Pediatric Annals

Risk Evaluation in Pediatric Practice

Barbara A Dennison, MD, FAAP, FAHA; Penny S Bayer, MS, RN

Abstract

Aids in Prevention of Childhood Overweight

Amain focus of pediatric primary care is prevention. Pediatric providers and support staff are well positioned to implement childhood prevention strategies prenatally through adolescence. Although the empirical evidence supporting efficacious strategies for the prevention of overweight in children is scant, we describe pediatric provider prevention efforts extrapolated from obesity epidemiology and treatment research.

The goal in prevention of childhood overweight is to ensure sufficient nutrition for optimal growth and development while regulating body weight and adiposity.1 A strategic plan to successfully combat the development of child overweight requires combining the cognitive, psychomotor, and affective domains. The initial strategic thrust requires recognition of beliefs and values about childhood overweight prior to discussing definitive measures that can be implemented by the pediatric provider and pediatric support staff.

RECOGNITION OF CHILDHOOD OVERWEIGHT

Prevention of childhood overweight must begin with the recognition of values and beliefs concerning adiposityheld by the pediatric provider, be it the pediatrician, family physician, physician assistant, or nurse practitioner, as well as support staff. Pediatric providers report increased concern about the rise in child and adolescent overweight and acknowledge treatment is needed.2 However, practitioner characteristics such as practice setting, years in practice, personal body mass index (BMI), personal dietary and exercise habits, and gender may influence practice approach to the management of childhood overweight.3 It is helpful for providers first to develop a heightened awareness of their own biases and perceptions concerning weight issues.

A method of inquiry that allows affective expression can help participants identify personal values and beliefs. Chamberlin et al.4 used focusgroup methodology with healthcare professionals to elucidate attitudes and beliefs about prevention and management of childhood overweight. Using a facilitator trained in group process, pediatric providers and support staff can safely discuss their feelings about childhood overweight and their roles in its recognition and prevention. It is imperative to include support staff in the focus group discussions, as they often interact with children and parents separately from the pediatric providers. As collaborative care models have been demonstrated to improve client outcomes in chronic illness care, it is reasonable to believe that collaborative practice will enhance successful implementation of preventative strategies to combat childhood overweight.5,6

An early recognition strategy that facilitates prevention is timely identification and tracking of the high-risk child as indicated by family history of obesity, low socioeconomic status, and the child's present weight, diet, and television-viewing and physical-activity habits.7 Assessment of eating behaviors and activity patterns at every well-child visit provides valuable information, as well as opportunities to provide and reinforce healthy eating and activity practices. Pediatric providers should assess the child's prenatal history regarding birth weight, excessive maternal weight gain, or gestational diabetes, all of which are factors that may be linked to the development of overweight in children.8,9

Because breastfeeding is the preferred method of infant feeding and may help prevent the development of pediatric overweight, exclusive breastfeeding for the first 6 months of life should be encouraged by the pediatric provider.10,11 Pediatric providers should assess breastfeeding of infants during office visits to provide encouragement and facilitate problem solving. Pro-viders and staff also should advocate for hospital policies and working environments that support breastfeeding.

CLASSIFICATION OF CHILDHOOD OVERWEIGHT

Infants receive frequent well-child visits the first year of life and, to a lesser extent, during the preschool and school years. Anthropometric measurements are routinely taken by the pediatric support staff. Accuracy of weight, height, or length can be more readily ensured when the staff follows recommended standards for obtaining measurements. Pediatric providers must ensure that staff are knowledgeable and skilled in measurement techniques. Equally essential is a…

Aids in Prevention of Childhood Overweight

Amain focus of pediatric primary care is prevention. Pediatric providers and support staff are well positioned to implement childhood prevention strategies prenatally through adolescence. Although the empirical evidence supporting efficacious strategies for the prevention of overweight in children is scant, we describe pediatric provider prevention efforts extrapolated from obesity epidemiology and treatment research.

The goal in prevention of childhood overweight is to ensure sufficient nutrition for optimal growth and development while regulating body weight and adiposity.1 A strategic plan to successfully combat the development of child overweight requires combining the cognitive, psychomotor, and affective domains. The initial strategic thrust requires recognition of beliefs and values about childhood overweight prior to discussing definitive measures that can be implemented by the pediatric provider and pediatric support staff.

RECOGNITION OF CHILDHOOD OVERWEIGHT

Prevention of childhood overweight must begin with the recognition of values and beliefs concerning adiposityheld by the pediatric provider, be it the pediatrician, family physician, physician assistant, or nurse practitioner, as well as support staff. Pediatric providers report increased concern about the rise in child and adolescent overweight and acknowledge treatment is needed.2 However, practitioner characteristics such as practice setting, years in practice, personal body mass index (BMI), personal dietary and exercise habits, and gender may influence practice approach to the management of childhood overweight.3 It is helpful for providers first to develop a heightened awareness of their own biases and perceptions concerning weight issues.

A method of inquiry that allows affective expression can help participants identify personal values and beliefs. Chamberlin et al.4 used focusgroup methodology with healthcare professionals to elucidate attitudes and beliefs about prevention and management of childhood overweight. Using a facilitator trained in group process, pediatric providers and support staff can safely discuss their feelings about childhood overweight and their roles in its recognition and prevention. It is imperative to include support staff in the focus group discussions, as they often interact with children and parents separately from the pediatric providers. As collaborative care models have been demonstrated to improve client outcomes in chronic illness care, it is reasonable to believe that collaborative practice will enhance successful implementation of preventative strategies to combat childhood overweight.5,6

An early recognition strategy that facilitates prevention is timely identification and tracking of the high-risk child as indicated by family history of obesity, low socioeconomic status, and the child's present weight, diet, and television-viewing and physical-activity habits.7 Assessment of eating behaviors and activity patterns at every well-child visit provides valuable information, as well as opportunities to provide and reinforce healthy eating and activity practices. Pediatric providers should assess the child's prenatal history regarding birth weight, excessive maternal weight gain, or gestational diabetes, all of which are factors that may be linked to the development of overweight in children.8,9

Because breastfeeding is the preferred method of infant feeding and may help prevent the development of pediatric overweight, exclusive breastfeeding for the first 6 months of life should be encouraged by the pediatric provider.10,11 Pediatric providers should assess breastfeeding of infants during office visits to provide encouragement and facilitate problem solving. Pro-viders and staff also should advocate for hospital policies and working environments that support breastfeeding.

CLASSIFICATION OF CHILDHOOD OVERWEIGHT

Infants receive frequent well-child visits the first year of life and, to a lesser extent, during the preschool and school years. Anthropometric measurements are routinely taken by the pediatric support staff. Accuracy of weight, height, or length can be more readily ensured when the staff follows recommended standards for obtaining measurements. Pediatric providers must ensure that staff are knowledgeable and skilled in measurement techniques. Equally essential is a system of office management that supports adequate time for the staff to take and plot the measurements.

Weight-for-length should be plotted for children younger than 2. Because rapid weight gain during infancy may indicate a predisposition to becoming overweight, this also should be identified and explored.8 After age 2, BMI can be determined using a calculator, a BMI wheel, or BMI charts (Sidebar 1).

Determining BMI is the standard of care for the early recognition of weight problems in children.12 BMI should be interpreted using sex- and age-specific charts13 and the recommended cut points14 (Sidebar 2). Examining the rate of weight gain relative to child age, sex, and linear growth will alert the pediatric provider to potential growth problems.7 As with infants, rapid weight gain during childhood is linked to the development of overweight.8

Providers should note that BMI application is a screening tool and is not diagnostic for overweight. They need to check to be sure that the excess weight represents increased adiposity. Children whose BMI-for-age qualifies them as at risk of overweight or overweight (Sidebar 1, see page 26) require a more indepth medical evaluation, including screening for overweight-related complications such as hypertension, dyslipidemia, or insulin resistance.12

COMMUNICATION OF WEIGHT STATUS

Communication of weight status to parents in a sensitive and nonjudgmental, blame-free manner is essential to gain parental support and cooperation. Parents and child may react to weight issues with embarrassment and guilt. Interaction must focus on the behavior, not personal characteristics. It is important for the provider to be objective and non-accusatory in these discussions.12

Many parents do not recognize that their child is developing a weight problem. Chubby children are often seen as a sign of health and good parenting.15,16 Providers and staff can minimize parent defensiveness by not using the words "obese" or "fat" when evaluating weight status; rather, they should use either "overweight" or "at risk of overweight."

When interviewing parents, openended questioning for descriptions of eating behaviors, diet, television viewing, and physical-activity habits can build a therapeutic relationship. Providers should review the health risks an overweight child can develop with the parents and allow time for parental reflection. It is helpful for providers and support staff to express empathy to the challenges that parents face and avoid arguments by sticking to the objective data. This may lay the foundation for parentprovider collaboration in successfully implementing changes in the child's eating behaviors, television viewing, or activity patterns. The goal is to improve the child's health, not traumatize the child or family. The efficacy of provider-initiated discussions in affecting behavior changes is supported by previous success with other health-promoting programs, such as breastfeeding promotion and smoking prevention.7

AGE-SPECIFIC ANTICIPATORY GUIDANCE

Increasing parental awareness of the dangers inherent to childhood overweight and providing counseling about healthy-eating behaviors, physicalactivity patterns, and media habits are key components in the preventive plan. At each well-child visit, the pediatric provider and, as appropriate, pediatric support staff should offer anticipatory guidance in prevention of childhood overweight to all children and families. Anticipatory guidance must begin at the first prenatal or infant visit and be reinforced at each subsequent visit, as intervention strategies that target younger children have more efficacious long-term results than those targeting adolescents.17

During the toddler and preschool years, it is especially important to stress anticipatory guidance. Adiposity rebound occurs during the preschool years, which is the time period linked with the early development of child overweight.18 Moreover, parents and other caregivers are both gatekeepers and role models, determining the foods and beverages available and teaching behaviors related to eating and physical activity or inactivity.

Children's food preferences, eating patterns, physical-activity levels, and media use develop early and are influenced by their sociocultural environments.19-21 Certain dietary practices such as over-consumption of fruit juice, sweetened beverages, and soft drinks, use of food as a reward, and eating meals or snacks in front of the television have been identified as potential contributors to childhood overweight.19,21-23 Therefore, anticipatory guidance should cover the areas of food and beverage consumption, behaviors with respect to eating and drinking, physical activity, television/video viewing, and computer use. Information should be geared to the developmental age of the child. Educational handouts must be culturally-sensitive and at an appropriate reading level geared to the layperson.

FOOD AND BEVERAGE CONSUMPTION

Pediatric providers should promote healthier dietary and lifestyle choices in families, including encouraging and supporting exclusive breastfeeding for the first 6 months of life.10 Providers should also promote consumption of a healthy diet. As children approach age 2, they should decrease intake of fat and increase intake of whole grain products, vegetables, fruits, and low-fat dairy products.24 Use of the Food Guide Pyramid for Young Children, developed by the United States Department of Agriculture, can teach parents about healthy food consumption for children ages 2 through 6 (Sidebar 2, page 27).

An effective way of creating a healthier diet is to increase the number and variety of vegetables that are eaten. Several studies in adults and children show individuals who eat a greater variety and quantity of vegetables are less likely to be or become overweight.25,26 Most children and adults do not consume recommended amounts of vegetables. The secret to getting children and adults to eat more vegetables is to serve more than one vegetable at a time and to serve vegetables at more eating occasions, such as both for meals and snacks.27 Because repeated exposure to any new food is needed in order for young children to accept them into their diets, it's important for parents to continue offering a given vegetable even if the child's initial response to it is negative.28

Parents should also limit consumption of juice, sweetened beverages, and soft drinks. Consumption of excess fruit juice is more common among preschool children, while excess soda consumption is more problematic among adolescents. Many parents and caregivers may view juice consumption as healthy and frequently do not limit the child's access to it. This unlimited consumption contributes to increased calories and compromises adequate calcium intake.21

The American Academy of Pediatrics has developed specific guidelines for juice intake, recommending that juice not be introduced to a child's diet before age 6 months. Pure, 100% juice intake should be limited to 4 to 6 ounces per day for children ages 1 to 6. Children older than 6 should limit juice consumption to two servings, or 12 ounces per day. Children should never be offered sugar-sweetened fruit drinks.29

Because 50% of all children and adolescents do not meet recommended calcium intakes, increased consumption of low-fat milk and dairy products is strongly encouraged.24 Children 1 to 2 years old should transition from formula and breast milk to whole or 2% milk. Older than age 2, lower fat (1% or fat-free) milk is recommended.30 Studies suggest increased dairy foods or calcium intake may be associated with a reduced risk of excess weight.31

FOOD BEHAVIORS

Once a healthy diet is established, food behaviors must be taught or modified. Pediatric providers should stress the correct portion size to parents, as currently available serving sizes have increased dramatically.32 Adults and children older than 5 eat proportionally larger amounts as the portion size increases.33 Children should not be prompted to eat when full, nor should they be rewarded for cleaning their plates, as both practices promote overeating and are associated with becoming overweight.19

Appropriate limits on food choices should be set. Because stringent parental food controls can lead to increased child preference for unhealthy foods and detrimental feeding practices, pediatric providers should suggest that parents offer a choice of healthy foods and allow the child to choose.19

Children mimic what other family members do; therefore, parents and other family members should display healthy dietary habits for the child. Parents should also avoid using food items, such as high-fat fast food or candy, as rewards for good behavior. They may substitute verbal praise, a fun activity, a book, or stickers instead.

PHYSICAL ACTIVITY

Parents and other family members have a powerful influence on whether children adopt an active lifestyle, which is just as important as a healthy diet for the prevention of childhood overweight.34 Activities that children and family can do together, such as walking, swimming, biking, skating, or playing sports, can be suggested. Both unstructured and structured play for children should also be encouraged. The recently released guide by the American Alliance for Health, Physical Education, Recreation, and Dance recommends that toddlers and preschoolers obtain a minimum of 30 and 60 minutes per day, respectively, of structured activity.35 They "should [also] engage in at least 60 minutes and up to several hours of daily, unstructured physical activity and should not be sedentary for more than 60 minutes at a time except when sleeping." Encourage daily play outdoors, because playing outside tends to be more physically active than playing inside.

TELEVISION/VIDEO VIEWING AND COMPUTER USE

Families should not eat meals or snacks while viewing television. It is difficult to regulate intake of calories while combining television viewing with eating. At the very least, parents should offer snacks of fruits or vegetables, and snacking directly out of a bag should be avoided. A single serving should be provided for snacking to limit unregulated consumption.

The total time devoted to media use, including television/video viewing and computer games, should be limited to no more than 1 to 2 hours per day.36 Not only will sedentary activity be decreased, but the child will not be exposed to the numerous advertisements targeted to children for high-fat, highsugar foods.

Children younger than 2 should be discouraged from watching television. The pediatric provider should encourage parents to engage in activities with infants or toddlers that will promote cognitive development, such as reading or singing.36 For children older than 2, televisions should not be placed in their bedrooms, as this promotes television viewing and has been associated with an increased risk of being overweight.21

PEDIATRIC PROVIDER OFFICE ENVIRONMENT

Because increased television-viewing is associated with excess weight in children, no pediatric office should have a television set in the waiting room. Alternative forms of entertainment can be provided, such as books, games, or coloring books and crayons. Opportunities should also be taken to open a dialogue with the child as well as the parents. For example, children who present for a physical exam playing a hand-held video game create an ideal opportunity for the pediatric provider or support staff to assess the amount of time spent with video and computer games and to discuss alternatives. Children often enter the exam room with a large cup filled with juice, sweetened beverage, or soda. Assessing the serving size and contents and suggesting appropriate serving sizes and healthy alternatives requires a minimal amount of time. Suggesting a non-food reward when the parent offers a fast-food treat for good behavior is a timely intervention.

Most important, pediatric providers need to be leaders and champion the preventive cause. They must support their office staffs by providing them with the training to conduct BMI assessment accurately and the education to initiate prevention strategies. Development of a pediatric well-child visit form that has a section to record and interpret BMI, plus a list of anticipatory guideline cues, will enhance prevention teaching and early recognition of childhood overweight. Lay educational materials should be easily accessible to the provider and staff so as to ensure parental distribution.

FUTURE RESEARCH PRIORITIES

Future research is needed to evaluate the most effective means for pediatric care providers to help parents safeguard their children from becoming overweight A better understanding of the reasons for the disparities in prevalence across racial and ethnic groups and among low-income children might lead to more effective prevention efforts. Prospective controlled trials involving principles of behavior change and counseling skills in culturally, racially/ethnically, and socio-economically diverse pediatric practice settings are also needed.

The role of pediatric providers, parents, and older children as advocates for change in their local daycare centers, schools, and communities cannot be underestimated. Analogous to the role parents, physicians, and concerned citizens played in changing policies and laws to decrease second-hand smoke exposure, such efforts are needed to affect changes in the current obesigenic environment.

SUMMARY

Pediatric providers and the pediatric support staff play important roles in the primary prevention of child overweight (Sidebar 3, page 28). Beliefs and values concerning overweight children must be examined so that biases and misunderstandings can be rectified. Early prevention of pediatric overweight begins with recognition of children who are predisposed to becoming overweight. BMI is the standard of care for screening pediatric weight status beginning at age 2. Office staff need to be knowledgeable about all aspects of BMI, including application and sensitive discussion with parents concerning the weight of their children. Pediatric providers should organize the office environment to support the staff in the screening process. Provision of age-appropriate anticipatory guidelines for the family to help with the prevention of childhood overweight needs to be provided at each well-child visit.

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10.3928/0090-4481-20040101-09

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