Bone mineral density during pregnancy in women participating in a randomized controlled trial of vitamin D supplementation.

Background: Little is known about bone mineral density (BMD) during pregnancy. Advances in technology with lower radiation emissions by dual-energy X-ray absorptiometry instruments now permit the safe measurement of BMD during pregnancy.Objective: We evaluated maternal BMD during pregnancy as a function of vitamin D status in women of diverse racial/ethnic backgrounds.Design: A total of 301 women who underwent BMD measurements at 12-20 wk of gestation and again at 0-14 wk postpartum were included in this analysis. Women were a subset of subjects who were recruited for a randomized, controlled, double-blind trial of vitamin D supplementation in pregnancy (400, 2000, or 4000 IU/d).Results: Treatment had no significant effect on changes in BMD that occurred between 12-20 wk of gestation and 0-14 wk postpartum. Similarly, changes in spine and femoral neck bone mineral contents (BMCs) were not significantly different in the treatment groups. In addition, vitamin D inadequacy (serum 25-hydroxyvitamin D concentration, averaged across pregnancy, <50 nmol/L) was not associated with changes in BMD or BMC. There were significant racial/ethnic differences in spine BMD. African Americans lost more spine BMD than did Caucasians (-0.04 ± 0.04 compared with -0.02 ± 0.04 g/cm2; P = 0.033). In addition, baseline obesity was associated with a greater loss of femoral neck BMD. The means ± SDs of femoral neck BMD loss were -0.02 ± 0.05 and 0.0 ± 0.03 g/cm2 for groups with baseline body mass index (BMI; in kg/m2) ≥30 and <30, respectively.Conclusion: These findings do not support a dose effect of vitamin D supplementation on bone health and suggest that race/ethnicity and BMI play an important role in pregnancy bone health. This trial was registered at clinicaltrials.gov as NCT00292591.

The Eye of the Beholder: A Discussion of Value and Quality From the Perspective of Families of Children and Youth With Special Health Care Needs.

There is broad agreement that increasing the cost-effectiveness and quality of health care services, thereby achieving greater value, is imperative given this country's current spiraling costs and poor health outcomes. However, how individuals or stakeholder groups define value may differ significantly. Discussion of value in the context of health care, in particular value-based purchasing and value-based insurance design, must acknowledge that there is no universal consensus definition as to what constitutes value. To date, the consumer perspective has been underrepresented in discussions of value-based strategies such as pay for performance, capitated and bundled payments, and high-deductible health plans, which have been driven primarily by payers and providers. This article will discuss 3 elements of value from the perspective of families of children and youth with special health care needs: the role of families in the delivery of care, consumer perspectives on what constitutes quality for children and youth with special health care needs, and health care and health care financing literacy, decision-making, and costs. The undervalued contributions made by family members in the delivery and oversight of pediatric care and the importance of partnering with them to achieve the goals of the Triple Aim are stressed. The article closes with a discussion of recommendations for a future policy and research agenda related to advancing the integration of the consumer perspective into value-based purchasing and value-based insurance design.

Parents' perspectives on a dental home for children with special health care needs.

The authors surveyed parent-leaders about aspects of a dental home for children with special health care needs (CSHCN). State leaders in two advocacy groups completed the survey; the response rate was 70.6% of all states. Two of the most highly rated aspects of a dental home, endorsed as "essential" by 89% of respondents, pertained to dentist-parent interactions: the dentist listens carefully to the family, and the dentist helps the family feel like a partner in treatment decisions. Likewise, 89% said it was essential that insurance coverage allows the child to see needed providers. Dentists' lack of knowledge or willingness to treat CSHCN and refusal of Medicaid insurance coverage were identified as major barriers to care. More than 84% of respondents reported that parents were unaware of the recommendation to establish dental care by 1 year of age. Establishing policy and educational strategies should help parents meet this dental health goal.

Children with special health care needs: acknowledging the dilemma of difference in policy responses to obesity.

Children with special health care needs (SHCN) account for part of the increasing prevalence of childhood obesity in the general population and can face an elevated risk for obesity. The federal government, in partnership with states, has assumed the role of steward for this vulnerable population and supports a network of services designed to promote their health through increased access to quality health services. Addressing obesity-related health risks among children with SHCN requires policies that support family- and community-based initiatives in addition to health services. We discuss the ethics of child obesity policy from the perspective of children with SHCN and their families, and identify salient issues to optimize benefits for children and families. We refer to the dilemma of difference to identify policy concerns that are specific to children with SHCN and ethically may require different approaches. Determining the appropriate mix of inclusive and special obesity prevention initiatives for children with SHCN and identifying approaches to ensure their full participation in community-based obesity prevention activities present challenges. Children with SHCN from low-income and minority communities are particularly vulnerable and warrant special attention.

Benefits for employees with children with special needs: findings from the collaborative employee benefit study.

Approximately 13-15 percent of U.S. children have special health care needs. The demands of their caregiving can affect their parents' health and workplace performance. We interviewed forty-one U.S. employers and conducted focus groups with working parents in four U.S. cities to determine the extent to which employers understand the needs of these families and to identify opportunities for improving workplace benefits for these employees beyond health insurance. Employers saw value in improving workforce performance and employee retention through expanded benefits and indicated promising opportunities to improve their response to the needs of employees with children with chronic conditions.

A look back: lessons in family activism and recommendations to address today's oral health challenges for children with special health care needs.

The US Maternal and Child Health Bureau's Division of Services to Children With Special Health Care Needs has developed a national agenda for the development of systems of care of children with special health care needs. The purpose of this presentation was to discuss family activism in the care of children with special health care needs, and to explore the obstacles and successes encountered between the 1970s and today regarding: (1) family centered care; (2) provision of health care services; (3) availability of information for families; and (4) financing. Recommendations are presented concerning: (1) family centered care and partnerships; (2) care and services; (3) information and data; and (4) financing.

Benefits for employees with children with ADHD: findings from the Collaborative Employee Benefit Study.

Parents of most children with attention-deficit hyperactivity disorder (ADHD) are employed. Employers have interest in decreasing employee absenteeism and improving workplace productivity, partly through employee benefits. The authors interviewed employers to (1) determine how they view the needs of employees with children with ADHD and (2) identify benefits that might help employees with children with ADHD. The authors carried out a systematic interview study of mainly family-friendly, large employers in four U.S. urban markets (Boston, Cleveland, Miami, Seattle). Multidisciplinary interview teams used a protocol to gather basic company information, benefit philosophy, current insurance and other employee benefits, and knowledge of ADHD and its impacts on employees. Initially, the interview team and then the larger project team reviewed all protocols for common themes. The authors interviewed staff of 41 employers (human resource managers, work/life program directors, benefits directors). Only 15 of 41 interviewees knew about ADHD, its prevalence, or its effects on parents. They had little knowledge of how differences in managed behavioral health may affect families' access to diagnostic and treatment services for ADHD, although most had experience with primary care management of depression among employees. Employers offer a variety of other benefits, including work/life and employee assistance programs, occasionally providing employees help with caring for a child with a mental health condition, on-site parent training programs, or assistance with child care. Other potentially useful employee benefits include flexible work and leave policies and information and referral services that can link parents with community programs. Although employers have limited awareness of ADHD and its potential effect on employees' work, this study identified opportunities to improve both health insurance and other benefits for employees with children with ADHD.