PEDIATRICS recent issues

Neighborhood Social Conditions, Family Relationships, and Childhood Asthma


Poor neighborhood conditions have established associations with poorer child health, but little is known about protective factors that mitigate the effects of difficult neighborhood conditions. In this study, we tested if positive family relationships can buffer youth who live in dangerous and/or disorderly neighborhoods from poor asthma outcomes.


A total of 308 youths (aged 9–17) who were physician-diagnosed with asthma and referred from community pediatricians and/or family practitioners participated in this cross-sectional study. Neighborhood conditions around families’ home addresses were coded by using Google Street View images. Family relationship quality was determined via youth interviews. Clinical asthma outcomes (asthma symptoms, activity limitations, and forced expiratory volume in 1 second percentile), asthma management behaviors (family response to asthma symptoms and integration of asthma into daily life), and asthma-relevant immunologic processes (lymphocyte T helper 1 and T helper 2 cytokine production and sensitivity to glucocorticoid inhibition) were assessed via questionnaires, interviews, spirometry, and blood draws.


Significant interactions were found between neighborhood conditions and family relationship quality (β = |.11–.15|; P < .05). When neighborhood danger and/or disorder was low, family relationships were not associated with asthma. When neighborhood danger and/or disorder was high, better family relationship quality was associated with fewer asthma symptoms, fewer activity limitations, and higher forced expiratory volume in 1 second percentile. Similar patterns emerged for asthma management behaviors. With immunologic measures, greater neighborhood danger and/or disorder was associated with greater T helper 1 and T helper 2 cytokine production and reduced glucocorticoid sensitivity.


When youth live in dangerous and/or disorderly neighborhoods, high family relationship quality can buffer youth from poor asthma outcomes. Although families may not be able to change their neighborhoods, they may nonetheless be able to facilitate better asthma outcomes in their children through strong family relationships.

Predictive Validity of the CRAFFT for Substance Use Disorder


The utility of CRAFFT (Car, Relax, Alone, Forget, Friends, Trouble) in identifying current and future problematic substance use and substance use disorders (SUDs) in pediatric emergency department (PED) patients is unknown. We conducted a secondary analysis of a study in 16 PEDs to determine the concurrent and predictive validity of CRAFFT with respect to SUD.


At baseline, 4753 participants aged 12 to 17 years completed an assessment battery (CRAFFT and other measures of alcohol, drug use, and risk behaviors). A subsample was readministered the battery at 1-, 2-, and 3-year follow-up to investigate future SUDs.


Of 2175 participants assigned to follow-up, 1493 (68.6%) completed 1-year, 1451 (66.7%) completed 2-year, and 1265 (58.1%) completed the 3-year follow-up. A baseline CRAFFT value of ≥2 was significantly associated with problematic substance use or mild or moderate to severe SUD diagnosis on the Diagnostic Interview Schedule for Children at baseline (P < .001). The results persisted after 1, 2, and 3 years (P < .001). The best combined sensitivity and specificity was achieved with a baseline CRAFFT value of ≥1 as a cutoff for predicting problematic substance use and a Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition diagnosis of mild SUD at 1, 2, and 3 years. The baseline CRAFFT score that best predicted a moderate to severe SUD at 1 year was ≥2; but at 2 and 3 years, the cutoff score was ≥1.


CRAFFT has good concurrent validity for problematic substance use and SUD in PED patients and is useful in predicting SUDs at up to 3 years follow-up but with limited sensitivity.

A Parent Treatment Program for Preschoolers With Obesity: A Randomized Controlled Trial


Early obesity treatment seems to be the most effective, but few treatments exist. In this study, we examine the effectiveness of a parent-only treatment program with and without booster sessions (Booster or No Booster) focusing on parenting practices and standard treatment (ST).


Families of children 4 to 6 years of age with obesity were recruited from 68 child care centers in Stockholm County and randomly assigned to a parent-only program (10 weeks) with or without boosters (9 months) or to ST. Treatment effects on primary outcomes (BMI z score) and secondary outcomes (BMI and waist circumference) during a 12-month period were examined with linear mixed models. The influence of sociodemographic factors was examined by 3-way interactions. The clinically significant change in BMI z score (–0.5) was assessed with risk ratios.


A total of 174 children (mean age: 5.3 years [SD = 0.8]; BMI z score: 3.0 [SD = 0.6], 56% girls) and their parents (60% foreign background; 39% university degree) were included in the analysis (Booster, n = 44; No Booster, n = 43; ST, n = 87). After 12 months, children in the parent-only treatment had a greater reduction in their BMI z score (0.30; 95% confidence interval [CI]: –0.45 to –0.15) compared with ST (0.07; 95% CI: –0.19 to 0.05). Comparing all 3 groups, improvements in weight status were only seen for the Booster group (–0.54; 95% CI: –0.77 to –0.30). The Booster group was 4.8 times (95% CI: 2.4 to 9.6) more likely to reach a clinically significant reduction of ≥0.5 of the BMI z score compared with ST.


A parent-only treatment with boosters outperformed standard care for obesity in preschoolers.

Early-Onset Sepsis Risk Calculator Integration Into an Electronic Health Record in the Nursery


An early-onset sepsis (EOS) risk calculator tool to guide evaluation and treatment of infants at risk for sepsis has reduced antibiotic use without increased adverse outcomes. We performed an electronic health record (EHR)–driven quality improvement intervention to increase calculator use for infants admitted to a newborn nursery and reduce antibiotic treatment of infants at low risk for sepsis.


This 2-phase intervention included programming (1) an EHR form containing calculator fields that were external to the infant’s admission note, with nonautomatic access to the calculator, education for end-users, and reviewing risk scores in structured bedside rounds and (2) discrete data entry elements into the EHR admission form with a hyperlink to the calculator Web site. We used statistical process control to assess weekly entry of risk scores and antibiotic orders and interrupted time series to assess trend of antibiotic orders.


During phase 1 (duration, 14 months), a mean 59% of infants had EOS calculator scores entered. There was wide variability around the mean, with frequent crossing of weekly means beyond the 3 control lines, indicating special-cause variation. During phase 2 (duration, 2 years), mean frequency of EOS calculator use increased to 85% of infants, and variability around the mean was within the 3 control lines. The frequency of antibiotic orders decreased from preintervention (7%) to the final 6 months of phase 2 (1%, P < .001).


An EHR-driven quality improvement intervention increased EOS calculator use and reduced antibiotic orders, with no increase in adverse events.

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


Although adolescent mental health interventions are widely implemented, little consensus exists about elements comprising successful models.


We aimed to identify effective program components of interventions to promote mental health and prevent mental disorders and risk behaviors during adolescence and to match these components across these key health outcomes to inform future multicomponent intervention development.


A total of 14 600 records were identified, and 158 studies were included.


Studies included universally delivered psychosocial interventions administered to adolescents ages 10 to 19. We included studies published between 2000 and 2018, using PubMed, Medline, PsycINFO, Scopus, Embase, and Applied Social Sciences Index Abstracts databases. We included randomized controlled, cluster randomized controlled, factorial, and crossover trials. Outcomes included positive mental health, depressive and anxious symptomatology, violence perpetration and bullying, and alcohol and other substance use.


Data were extracted by 3 researchers who identified core components and relevant outcomes. Interventions were separated by modality; data were analyzed by using a robust variance estimation meta-analysis model, and we estimated a series of single-predictor meta-regression models using random effects.


Universally delivered interventions can improve adolescent mental health and reduce risk behavior. Of 7 components with consistent signals of effectiveness, 3 had significant effects over multiple outcomes (interpersonal skills, emotional regulation, and alcohol and drug education).


Most included studies were from high-income settings, limiting the applicability of these findings to low- and middle-income countries. Our sample included only trials.


Three program components emerged as consistently effective across different outcomes, providing a basis for developing future multioutcome intervention programs.