochrane Library, and Web of Science. We included studies on patients ≤18 years old admitted to a PICU that investigated the effect of BMI on mortality, PICU or hospital length of stay (LOS), or duration of mechanical ventilation (MV). Classification of underweight, overweight, and obese were based on each study's criteria.

RESULTS

There was a total of 21,558 patients from 20 included studies. 12,936 (60.0%), 2965 (13.8%), 2182 (10.1%), 3348 (15.5%) were normal weight, underweight, overweight, and obese patients, respectively. Relative to normal weight patients, underweight (OR 1.32, 95% CI 0.89-1.98; p = 0.171) and overweight/obese patients (OR 1.10, 95% CI 0.86-1.42; p = 0.446) did not have an increase risk in mortality. There was also no difference in duration of MV, PICU and hospital LOS between all three weight categories. Included studies were heterogeneous and lacked standardized nutritional categorization. Sensitivity analysis including only studies that used BMI z-scores as nutritional classification (n = 5) revealed that underweight patients had higher odds of mortality compared to patients with normal weight (OR 1.61, 95% CI 1.35-1.92; p < 0.001); studies that used percentiles as classification did not reveal any differences in mortality. Sensitivity analysis including only studies containing mixed PICU cohorts (i.e., excluding specialized cohorts e.g., congenital heart surgeries, burns) revealed higher mortality odds in underweight patients (OR 1.53, 95% CI 1.25-1.87; p < 0.001) and overweight/obese patients (OR 1.51, 95% CI 1.14-2.01; p = 0.004) relative to normal weight patients.

CONCLUSIONS

Our systematic review did not reveal any association between PICU admission BMI status and outcomes in critically ill children. Further investigation with standardized nutrition status classification on admission, stratified by patient subgroups, is needed to clarify the association between nutritional status and clinical outcomes of PICU patients.

Obesity and Corticosteroid Dosing Guideline Adherence in Children Hospitalized With Asthma

OBJECTIVES

Drug dosing recommendations for children with obesity remain limited. This may lead to variability in medication dosing among children with obesity. Therefore, our objective was to determine differences in the prevalence of guideline-nonadherent systemic corticosteroid orders by weight category in children hospitalized for asthma.

METHODS

We performed a retrospective cross-sectional study of children aged 2 to 17 years hospitalized with asthma and prescribed systemic corticosteroids between January 1, 2010, and December 31, 2017, using the Cerner Health Facts deidentified database. Weight categories ranging from underweight to class III obesity were defined on the basis of BMI percentiles by using CDC guidelines. Corticosteroid orders were categorized as guideline adherent or nonadherent on the basis of total body weight-based dosing guidelines from the National Heart, Lung, and Blood Institute. χ² test and multivariable logistic regression models were used to determine differences in guideline adherence between weight categories.

RESULTS

We identified 21 488 children prescribed systemic corticosteroids during asthma hospitalizations. Most (54.2%) had a healthy weight, and 23.8% had obesity. Almost one-quarter received guideline-nonadherent orders (22.2%), with increasing prevalence among higher weight categories (19.4% of healthy weight children versus 36.0% of those with class III obesity; P < .001). After controlling for demographic and clinical covariates, weight category remained significantly associated with receiving a guideline-nonadherent order (P < .001).

CONCLUSIONS

The prevalence of guideline-nonadherent corticosteroid orders for children hospitalized with asthma increases linearly with weight category, disproportionately affecting children with severe obesity. Standardization of drug dosing guidelines for children with obesity may help reduce variability in drug doses prescribed that may increase risk of harm.

The Impact of Malnutrition on Hospitalized Children With Cerebral Palsy

Children with cerebral palsy (CP) and other medical complexity comprise an outsized proportion of health care use. In this review, we describe the current science of assessment of nutritional status for children with CP, outline a systematic approach to assessing their nutritional status, delineate ramifications of malnutrition on hospitalization-associated outcomes, and identify knowledge gaps and means of addressing those gaps using quality improvement and clinical research tools. Methods to accurately assess body composition and adiposity in this population by using skinfolds, age, sex, and activity level are available but are not widely used. There are limitations in our current method of estimating energy needs in children with CP, who are at higher risk of both obesity and micronutrient deficiencies. There is some evidence of an association between malnutrition, defined as either underweight or obesity, and hospitalization-associated outcomes in children generally, although we lack specific data for CP. The gaps in our current understanding of optimal nutritional status and between current science and practice need to be addressed to improve health outcomes for this vulnerable patient population.

Associations Between Obesity and Use for Pediatric Hospitalizations

BACKGROUND

Obesity is associated with poor outcomes for specific clinical groups of hospitalized children, but few data exist on outcomes of children with obesity on a larger scale during hospitalization. Therefore, we aimed to determine if use outcomes differ between hospitalized children with obesity and hospitalized children without obesity.

METHODS

We performed a retrospective longitudinal cohort study of all children aged 2 to 19 years hospitalized at a single academic institution between January 1, 2009, and December 31, 2016. BMI was calculated from documented height and weight; obesity was defined by using age- and sex-specific BMI percentile guidelines from the Centers for Disease Control and Prevention. Only All Patient Refined Diagnosis-Related Groups (APR-DRGs) with >100 admissions during the study period were included. Primary outcome measures included hospital length of stay, hospital cost, and 14-day readmission. Generalized linear and logistic models were used to determine adjusted differences for outcome measures between patients with and without obesity.

RESULTS

Of 78 756 included hospitalizations, obesity rates increased from 16.5% in 2009-2010 to 17.3% in 2015-2016 (P = .002). Only 6 (4.7%) of the 128 APR-DRGs examined were associated with increased use for patients with obesity: spinal procedures, tonsil and adenoid procedures, major respiratory procedures, peptic ulcer and gastritis, other musculoskeletal diagnoses, and other kidney and urinary tract diagnoses. There were no APR-DRGs with increased length of stay for children with obesity.

CONCLUSIONS

Obesity is associated with increased hospitalization cost and readmission rates for a minority of diagnosis groups. Some groups of hospitalized children with obesity may benefit from targeted interventions to reduce obesity-specific risks. Future research should be focused on disparities in other relevant clinical outcomes.

Clinical Outcomes in Critically Ill Children With Excess Weight: A Retrospective Cohort Study

BACKGROUND

Because of its high prevalence and negative impact on quality of life and longevity, overweight in childhood and adolescence is a major public health concern. The objective of the present study was to determine whether excess weight is associated with clinical outcomes in critically ill children and adolescents admitted to the pediatric intensive care unit (PICU).

METHOD

This retrospective cohort study was performed with children and adolescents admitted to a PICU over 3 years. Nutrition status was classified based on the body mass index z-score for age, following World Health Organization (WHO) criteria. The following outcomes were assessed: mortality, need for mechanical ventilation, length of admission, and multiple organ dysfunction syndrome.

RESULTS

Of 1468 patients admitted during the study period, 1407 were included in the study: 956 (68.0%) had adequate weight, 228 (16.2%) were overweight, and 223 (15.8%) were underweight. Associations were detected between most variables and all nutrition categories (underweight, adequate weight, and overweight). In the descriptive analysis, mortality was more prevalent in nutrition status extremes (extremely underweight or overweight). An independent association between nutrition status and mortality was not detected in any category.

CONCLUSION

Nutrition status was not independently associated with poor outcomes. However, overweight should be considered a potential risk factor for adverse clinical outcomes in PICU admissions.

Demand for health services and drug prescriptions among overweight or obese preschool children

OBJECTIVES

To evaluate the association between excess weight and the demand of health services in preschool children compared with healthy weight.

METHODS

The data come from the Longitudinal Study of Childhood Obesity cohort (1884 4-year-old children, residing in the Madrid region, Spain) who provided information through telephone questionnaire, physical examination and electronic medical records. We defined overweight, general and abdominal obesity based on body mass index, waist circumference and waist-to-height ratio. Using mixed models of multivariable negative binomial regression we calculated the incidence rate ratio (IRR) regarding primary care (PC) doctor visits, drug prescriptions and hospital admissions by weight status at the end of the 2-year follow-up.

RESULTS

Childhood general obesity was associated with a higher demand for PC services related to psychological problems (IRR=1.53; 95% CI 1.02 to 2.28) and childhood abdominal obesity, according to waist-to-height ratio, was related to more frequent problems of the musculoskeletal system (IRR=1.27; 95% CI 1.00 to 1.62). Drugs were prescribed more frequently to children falling under all three definitions of excess weight, compared with healthy weight children. No differences in the number of hospital admissions were observed.

CONCLUSIONS

The demand of health services related to early childhood obesity was small. Nevertheless, obesity was associated with a slightly greater demand for drug prescriptions and for PC doctor visits related to psychological and musculoskeletal problems.

Prevalence and Trends in Obesity Among Hospitalized Children

OBJECTIVES

As obesity rates rise in children, it is likely that the number of hospitalized children with obesity is also increasing. However, characterization of the inpatient population with obesity as a whole has not been reported. We aimed to examine trends in the annual prevalence of obesity in hospitalized children and to identify demographic and clinical characteristics associated with higher obesity prevalence in children who are hospitalized.

METHODS

We completed a retrospective cohort analysis of children aged 2 to 19 years admitted to a single tertiary children's hospital system for any reason in 2009-2016. Body mass index was calculated from documented height and weight. Children with obesity were defined by using age- and sex-specific body mass index percentile guidelines established by the Centers for Disease Control and Prevention. Annual obesity prevalence was calculated on the encounter level for service line and All Patients Refined Diagnosis-Related Groups (diagnosis groups). χ² tests were used to determine statistical differences between groups, and the Cochran-Armitage test of trend was used to describe changes in obesity over time.

RESULTS

Of 83 329 children who were hospitalized, 17.0% had obesity, increasing from 16.5% of hospitalizations in 2009-2010 to 17.3% in 2015-2016 (P = .002). Service lines with the highest obesity prevalence included orthopedics (22.1%), infectious disease (20.6%), and neuroscience (18.7%). Diagnosis groups with the highest obesity prevalence included cellulitis (22.5%), tonsil/adenoid procedures (22.0%), and some orthopedic procedures (28.7%).

CONCLUSIONS

Some groups of children who were hospitalized experience higher obesity prevalence, including children hospitalized with orthopedic, infectious disease, and neurologic problems. In future research, investigators should target disproportionately affected groups by examining health outcomes, patient safety, and satisfaction issues.

Association of obesity with morbidity and mortality in critically ill children: a systematic review and meta-analysis of observational studies

Recent studies have suggested that obesity might be protective in specific conditions such as critical illness; however, there are controversial data in critically ill children with obesity. The aim of this study was to investigate the association of obesity with mortality and other outcomes in these patients. We conducted a systematic review of observational studies investigating obesity in critically ill children, published by August 2017 in PubMed and Scopus. After screening documents, 15 articles with 142119 patients were included in the systematic review and meta-analysis. The results were reported with odds ratio (OR) or standard mean difference (SMD). The primary outcome was mortality and the secondary outcomes were length of ICU stay (ICU LOS), length of hospital stay (hospital LOS), and duration of mechanical ventilation (MV). The analysis showed that critically ill children without obesity had lower risk of mortality compared to patients with obesity (OR 0.79, 95% CI 0.64 to 0.97, P = 0.025, I² = 35.2%). Hospital LOS was also significantly lower in children without obesity (pooled SMD -0.12, 95% CI -0.21 to -0.04, P = 0.004, I² = 8.1%). There were no differences in ICU LOS (95% CI -0.19 to 0.01, P = 0.083) and duration of MV (95% CI -0.22 to 0.03, P = 0.136) between critically ill children with and without obesity. In conclusion, the current systematic review and meta-analysis revealed that critically ill children with obesity have higher risk of mortality and length of hospital stay compared to the group without obesity. Further prospective studies are essential to elucidate the role of obesity and underlying mechanisms in predicting outcomes of critically ill children.

Weight Bias in Pediatric Inpatient Care

OBJECTIVE

Weight bias can influence medical care but has not been studied in the pediatric inpatient setting. We will quantify implicit and explicit weight bias of pediatric inpatient providers and qualitatively explore providers' attitudes toward children with obesity and patient/family perceptions of weight bias in the hospital.

METHODS

We performed a mixed-methods study including semistructured key informant interviews and validated tests for implicit (Implicit Association Test) and explicit (Crandall's Anti-Fat Attitudes Questionnaire) bias with pediatric hospitalists, residents, and acute care nurses. We performed semistructured key informant interviews with pediatric inpatients aged 7 to 17 years and the patient's parent(s) or guardian(s). Interviews were coded using an inductive approach to identify recurrent themes.

RESULTS

We enrolled 28 pediatric providers, 12 patients, and 12 parents/guardians. In total, 71% of providers exhibited moderate or strong implicit weight bias, with generally lower scores for explicit bias. Qualitative analysis identified seven themes: the existence of weight bias, shared responsibility for a child's obesity, a potential for provider bias toward the parents of pediatric patients with obesity, possible effects of patient weight on inpatient care, importance of terminology in addressing obesity, and the possibility of addressing obesity inpatient but a preference for obesity to be addressed in the outpatient setting.

CONCLUSIONS

Health care providers, patients, and families in the pediatric inpatient setting identified multiple ways that obesity could impact care, including provider weight bias.

Inconsistencies in dosage practice in children with overweight or obesity: A retrospective cohort study

Obesity can affect the pharmacokinetics of most drugs, which may result in under- or overdosing if traditional pediatric dosing strategies are used. To investigate currently applied dosage strategies in children with overweight or obesity (overweight/obesity), in a clinical treatment facility. In particular, whether dosing guidelines were available and metrics of body size applied. A retrospective cohort study of 200 patients admitted to the Danish Children's Obesity Clinic. Data were collected from 2007 to 2015. Overweight/obese children 3-18 years were included if they had at least one drug prescription. Overall there were 658 prescriptions, primarily analgesics, psychotropics, asthma medications, and antibiotics. Except for one prescription, guidelines for dosage of overweight/obese children were not available in the clinic. In one prescription of gentamicin, the dose was adjusted by a metric body size. Otherwise dose was predominately prescribed either by total body weight or as fixed dose by age, in accordance with the recommendations of normal weight children. In drugs with a narrow therapeutic interval, we found large interindividual variations in dosing regimens, that is, for gentamicin, paracetamol, and prednisolone. Reduction of dose to the maximum recommended adult dose was common practice, when the dose calculated by total body weight (ie, mg/kg) exceeded this maximum. This study highlights the shortage of dosing guidelines in overweight/obese children. We found a large interindividual variability in dosage regimens, even in drugs with narrow therapeutic intervals. The clinicians rely on "best practice", as evidence-based dosage regimens are missing for many drugs prescribed during childhood.

Vascular Access in Critically Ill Pediatric Patients With Obesity

OBJECTIVES

Pediatric obesity is highly prevalent and has been associated with poor outcomes for hospitalized children. Vascular access is essential in critically ill patients. The aim of this study was to evaluate whether critically ill children with obesity are more likely to undergo vascular device insertion (excluding peripheral IV catheters) and develop related complications.

DESIGN

Multi-institutional retrospective observational cohort study.

SETTING

Ninety-four U.S. PICUs included in the Virtual Pediatric Systems, LLC database.

PATIENTS

120,272 unique patients 2 to less than 18 years old admitted between January 2009 and December 2014.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patients were categorized into normal weight, overweight, and obese (class 1, 2, or 3); underweight patients were excluded. We used mixed-effects multivariable logistic regression to test body mass index category as an independent predictor of vascular device placement and associated complications, adjusted for age, sex, severity of illness, primary diagnosis, presence of a complex chronic condition, and admission related to trauma or surgery. A total of 73,964 devices were placed in 45,409 patients (37.8% of the total cohort received a vascular device). Most device types placed differed significantly by weight status. Subjects with class 3 obesity were less likely (odds ratio, 0.74; 95% CI, 0.67-0.81) to undergo placement of any device compared with normal weight patients. Patients with all classes of obesity were more likely to undergo placement of a peripherally inserted central catheter, with the strongest association in those with class 2 obesity (odds ratio, 1.26; 95% CI, 1.14-1.40). Class 1 and class 3 obesity were independent risk factors for developing a complication, with odds ratio of 1.31 (95% CI, 1.11-1.53) and 1.45 (95% CI, 1.07-1.99), respectively.

CONCLUSIONS

Severe obesity is associated with decreased overall likelihood of placement of a vascular access device but increased likelihood of peripherally inserted central catheter placement and of device-related complications.

Factors Associated With Documentation of Obesity in the Inpatient Setting

OBJECTIVES

Childhood obesity is rarely identified in hospitalized pediatric patients despite the high prevalence of obesity and potential for associated morbidity. The purpose of this study was to identify specific patient characteristics associated with the documentation of obesity and related weight management recommendations in the inpatient setting.

METHODS

Retrospective chart review was conducted on all pediatric patients ages 2 to 18 years old and discharged between January 1, 2012, and December 31, 2014, to determine the following: (1) if obesity was noted in the clinical documentation of those with a BMI ≥95th percentile; and (2) if those with documented obesity had evidence of an obesity-specific management plan. Using χ2 and multivariable logistic regression, we determined patient characteristics associated with the documentation of obesity and presence of a management plan.

RESULTS

Only 26% (214 of 809) of inpatients with obesity had documentation of weight status. The odds of obesity documentation were higher in patients with comorbid cholelithiasis, severe obesity, and older age. Of those with obesity documentation, 23% (49 of 214) had an obesity management plan. Comorbid sleep apnea and admission to a surgical service with a pediatric hospital medicine consult were significantly associated with the presence of an obesity management plan.

CONCLUSIONS

Increased efforts are necessary to improve obesity diagnosis and management in younger children who have not yet developed comorbidities. Additionally, the role of pediatric hospitalists as consultants for surgical patients should be further explored as a tool for addressing obesity during inpatient hospitalization.

Nutritional Status Based on Body Mass Index Is Associated With Morbidity and Mortality in Mechanically Ventilated Critically Ill Children in the PICU

OBJECTIVE

To determine the influence of admission anthropometry on clinical outcomes in mechanically ventilated children in the PICU.

DESIGN

Data from two multicenter cohort studies were compiled to examine the unique contribution of nutritional status, defined by body mass index z score, to 60-day mortality, hospital-acquired infections, length of hospital stay, and ventilator-free days, using multivariate analysis.

SETTING

Ninety PICUs from 16 countries with eight or more beds.

PATIENTS

Children aged 1 month to 18 years, admitted to each participating PICU and requiring mechanical ventilation for more than 48 hours.

MEASUREMENTS AND MAIN RESULTS

Data from 1,622 eligible patients, 54.8% men and mean (SD) age 4.5 years (5.1), were analyzed. Subjects were classified as underweight (17.9%), normal weight (54.2%), overweight (14.5%), and obese (13.4%) based on body mass index z score at admission. After adjusting for severity of illness and site, the odds of 60-day mortality were higher in underweight (odds ratio, 1.53; p < 0.001) children. The odds of hospital-acquired infections were higher in underweight (odds ratio, 1.88; p = 0.008) and obese (odds ratio, 1.64; p < 0.001) children. Hazard ratios for hospital discharge were lower among underweight (hazard ratio, 0.71; p < 0.001) and obese (hazard ratio, 0.82; p = 0.04) children. Underweight was associated with 1.3 (p = 0.001) and 1.6 (p < 0.001) fewer ventilator-free days than normal weight and overweight, respectively.

CONCLUSIONS

Malnutrition is prevalent in mechanically ventilated children on admission to PICUs worldwide. Classification as underweight or obese was associated with higher risk of hospital-acquired infections and lower likelihood of hospital discharge. Underweight children had a higher risk of mortality and fewer ventilator-free days.

Impact of Weight Extremes on Clinical Outcomes in Pediatric Acute Respiratory Distress Syndrome

OBJECTIVES

To determine whether weight extremes impact clinical outcomes in pediatric acute respiratory distress syndrome.

DESIGN

Post hoc analysis of a cohort created by combining five multicenter pediatric acute respiratory distress syndrome studies.

SETTING

Forty-three academic PICUs worldwide.

PATIENTS

A total of 711 subjects prospectively diagnosed with pediatric acute respiratory distress syndrome.

INTERVENTION

Subjects more than 2 years were included and categorized by Center for Disease Control and Prevention body mass index z score criteria: underweight (< -1.89), normal weight (-1.89 to +1.04), overweight (+1.05 to +1.64), and obese (≥ +1.65). Subjects were stratified by direct versus indirect lung injury leading to pediatric acute respiratory distress syndrome. The primary outcome was in-hospital mortality. In survivors, secondary analyses included duration of mechanical ventilation and ICU length of stay.

MEASUREMENTS AND MAIN RESULTS

A total of 331 patients met inclusion criteria; 12% were underweight, 50% normal weight, 11% overweight, and 27% obese. Overall mortality was 20%. By multivariate analysis, body mass index category was independently associated with mortality (p = 0.004). When stratified by lung injury type, there was no mortality difference between body mass index groups with direct lung injury; however, in the indirect lung injury group, the odds of mortality in the obese were significantly lower than normal weight subjects (odds ratio, 0.11; 95% CI, 0.02-0.84). Survivors with direct lung injury had no difference in the duration of mechanical ventilation or ICU length of stay; however, those with indirect lung injury, the overweight required longer duration of mechanical ventilation than other groups (p < 0.001).

CONCLUSIONS

These data support the obesity paradox in pediatric acute respiratory distress syndrome. Obese children with indirect lung injury pediatric acute respiratory distress syndrome have a lower risk of mortality. Importantly, among survivors, the overweight with indirect lung injury requires longer duration of mechanical ventilation. Our data require prospective validation to further elucidate the pathobiology of this phenomenon.

[Nutritional assessment in hospitalized children in a Paediatric service]

INTRODUCTION

Malnutrition in hospitalized children is associated with increased morbidity and mortality.

OBJECTIVE

To determine the nutritional status in children admitted to the Hospital Clínico de la Universidad Católica de Chile.

PATIENTS AND METHOD

A retrospective, cross-sectional study was conducted on hospital patients less than 17 years old within the period from November 2010 to April 2011. A record was made of the demographic data, admission diagnosis, biochemistry results (albumin, haemoglobin, haematocrit), hospital stay, and anthropometry data. Nutritional diagnosis was expressed as standard deviation (SD) for weight-for-height (WFH) by WHO in children younger than 5 y, and body mass index (BMI) by CDC-NCHS in older children. Height-for-age (HFA) ≤-2SD indicated stunted growth.

RESULTS

A total of 365 children, including 201 boys (55.1%), were evaluated. The median age was 3.35 years (IQR: 1.2-8.2). The most frequent reason for admission was heart disease (30.4%). The median hospital stay was 2 days (IQR: 2.0-4.0). Undernutrition was observed in 3.3% of the children, 8% were nutritionally at risk, 15% were overweight, and 10.9% were obese. As regards HFA, short stature was reported in 12.9%. There was a significant relationship between lower age and heart disease, and higher age with gastrointestinal and neurological diseases. By ordinal logistic regression for each year of age, the weight/height ratio (ZP/T) increases by 6.9% (OR=1.07). The biochemistry results (albumin, haemoglobin and haematocrit levels) were not associated with nutritional status.

CONCLUSIONS

A high percentage of children at risk of undernutrition was found. The percentage overweight was similar to the general Chilean paediatric population. Early detection will allow an opportune intervention, and nutritional monitoring at discharge.

Energy and Protein Delivery in Overweight and Obese Children in the Pediatric Intensive Care Unit

BACKGROUND

Early and optimal energy and protein delivery have been associated with improved clinical outcomes in the pediatric intensive care unit (PICU). Overweight and obese children in the PICU may be at risk for suboptimal macronutrient delivery; we aimed to describe macronutrient delivery in this cohort.

METHODS

We performed a retrospective study of PICU patients ages 2-21 years, with body mass index (BMI) ≥85th percentile and >48 hours stay. Nutrition variables were extracted regarding nutrition screening and assessment, energy and protein prescription, and delivery.

RESULTS

Data from 83 patient encounters for 52 eligible patients (52% male; median age 9.6 [5-15] years) were included. The study cohort had a longer median PICU length of stay (8 vs 5 days, P < .0001) and increased mortality rate (6/83 vs 182/5572, P = .045) than concurrent PICU patient encounters. Detailed nutrition assessment was documented for 60% (50/83) of patient encounters. Energy expenditure was estimated primarily by predictive equations. Stress factor >1.0 was applied in 44% (22/50). Median energy delivered as a percentage of estimated requirements by the Schofield equation was 34.6% on day 3. Median protein delivered as a percentage of recommended intake was 22.1% on day 3.

CONCLUSIONS

The study cohort had suboptimal nutrition assessments and macronutrient delivery during their PICU course. Mortality and duration of PICU stay were greater when compared with the general PICU population. Nutrition assessment, indirect calorimetry-guided energy prescriptions, and optimizing the delivery of energy and protein must be emphasized in this cohort. The impact of these practices on clinical outcomes must be investigated.

Changes of Overweight and Obesity Prevalence Among School Children in North West of Iran After 3 Years Follow-up (2009-2011): A Longitudinal Study

Background:

Obesity and overweight among children is a major public health problem in developed and developing countries and has important health and economic implications. This longitudinal study aimed to assessing the prevalence trend of overweight and obesity in West Azerbaijan in North West of Iran.

Methods:

This study was a longitudinal follow-up study and was conducted in school children at 2009–2011 year. The subjects were all school children (12 years of age) that were recruited from rural and urban schools in West Azerbaijan. Overall, 22,820 girls and 28,763 boys were enrolled in 2009 and were followed for 3 years. A body mass index (BMI) 85^th–95^th percentile was classified as overweight and a BMI >95^th percentile was classified as obese. All statistical analyses were performed using the Excel Software. Descriptive statistics were used to characterize the sample in different time periods. The prevalence was calculated as the ratio of number of present cases to a given population number in a given subgroup at a given time.

Results:

In urban schools, the prevalence of overweight among girls and boys was 118.26 and 103.9 per 1000 persons in 2009 year, respectively, and this trend was increased in both girls (152.90 per 1000 persons) and boys (125.72 per 1000 persons) in 2011. The obesity trend was increased among both girls and boys (22.26 and 26.52 among girls and boys in 2009 to 24.66 and 28.65 per 1000 persons in 2011), respectively. In rural schools, the prevalence of overweight among girls was increased from 84.5 in 2009 to 108.89 per 1000 persons in 2011, but this trend was decreased among boys (from 95.49 in 2009 to 43.9 per 1000 persons in 2011), and the prevalence of obesity among boys was increased at the end of follow-up, but this trend was decreased among girls.

Conclusions:

Overweight and obesity in children has increased. Further studies are necessary to evaluate the relationship between obesity and overweight and risk factors such as dietary pattern and physical inactivity.

Malnutrition in Hospitalized Pediatric Patients: Assessment, Prevalence, and Association to Adverse Outcomes

Malnutrition is a frequent finding in pediatric health care settings in the form of undernutrition or excess body weight. Its increasing prevalence and impact on overall health status, which is reflected in the adverse outcomes, renders imperative the application of commonly accepted and evidence-based practices and tools by health care providers. Nutrition risk screening on admission and nutrition status evaluation are key points during clinical management of hospitalized pediatric patients, in order to prevent health deterioration that can lead to serious complications and growth consequences. In addition, anthropometric data based on commonly accepted universal growth standards can give accurate results for nutrition status. Both nutrition risk screening and nutrition status assessment are techniques that should be routinely implemented, based on commonly accepted growth standards and methodology, and linked to clinical outcomes. The aim of the present review was to address the issue of hospital malnutrition in pediatric settings in terms of prevalence, outline nutrition status evaluation and nutrition screening process using different criteria and available tools, and present its relationship with outcome measures. Key teaching points • Malnutrition-underweight or excess body weight-is a frequent imbalance in pediatric settings that affects physical growth and results in undesirable clinical outcomes. • Anthropometry interpretation through growth charts and nutrition screening are cornerstones for the assessment of malnutrition.To date no commonly accepted anthropometric criteria or nutrition screening tools are used in hospitalized pediatric patients. • Commonly accepted nutrition status and screening processes based on the World Health Organization's growth standards can contribute to the overall hospital nutrition care of pediatric patients.

Trend of Overweight and Obesity, Based on Population Study among School Children in North West of Iran: Implications for When to Intervene

INTRODUCTION

Childhood overweight and obesity is a major public health problem in both developed and developing countries. Overweight and obesity in children may have severe consequences later in a dolescence and adulthood. The aim of current study was to determine the prevalence trend of overweight and obesity in school-aged children from 2009 to 2011.

METHODS

The present study was a population-based study and conducted in three consecutive years, from 2009 to 2011. The study population included all of primary, secondary and high school children in rural and urban regions of West Azerbaijan province in West-North of Iran. Body mass index (BMI), the ratio of weight to height squared [weight (kg)]/ [height (m)]2, was calculated to the nearest decimal place. Overweight and obesity were classified using CDC recommendations for age and sex: a BMI 85th- 95th percentile was classified as overweight and a BMI >95th percentile was classified as obese. All statistical analyses were performed using the Excel Software. Descriptive statistics were used to characterize the sample in different time periods. The prevalence was calculated as the ratio of number present cases to a given population number in a given subgroup at a given time.

RESULTS

Overall, 165740, 145146 and 146203 school children were assessed at 2009, 2010 and 2011, respectively. Prevalence of overweight in primary school children among girls were 52.83, 86.93 and 116.36 and for boys were 57.07, 53.4 and 93.55 per 1000 person in 2009, 2010 and 2011 years, respectively. The prevalence of obesity in secondary school children for girls were 22.26, 27.75 and 28.43 and 26.52, 25.72 and 35.85 for boys per 1000 person in 2009, 2010 and 2011, respectively, The highest prevalence of overweight was 77.58, 142.4 and 126.46 per 1000 person among primary, secondary and high school children, respectively, in 2011. The lowest prevalence of obesity was 12.52, 24.1 and 21.61 per 1000 person among primary, secondary and high school children, respectively, in 2009.

CONCLUSIONS

However, the rapid increase in both obesity and overweight should have a special attention. Research on prevalence trend of overweight and obesity in children is poorly reported in Iran. So that, future studies need to follow-up on the associations between overweight and obesity with health outcomes when children develop and reach adolescence and adulthood.

Gaps in Drug Dosing for Obese Children: A Systematic Review of Commonly Prescribed Emergency Care Medications

PURPOSE

Approximately 1 of 6 children in the United States is obese. This has important implications for drug dosing and safety because pharmacokinetic (PK) changes are known to occur in obesity due to altered body composition and physiologic mechanisms. Inappropriate drug dosing in an emergency setting can limit therapeutic efficacy and increase drug-related toxic effects for obese children. Few systematic reviews examining PK properties and drug dosing in obese children have been performed.

METHODS

We identified 25 emergency care drugs from the Strategic National Stockpile and Acute Care Supportive Drugs List and performed a systematic review for each drug in 3 study populations: obese children (2-18 years of age), normal weight children, and obese adults (aged >18 years). For each study population, we first reviewed a drug's Food and Drug Administration label and then performed a systematic literature review. From the literature, we extracted drug PK data, biochemical properties, and dosing information. We then reviewed data in 3 age subpopulations (2-7 years, 8-12 years, and 13-18 years) for obese and normal weight children and by route of drug administration (intramuscular, intravenous, oral, and inhaled). If sufficient PK data were not available by age and route of administration, a data gap was identified.

FINDINGS

Only 2 of 25 emergency care drugs (8%) contained dosing information on the Food and Drug Administration label for obese children and adults compared with 22 of 25 (88%) for normal weight children. We found no sufficient PK data in the literature for any of the emergency care drugs in obese children. Sufficient PK data were found for 7 of 25 emergency care drugs (28%) in normal weight children and 3 of 25 (12%) in obese adults.

IMPLICATIONS

Insufficient information exists to guide dosing in obese children for any of the emergency care drugs reviewed. This knowledge gap is alarming, given the known PK changes that occur in the setting of obesity. Future clinical trials examining the PK properties of emergency care medications in obese children should be prioritized.

Drug Dosing and Pharmacokinetics in Children With Obesity: A Systematic Review

IMPORTANCE

Obesity affects nearly one-sixth of US children and results in alterations to body composition and physiology that can affect drug disposition, possibly leading to therapeutic failure or toxic side effects. The depth of available literature regarding obesity's effect on drug safety, pharmacokinetics, and dosing in obese children is unknown.

OBJECTIVE

To perform a systematic literature review describing the current evidence of the effect of obesity on drug disposition in children.

EVIDENCE REVIEW

We searched the MEDLINE, Cochrane, and EMBASE databases (January 1, 1970-December 31, 2012) and included studies if they contained data on drug clearance, volume of distribution, or drug concentration in obese children (aged ≤18 years). We compared exposure and weight-normalized volume of distribution and clearance between obese and nonobese children. We explored the association between drug physicochemical properties and clearance and volume of distribution.

FINDINGS

Twenty studies met the inclusion criteria and contained pharmacokinetic data for 21 drugs. The median number of obese children studied per drug was 10 (range, 1-112) and ages ranged from newborn to 29 years (1 study described pharmacokinetics in children and adults together). Dosing schema varied and were either a fixed dose (6 [29%]) or based on body weight (10 [48%]) and body surface area (4 [19%]). Clinically significant pharmacokinetic alterations were observed in obese children for 65% (11 of 17) of the studied drugs. Pharmacokinetic alterations resulted in substantial differences in exposure between obese and nonobese children for 38% (5 of 13) of the drugs. We found no association between drug lipophilicity or Biopharmaceutical Drug Disposition Classification System class and changes in volume of distribution or clearance due to obesity.

CONCLUSIONS AND RELEVANCE

Consensus is lacking on the most appropriate weight-based dosing strategy for obese children. Prospective pharmacokinetic trials in obese children are needed to ensure therapeutic efficacy and enhance drug safety.

Factors associated with patient and provider delays for tuberculosis diagnosis and treatment in Asia: a systematic review and meta-analysis

Background

Delays in tuberculosis (TB) diagnosis and treatment is a major barrier to effective management of the disease. Determining the factors associated with patient and provider delay of TB diagnosis and treatment in Asia may contribute to TB prevention and control.

Methods

We searched the PubMed, EMBASE and Web of Science for studies that assessed factors associated with delays in care-seeking, diagnosis, or at the beginning of treatment, which were published from January 1992 to September 2014. Two reviewers independently identified studies that were related to our meta-analysis and extracted data from each study. Independent variables were categorized in separate tables for patient and provider delays.

Results

Among 45 eligible studies, 40 studies assessed patient delay whereas 30 assessed provider delay. Cross-sectional surveys were used in all but two articles, which included 17 countries and regions. Socio-demographic characteristics, TB-related symptoms and medical examination, and conditions of seeking medical care in TB patients were frequently reported. Male patients and long travel time/distance to the first healthcare provider led to both shorter patient delays [odds ratio (OR) (95% confidence intervals, CI) = 0.85 (0.78, 0.92); 1.39 (1.08, 1.78)] and shorter provider delays [OR (95%CI) = 0.96 (0.93, 1.00); 1.68 (1.12, 2.51)]. Unemployment, low income, hemoptysis, and positive sputum smears were consistently associated with patient delay [ORs (95%CI) = 1.18 (1.07, 1.30), 1.23 (1.02, 1.49), 0.64 (0.40, 1.00), 1.77 (1.07, 2.94), respectively]. Additionally, consultation at a public hospital was associated with provider delay [OR (95%CI) = 0.43 (0.20, 0.91)].

Conclusions

We propose that the major opportunities to reduce delays involve enabling socio-demographic factors and medical conditions. Male, unemployed, rural residence, low income, hemoptysis, positive sputum smear, and long travel time/distance significantly correlated with patient delay. Male, long travel time/distance and consultation at a public hospital were related to provider delay.

Childhood obesity and in-hospital asthma resource utilization

OBJECTIVE

To examine the relationship between pediatric obesity and inpatient length of stay (LOS), resource utilization, readmission rates, and total billed charges for in-hospital status asthmaticus.

DESIGN/METHODS

We conducted a cross-sectional study of patients 5 to 17 years old hospitalized with status asthmaticus to 1 free-standing children's hospital system over 12 months. Only hospitalized patients initially treated in the hospital's emergency department were included to ensure all therapies/charges were examined. Patients with complex chronic conditions, pneumonia, or lacking recorded body mass index (BMI) were excluded. The primary exposure was BMI percentile for age. The primary outcome was LOS (in hours). Secondary outcomes were 90-day readmission rate, billed charges, and resource utilization: number of albuterol treatments, chest radiographs, intravenous fluids, intravenous or intramuscular steroids, and intensive care unit admission. Bivariate, adjusted Poisson and logistic regression model analyses were performed.

RESULTS

Five hundred eighteen patients met inclusion criteria. Most had a normal BMI (59.7%); 36.7% were overweight or obese. LOS, readmissions, and resource utilization outcomes were not associated with BMI category on bivariate analyses. After adjustment for demographic/clinical characteristics, LOS decreased by 2% for each decile increase in BMI percentile for age. BMI percentile for age was not associated with billed charges, readmissions, or other measures of resource utilization.

CONCLUSIONS

Although BMI decile for age is inversely associated with LOS for in-hospital pediatric status asthmaticus, the effect likely is not clinically meaningful.

Excess body weight in children may increase the length of hospital stay

OBJECTIVES

To investigate the prevalence of excess body weight in the pediatric ward of University Hospital and to test both the association between initial nutritional diagnosis and the length of stay and the in-hospital variation in nutritional status.

METHODS

Retrospective cohort study based on information entered in clinical records from University Hospital. The data were collected from a convenience sample of 91 cases among children aged one to 10 years admitted to the hospital in 2009. The data that characterize the sample are presented in a descriptive manner. Additionally, we performed a multivariate linear regression analysis adjusted for age and gender.

RESULTS

Nutritional classification at baseline showed that 87.8% of the children had a normal weight and that 8.9% had excess weight. The linear regression models showed that the average weight loss z-score of the children with excess weight compared with the group with normal weight was -0.48 (p = 0.018) and that their length of stay was 2.37 days longer on average compared with that of the normal-weight group (p = 0.047).

CONCLUSIONS

The length of stay and loss of weight at the hospital may be greater among children with excess weight than among children with normal weight.

Diet, behavior and immunity across the lifespan

It is increasingly appreciated that perinatal events can set an organism on a life-long trajectory for either health or disease, resilience or risk. One early life variable that has proven critical for optimal development is the nutritional environment in which the organism develops. Extensive research has documented the effects of both undernutrition and overnutrition, with strong links evident for an increased risk for obesity and metabolic disorders, as well as adverse mental health outcomes. Recent work has highlighted a critical role of the immune system, in linking diet with long term health and behavioral outcomes. The present review will summarize the recent literature regarding the interactions of diet, immunity, and behavior.

Pediatric obesity and safety in inpatient settings: a systematic literature review

OBJECTIVE

Pediatric obesity affects more than 16% of American children and is associated with worse outcomes in hospitalized patients. A systematic literature review was performed to identify studies of adverse care events affecting obese pediatric patients in the emergency room, operating room, or inpatient wards.

EVIDENCE REVIEW

We systematically searched Medline for articles published from 1970 to 2013 regarding obesity and patient safety events in pediatric acute care settings. We determined the study design, number of patients studied, definition and prevalence of obesity, the relevant acute care setting, the specific association with obesity addressed, and the results of each study.

RESULTS AND CONCLUSION

Thirty-four studies documented both procedural complications and issues with general hospital care. Most were retrospective and focused on surgery or anesthesia. Obese patients may have increased risk for a variety of adverse events. Further study could improve institutional patient safety guidelines to enhance care for obese children.