One Simple Trick to Get Kids to Eat Their Veggies: A Randomized Trial

Kids these days are supposed to be much more sophisticated than when we were growing up. My kids can use Iphones, play shows on Netflix.  I caught my six-year old looking for shoes on macys.com the other day. So the fact that some colorful cartoon vegetables could meaningfully change elementary school kids eating habits seemed unlikely to me at first.  Nevertheless, that's what a study appearing in the journal Pediatrics suggests.  And these effects were far from subtle. For the video version of this post, click here.

Here's what you need to know.  Ten urban elementary schools participated in this study. These were schools with a largely minority population and where the large majority of students participated in the school lunch program.  They all had a regular lunch line as well as a salad bar. The researchers randomized these ten schools into 3 intervention groups and one control.  The intervention involved… well… this:

Colorful, smiling, anthropomorphic vegetables. With muscles. One group of schools got these happy little fellows, one group got a video playing some edutainment about healthy eating, and one group got the deluxe package of both. Check out SuperSprowtz for more adorableness.

It seems a bit hokey, but here's the thing.  This worked.  Surprisingly well.  Researchers examined two main outcomes – the number of kids visiting the salad bar, and the percent of kids who ended up buying vegetables from anywhere in the cafeteria.

Here are some numbers: In schools with the vinyl banners, the percent of kids who visited the salad bar increased from 12.6 to 24%. In schools that got the banners as well as the TV spots, the rate went from 10 to 35%. These were pretty impressive numbers.

The main issue here is that the interventions only occurred over a six-week period.  That means that some of this effect could be due to novelty. As the great ad man Don Draper once said, "Even though success is a reality, its effects are temporary".

And it should be noted that there are groups out there who are opposed to marketing to children in all its forms. To some extent, I get that – kids minds are manipulated by cleverly-designed ads all the time.  But could this be a case of the ends justifying the means?

I mean, if it would get my kids to eat their vegetables, I might dress up like Brian the Brawny Broccoli myself.

Do Smarter Babies Walk Earlier?

Do you remember when your little baby took her first step? How about when she sat without support?  How about standing with assistance? Yes, for many of us these "milestones" are not exactly burned in our brain, but a new study from the journal Pediatrics suggests that some of these milestones may be really important – not just for baby journals, but for childhood development. For the video version of this post, click here.

Here’s the deal. We've known for a long time that kids with severe developmental disabilities in childhood seem to meet some gross motor milestones later than expected. But that's looking at an extreme case. The question these researchers had was whether delayed gross motor development would associate with later childhood development in kids without developmental delay.

To answer this question, they turned to the Upstate KIDS study, a prospective cohort study of over 6000 babies born in the New York area.  The study focuses only on 501 of the children though – a subset who agreed to a follow-up examination at 4 years.  So, if you’re keeping score, we’re already looking at a group that is not representative of the population at large.

Based on logs the mothers kept, the researchers looked at when the child achieved certain gross motor milestones like walking. They looked at 6 milestones in all, and compared them to the total developmental score at four years of age. The findings were… subtle.

After adjustment for factors like maternal age, prematurity, and others, there was a statistically significant association between one of the six milestones - later standing-with-assistance and total developmental score. That total score is driven by 5 subcomponents, and when those were analyzed individually, later standing with assistance was associated with worse adaptive and cognitive development.

Similar results were seen in the subset of kids with no developmental disability – the subset, which, speaking editorially here, really should have formed the primary analysis of this study.

So… ok… should we panic if our kids aren't standing and walking like a bunch of little Rory Calhoun's? I'm not ready for that yet. For one, the authors don't appear to have accounted for the multiple comparisons evaluated here – so the marginally statistically significant result has a pretty high risk of being a false-positive. Second, it's not immediately obvious what you would do with a kid who stands with assistance 2.1 months later than the average. Stand them up more? Send them to a neurologist?

In the end, we’d end up giving moms and dads just one more metric to worry about in a world obsessed with measuring kids' performance at every turn. Or every step.

Sudden Cardiac Death in Young People: More Answers

When tragedy strikes, physicians are often asked to answer two questions.  The first is the how question. How did this happen? Long illnesses provide time for patients and family members alike to come to terms with a diagnosis and prognosis. Not always, and not easily, but the time is there.  In the case of sudden cardiac death in a young person, there is no time. Sudden cardiac death is a condition that feels out of place in 2016. That a healthy person can be alive and then, simply, not, feels wrong to modern sensibilities. Nevertheless, the incidence of sudden cardiac death, about 1 per 100,000 young people per year is similar across multiple countries and cultures. Now a manuscript appearing in the New England Journal of Medicine attempts to shed light on how sudden cardiac death can happen. For the video version of this post, click here.

The researchers examined literally every case of sudden cardiac death occurring in individuals less than age 35 in Australia and New Zealand from 2010 to 2012 in a prospective fashion. With each of the 490 cases, they examined autopsy and toxicology reports to determine how the death occurred. While 60% of the cases were explainable by conditions like coronary artery disease and hypertrophic cardiomyopathy, a disturbing 40% had no revealing findings.

So they expanded the search, in a subset of that 40%, the researchers performed advanced genetic sequencing to look for gene mutations that could predispose to sudden death. They found mutations of that type in 27% of the otherwise unexplained cases. While the gap of understanding was narrowed a bit, the how question remained unanswered for many individuals.

Now I should mention that identifying disease-causing mutations is not as easy as it sounds. Most of the mutations identified were classified as “probably pathogenic”. Basically, that means that the mutations are predicted to do harmful things to the protein they affect, but we don’t know for sure at this time.

To take the analysis a step farther, the researchers examined family members of the deceased to screen for the presence of heritable cardiac conditions. In 12 of 91 families screened, such a condition – like long QT syndrome – was found.

So what we have here is a great example of a well-conducted, methodical, and meticulous study that has moved us incrementally towards greater understanding. For some of the families who suddenly lost a loved one – the answer to “how did this happen” is now clear.

Of course that’s only one of the two questions we get asked.  The other is “why did this happen”? And that’s a question that no methodology, no matter how advanced, can answer.

Hypertensive Urgency in the Office: Should You Send the Patient to the ER?

You’re in the office seeing a patient, and take a look at the vitals.  Blood pressure 190/110. Being the diligent physician you are, you recheck the blood pressure manually, in both arms, after having the patient relax in a quiet room for 5 minutes.  190/110. There are no symptoms. What do you do? The situation I just described is known as hypertensive urgency, which is a systolic pressure over 180 or a diastolic pressure over 110 without any evidence of end-organ damage. And what to do with patients in this situation is a clinical grey area that, thanks to a manuscript appearing in JAMA Internal Medicine, may finally be seeing the light of day.

For the video version of this post, click here.

The Methods

The study, out of the Cleveland Clinic, gives us some really important data. Here’s how it was done. The researchers identified everyone in that Healthcare system who had an outpatient visit with hypertensive urgency over a 6-year time frame. Of over 1 million visits – just under 60,000, about 5% - had blood pressures consistent with hypertensive urgency. Now, some of those individuals were sent to the hospital for evaluation, the rest were sent home. What percent do you think went to the hospital?

If you answered “less than 1%”, you’re spot on and a way better guesser than I am. I actually assumed the rate would be much higher.  Now, how can we evaluate whether sending someone to the hospital is the “right” move. And let’s not fall into the assumption that sending someone to the hospital is a “safe” option. Those of us who work in hospitals will quickly disabuse anyone of that notion.

The problem is that those who got sent to the hospital were doing worse than those who got sent home. They had higher blood pressures in the “urgency” range, with a mean systolic of 198 compared to 182 in those sent home.

To create a fair assessment of the effects of sending someone to the hospital, the authors performed a propensity-score match.  Basically, they matched the people who got sent to the hospital with people of similar characteristics that didn't. Comparing the matched groups, they found… nothing.

No increased risk of major adverse cardiovascular events.  In other words, the people sent home weren’t having strokes during the car ride.

A curious finding

One thing I did note was that those sent to the hospital were much more likely to have a hospital admission sometime in the next 8 – 30 days compared to those who got to go home.  This either means that some bad stuff happens in that initial hospital referral that leads them to bounce back later in the month or, and I’m favoring this interpretation here, the propensity match didn’t catch some factors that predisposed the hospitalized people to hospitalization in general – factors like socioeconomic status, for instance. If that’s true, then we’d actually expect the hospitalized group to do worse than their controls. The fact that they didn’t may argue that the hospital actually did something beneficial. But we are way down the causality rabbit hole here.

Conclusion

In the end I take home two things from this study.  First, the shockingly low rate of referral to hospital for hypertensive urgency.  Seriously – is this just a Cleveland Clinic thing? Feel free to let me know in the comments.  And two – that for the right patient, a dedicated outpatient physician can probably do just as much good as a costly trip to the ED.

Birth at 41 Weeks = Baby Genius?

A study appearing in JAMA Pediatrics suggests that children born late-term have better cognitive outcomes than children born full-term. As if pregnant women didn’t have enough to worry about. For the video version of this post, click here.

Let’s dig into the data a bit, but first some terms (sorry for the pun). “Early term” means birth at 37 or 38 weeks gestation, “full term” 39 or 40 weeks, and “late term” 41 weeks. In other words, this study is not looking at pre-term or post-term babies, all of the children here were born in a normal range.

Ok, here’s how the study was done.  Researchers used birth records from the state of Florida and linked them to standardized test performance in grades 3 through 10. Compared to children born at 39 or 40 weeks of gestation, those born at 41 weeks got test scores that were, on average, about 5% of a standard deviation higher. To get a sense of what the means, if these were IQ tests (they weren’t) that would translate to a little less than 1 IQ point difference. Not huge, but the sample size of over one million births makes it statistically significant.

10.3% of those born at 41 weeks were designated as “gifted” in school, compared to 10.0% of those born at full-term.

Before I look at what might go wrong in a study like this – is the effect plausible? To be honest, I sort of doubt it. One week extra development in utero certainly will lead to some differences at or near birth, but I find it hard to believe that any intelligence signal wouldn’t simply be washed away amid all the other factors that affect developing young minds prior to age 8.

Now, the authors did their best to adjust for some of these things – race, sex, socioeconomic status, birth order, but it seems likely that there are unmeasured factors here that might lead to longer gestation and better cognitive outcomes – maternal nutrition comes to mind, for example.

We also need to worry about systematic measurement error. These gestation times came from birth certificate data – in other words, many of these measurements may have been some doctors best guess. If the dates were determined by ultrasound, larger babies might be misclassified as later term.  Also, I suspect that if conception dates weren’t well known, a lot of doctors filling out the birth certificate may have just written “40 weeks” to put something in that box.

The authors attempted to look just at women where the likelihood of prenatal care was high, finding similar results, but again, with the tiny effect size, any small systematic measurement error could lead to results like this.

The authors state that this information is relevant to women who are considering a planned cesarean or induction of labor. Currently, the American College of Obstetrics and Gynecology recommends “targeting” labor to 39-40 weeks to avoid some physical complications of late-term birth. In my opinion, having this study change that recommendation at all would be premature.