By Helga Toriello, PhD, genetics specialist, Spectrum Health and the College of Medicine, Michigan State University

A recent statement from the American Academy of Pediatrics and the American College of Medical Genetics and Genomics, the first time the two groups have collaborated on a policy, brings to the a forefront an issue that is being widely discussed in the lay media: genetic testing. The policy updates older statements, most of which were written when the potential of wide scale genetic screening and testing was just that—potential.

Today it is a reality. As the statement noted, about 4 million infants a year in the US undergo newborn screening for a variety of conditions. Screening and testing in older children is far less common but, as direct-to-consumer genetic tests that only require a mouth swab become more common, that will likely increase significantly.

Since these tests can be purchased and used without physician involvement, it is important that clinicians are aware of the potential ramifications of genetic testing in children in order to have informed discussions with your patients. It is also important that as new screening tests become available to clinicians we understand the implications of those tests and when it is most appropriate to order them. As the statement notes “Results of such tests may have significant medical, psychological, and social implications, not only for the minor but also for other family members.”

The report has numerous recommendations, all of which apply to biological as well as adopted children. I’ve highlighted a few below.  

•  Parents should be informed about the potential risks and benefits of “mandatory” newborn screenings and provide permission, even if given verbally. That often does not occur today.
• The use of direct-to-consumer and home kit genetic testing is “strongly” discouraged.
• The best interest of the child should drive any decision about whether to offer genetic testing and screening. Any screening/testing should be done in conjunction with genetic counseling.
• Parents and guardians (and the child, if old enough) should be informed about the risks and benefits and provide all needed permissions.
• Routine carrier testing in minors is not recommended unless such testing will provide health benefits in childhood.
• Predictive genetic testing for adult-onset conditions should typically be deferred unless an intervention initiated in childhood could reduce morbidity or mortality.
• Encourage parents and guardians to inform their child of the test results at an appropriate age, and to honor requests for the results from a mature adolescent.
• Have a plan in place for disclosure if issues around paternity, donor gametes, adoption, or other family relationships are uncovered “incidentally.” 

With this new technology comes increased responsibility for communication and education.  It cannot be stated enough that patients and their families need to be informed of what the test can or cannot provide.  Physicians need to be educated about the benefits and limitations of a growing menu of tests, and should be able to provide at least basic information to families that might be requesting such tests.

Have you been getting questions from parents and patients about genetic screening? How do you respond? What are your thoughts about the new policy statement?

Helga Toriello, PhD, is a genetics specialist at Spectrum Health and the College of Medicine, Michigan State University.

By Martina Keeler, MD, pediatric hospitalist, Spectrum Health Medical Group, Helen DeVos Children’s Hospital

In the past year, there has been a great deal of attention paid to high rates of readmissions in adult hospitals. This stems from new Medicare rules that penalize hospitals if patients with pneumonia, acute myocardial infarction, or heart failure are readmitted within 30 days of discharge.

But readmissions are also a problem for children’s hospitals. One analysis of 30,188 hospital admissions in a children’s hospital found that 8.4% of children were readmitted within 15 days of discharge, most of them with an underlying chronic illness. Forty-five percent of the readmissions were unplanned and were related to the same diagnosis as the index admission.

A more recent article in the Journal of the American Medical Association analyzed unplanned readmissions at 72 children’s hospitals and found an overall adjusted rate of 6.4% of patients who were readmitted within 30 days. The most common diagnoses were anemia or neutropenia, ventricular shunt procedures, and sickle cell anemia crisis. Studies also find high rates of readmission for children with asthma, particularly those in the Medicaid population.[1]^,[2]

Unlike adult hospitals, pediatric hospitals are not being penalized for preventable readmissions—yet. But unplanned readmissions are a quality issue. The Pediatric Quality Measures Program, mandated in the Children’s Health Insurance Preauthorization Act, lists pediatric readmissions as a future measure, while the federal “Partnership for Patients” initiative has set a goal of reducing pediatric readmissions by 20%.

So, like adult hospitals, we are working to reduce readmission rates. Studies find one of the most effective ways to do this is by improving transitions of care and discharge planning to improve coordination between inpatient and outpatient care. This is relatively easy for children who already have a medical home, but many of our patients, particularly those on Medicaid, often do not have access to outpatient care.

At the national level, the Children’s Hospital Association (formerly NACHRI), is working to identify barriers in the discharge process that makes the transition more stressful for parents and patients. Among them are a lack of transportation, waiting for subspecialists to discharge the patient, and waiting for medications.

In our hospital, we have an interprofessional team that begins the discharge process on the day of admission. A care manager identifies what services the child will need after discharge, including any support services from the primary care physician office.  If the primary care physician can’t provide those services, we try to find them elsewhere.  Well before discharge, the care manager works to ensure that families are connected to the resources they need so their child can continue recovering at home.

The key to a smooth transition of care from the inpatient to the outpatient setting is communication. The hospitalist team assures that the primary care office is aware of the child’s hospitalization, medical status, and needs at time of discharge and.  Parents receive help in coordinating appointments, and we make sure that no one on either side of the transition process “drops the ball.”

In early 2013, the pediatric hospitalist team from Helen DeVos Children’s Hospital  sent a letter to more than 2,000 primary care physicians in western Michigan asking how they preferred to receive communication about patients who are being discharged (fax, e-mail, phone). We are now collecting and analyzing that data and encourage our primary care partners to return their surveys.   Our goal – and, we know, your goal—is to make sure we hand off patients safely and improve long-term outcomes.

Martina Keeler, MD is a pediatric hospitalist with Spectrum Health Medical Group at Helen DeVos Children’s Hospital in Grand Rapids, MI. 

[1] Bloomberg, GR, Trinkaus KM, Fisher  EB, et al. Hospital Readmissions for Childhood Asthma: A 10-year Metropolitan Study, Am J Resp Crit Care Med. 2003;167(8):1068–76.

[2] Liu SY, Pearlman DN. Hospital Readmissions for Childhood Asthma: The Role of Individual and Neighborhood Factors. Public Health Reports. 2009;124(1):65–7.

By Lisa Lowery, MD, MPH, adolescent medicine specialist, Spectrum Health Medical Group,  Helen DeVos Children’s Hospital 

If they don’t, you need to tell them. That’s the bottom line of a new policy statement from the American Academy of Pediatrics (AAP). First, the facts:

• Using emergency contraception up to 120 hours after unprotected intercourse of contraceptive failure can prevent pregnancy. It is most effective, however, when used within 24 hours.
• Emergency contraception will not disrupt an established pregnancy.
• Types of emergency contraception include two pills of levonorgestrel (Plan B and Next Choice), both of which can be taken as a single dose, or the single-pill option, Plan B One Step.  

These are the preferred method for adolescents because of their high effectiveness and low risk of adverse effects. No examination or ruling out of pregnancy is required. Other options include:

• Ulipristal acetate progesterone agonist/antagonist (ella), a single pill. Pregnancy should be ruled out because of the risk of fetal loss if taken in the first trimester.
• Combination oral contraceptives (the “Yuzpe method”). This involves a double dose of a combination estrogen/levonorgestrel or norgestrel birth control pill. The primary side effect is nausea and vomiting. 
• Teenagers younger than 17 need a prescription in many states. Some states allow pharmacists to refuse to provide emergency contraception, some require emergency rooms to provide it in cases of sexual assault. Michigan has no restrictions or laws concerning emergency contraception. You can view state policies here. 

I welcome this policy because, as the authors note, the US still has one of the highest teen pregnancy rates in the developed world, with 27 percent ending in abortion and 57 percent in live births. Although the rate has been dropping in the past 15 years, it is still unacceptably high, and about 40 percent of teens 15 to 19 say they’ve had intercourse (70 percent of 19 year olds). Particularly concerning is that about 10 percent say they were forced to have sex, which means they were likely not using contraception.

Overall, 80 percent of teen pregnancies are unintended, resulting from not using contraception or the contraception failing.

When discussing emergency contraception with your patients, the AAP policy states, you should make sure to warn them that it does not protect against sexually transmitted diseases, and that they should make an appointment to see you after using it. Also stress the fact that emergency contraception should not be used as a contraceptive to prevent pregnancy.

Don’t forget the boys in your practice; it is important that they are aware of this option if they do not use a condom or the condom breaks or slips off

You might also consider giving adolescents a prescription for emergency contraception “just in case.” Studies find no increase in sexual activity when youth have early access to the drugs.

As for refusing to prescribe the pills on the basis of conscience, the AAP policy states that: “Pediatricians have a duty to inform their patients about relevant, legally available treatment options to which they object and have a moral obligation to refer patients to other physicians who will provide and educate about those services. Failure to inform/educate about availability and access to emergency-contraception services violate this duty to their adolescent and young adult patients.”

I am in agreement with the AAP’s  stance on emergency contraception and the duties of pediatricians.

What are your thoughts about this topic? Do you routinely educate your patients about emergency contraception? If not, will this new policy change your practice?

Daniel McGee, MD, Pediatric Hospitalist, Spectrum Health Medical Group, Helen DeVos Children's Hospital 

A recent study published online in The Journal of the American Medical Association-Pediatrics  found that rates of undervaccination are increasing. The study also found that undervaccinated children have a higher rate of hospital admissions than children who received all age-appropriate vaccines.

The researchers evaluated immunization records for of 323,000 children in eight managed care organizations, creating two cohorts of undervaccinated children: those who did not receive vaccines because of parental choice and those who were not vaccinated for any reason. They found that nearly half the children overall were undervaccinated for at least one day before age 24 months, a prevalence of about 13 percent. Between 2004 and 2008, the average days of undervaccination increased by 50 percent, they reported, and the median from 0 to 3 days.

Undervaccinated children had lower outpatient visit rates than those who received all age-appropriate vaccines, which is likely one reason why they missed being vaccinated.

As the authors wrote: "This large multisite cohort study suggests that undervaccination is an increasing trend. Our results also suggest that specific patterns of undervaccination have been occurring with greater frequency over time. In addition, our cohort analyses comparing undervaccinated and age-appropriately vaccinated children demonstrated differences in healthcare utilization, which appear to increase as the magnitude of undervaccination increases."

So what’s an already-overwhelmed physician to do?

The Affordable Care Act does away with copayments for well-child visits and vaccinations, which should help with this problem. Other opportunities for improving vaccine rates include: 

• Educate, educate, educate. If parents oppose vaccinations because of medical concerns, educate them. Don’t argue, but use gentle persuasion. Rather than statistics, tell them the story of one child who was hospitalized or died because he/she contracted a preventable disease. Studies find that physicians have tremendous influence over their patients, particularly if they show concern for the patient rather than espousing some lofty public health goal.[1] You can find resources on communication designed to enhance trust and provide reliable information at www.cdc.gov/vaccines/conversations.
• Address any misinformation in the media with the facts.
• Use the electronic health record to send out automatic reminders.
• Administer all eligible vaccinations at an 18-month visit. One study found that doing so could increase the series completion rate of recommended vaccines at 18 months from a median of 51 percent to 98 percent.[2]

What are you doing in your practice to improve vaccination rates?

[1] Diekema DS. N Engl J Med. Improving childhood vaccination rates. 2012;366(5):391-3.

[2] McElligott JT, Roberts JR, O'Brien ES, et al. Improving immunization rates at 18 months of age: implications for individual practices. Public Health Rep. 2011;126 Suppl 2:33-8.

By William Stratbucker, MD, medical director, Healthy Weight Center, Helen DeVos Children’s Hospital, Grand Rapids, Michigan

A Canadian study published in the "Archives of Pediatrics & Adolescent Medicine" found that children need at least seven minutes a day of vigorous physical activity (think running, playing basketball, dancing) to prevent weight gain and obesity, but that most don’t get anywhere close to that amount.

The researchers used monitors to track physical activity for one week in more than 600 children, and monitored the children’s weight, waist circumference and blood pressure. They found that kids spent nearly 70 percent of their awake time engaged in sedentary activities, about 25 percent in light physical activity, about 7 percent in moderate physical activity, and less than 1 percent (0.6) in vigorous physical activity. Most showed little activity at all in the evenings and on weekends.

As the authors said in a press release about the study: "This research tells us that a brisk walk isn't good enough. Kids have to get out and do a high-intensity activity in addition to maintaining a background of mild-to-moderate activity.”

I’m not all surprised by these findings. This is the same kind of thing we see every day in the Helen DeVos Children's Hospital Healthy Weight Center. Many parents think their children are “active” but when I ask what they mean by this, they give examples of “being outside” or “playing.” While these are certainly healthier activities than sitting on the couch and watching television, they rarely raise the heart and breathing rates or make the child sweat, all required for the definition of “vigorous” activity.

Other studies suggest that many physicians don’t ask about specifics regarding physical activity. Simply hearing that the child is active, i.e., plays soccer, is not enough. We need to ask, “How much time for how many days per week—year-round—does your child get vigorous activity and how do you, as a parent, promote such activity?”

For instance, soccer could be 12 one-hour sessions per year, or a child might be a goalie and so rarely runs. It is our role to understand why a child might be avoiding vigorous activity. In my experience, the list starts with undiagnosed or undertreated asthma, bullying or teasing, and mental health concerns, including depression.

Many parents need help obtaining strategies to prioritize vigorous activity within their family. Let them know that one of the best ways to do this is by modelling the same behavior. The physician can bring attention to this through discussions about the importance of the whole family being active—vigorously active.

This study, then, provides an important opening for that conversation. Seven minutes a day is really miniscule when you think about it. If the child is doing very little and added two minutes of jumping jacks every time a commercial came on TV, or whenever they reached the next level on their video game, they’d be there in no time. Or how about running around the block twice when they get home from school?

Make sure both parent and child understand what “vigorous” means and challenge them to see how many minutes a day they can reach by their next checkup. Options to get them more engaged include downloading apps to track progress or starting a competition with Facebook friends.

Then come back here and let me know how it goes!

By Kristi Paguio, licensed master social worker, Helen DeVos Children’s Hospital Healthy Weight Center, Grand Rapids, Michigan

Two recent online articles in Pediatrics provide important information for pediatric health care providers about bullying.

The first focused on bullying in children with food allergies. Of the 251 families surveyed, nearly half the children and a third of their parents said the child had been bullied or harassed, with a third of the children and a quarter of the parents attributing the bullying directly to the food allergy.

Such bullying included making the child touch the threatening food, throwing it at the child, or waving the food in front of the child’s face. Although all children who reported bullying scored lower on quality-of-life assessments, those whose parents did not know about the bullying had far worse quality-of-life scores.

Overall, between 17 percent and 35 percent of school-aged children are harassed or bullied. Research finds that bullying can increase the risk of suicide and, in allergic children, a serious allergic reaction.[1]

Findings from the second study were also surprising. Researchers found that overweight children were not only subjected to frequent bullying from their peers, but also from parents, teachers and coaches. And the school bullying continued even after the child lost weight.

We should view both studies as a wake-up call for action at the national, state and local levels. But it should also be viewed as a call to action at the individual provider level.

Guidelines from the American Academy of Pediatrics (AAP) call for pediatricians to intervene, manage and, hopefully, prevent youth violence. They urge clinicians to stay current on the latest research and interventions, provide resources and treatment options, and advocate for increased awareness of bullying among teachers, administrators and parents.

In an editorial accompanying the new bullying articles, the authors also suggest that clinicians provide anticipatory guidance about bullying for all children and parents (defining and describing bullying, explaining its consequences and telling parents what signs to look for), but particularly for those at the highest risk, such as kids with food allergies and weight problems.

“We also need to be hyperaware of the signs of bullying,” the editorial noted, such as “unexplained bruises, cuts and scratches, as well as school avoidance, social isolation, anxiety, depression, substance use and chronic physical symptoms (e.g., headaches, stomachaches).”

How do you address bullying in your practice?

[1]Winsper C, Lereya T, Zanarini M, Wolke D. Involvement in bullying and suicide-related behavior at 11 years: a prospective birth cohort study. J Am Acad Child Adolesc Psychiatry. 2012;51(3):271–282, e3

By Yaw Appiagyei-Dankah, MD, pediatric endocrinology, Spectrum Health Medical Group, Helen DeVos Children’s Hospital, Grand Rapids, Michigan

We've known for quite a while that girls are entering puberty earlier than they did several decades ago. This research has garnered quite a lot of media attention, with numerous theories as to the reason for the change, including better nutrition and greater exposure to hormone-disrupting chemicals.

Now a large study published in Pediatrics finds the same occurring in boys. The study, from researchers at the University of North Carolina at Chapel Hill and others, used Tanner stage and testicular volume data obtained during well-child visits on 4,131 boys seen by 212 practitioners in 144 pediatric offices across the United States and Canada.

The researchers found that, on average, boys are entering puberty about six months to two years earlier than the 11.5 years we’ve long considered as average.

Since this study received wide media coverage, it is important that you are able to put it into perspective for your patients’ parents. The key thing to remember is that any sign of puberty before age 9 is not considered normal. That is the cutoff point at which you should refer boys to an endocrinologist for evaluation.

The other thing to consider about this study is that it relied only on the Tanner stage and testicular volume—not on hormone levels or X-rays to evaluate bone density. So, I would not leap to the conclusion that we need to push our definition of puberty back.

I suspect one reason for the findings is that, compared to previous studies, more children today are overweight and obese. In fact, the study found that after controlling for race, ethnicity and age, boys with a body mass index (BMI) less than the 15^thpercentile had later mean ages of transition to stages 2 and 4 for genital and pubic hair growth compared with those with BMIs greater than the 85^th percentile. This makes sense, given the understanding that obesity causes bone-age advancement and early activation of the adrenal glands, leading to pubic hair development. Whether this means a child is truly undergoing puberty is not clear.

Still, as the authors note, the findings demonstrate the need to document changes in testicular volume and pubic hair growth. And, as I said earlier, they agreed that such changes in a 7-year-old warrant closer attention and concern than such changes in a 10-year-old. As they wrote: “In the absence of increased testicular volume or systemic changes of androgenization, the more likely process in this example would be that of ‘benign’ premature adrenarche.” In other words, it’s nothing to worry about.

The message for you as community providers is to reassure parents that they should only be concerned about early “puberty” if the child is younger than 9 years old. And, if their child is overweight and showing physical signs of puberty, weight loss through appropriate lifestyle interventions could stem the process.

What are you seeing in your practice? Click “Add Comment” below.

By Anthony J. Richtsmeier Jr., MD, developmental-behavioral pediatrics, Spectrum Health Medical Group, Helen DeVos Children’s Hospital, Grand Rapids, Michigan

With rates of autism spectrum disorder (ASD) diagnosis rising like the sea level, and no approved medication to treat core symptoms, it’s important that we understand the evidence base behind the nonmedical treatments we have to help manage children with autism spectrum disorders.

The publication this month in the supplement to Pediatrics of new consensus guidelines from the Technical Expert Panel (TEP), supported by Health Resources and Services Administration, provides helpful information in a field with a rapidly expanding literature.

The TEP panel is a large, multidisciplinary group composed of experts in psychology, developmental pediatrics, child psychiatry and education, as well as parents of children with autism.

TEP members reached a consensus on a final set of guidelines statements in the report. However, as the group noted, the evidence behind even those recommendations is less-than-robust, and there are few, if any, head-to-head trials to determine which interventions are most effective. The strength of evidence of efficacy varied by intervention type from insufficient to moderate.

Nonetheless, the panel did note that comprehensive programs, such as the Early Start Denver Model and other comprehensive, intensive behavioral programs that utilize applied behavioral analysis (ABA) “have the potential for remediating multiple core deficits simultaneously and allow for potential synergistic effects of intervention components.”

The final guidelines call for a comprehensive intervention program that addresses deficits in the areas of social communication, language and play skills, and also addresses maladaptive function and behavior. It should also include ongoing parent education. The panel also reported that there is moderate evidence that greater intensity of treatment (hours per week) and greater duration (in months) leads to better outcomes.

In addition to recommending comprehensive programs, the panel also gave moderate support for social skills programs and the picture exchange program (PECS) for children who have little or no language.

Although the panel noted that the evidence is weak on just when interventions should begin, it recommended starting within 60 days of diagnosis and customizing all approaches to address the “unique strengths and core deficits of each individual with ASDs.”  Many experts stress that early identification and intervention are critical for optimal progress, and the panel concluded that “there is no theoretical basis for delaying treatment.”  It also noted that the needs of children with ASD vary depending on individual characteristics of the child, and emphasized that the literature is not clear as to which individual characteristics are associated with success or lack of success of various approaches.

Your parents might be interested in the finding that most high-quality behavioral interventions found in the literature required 20 to 40 hours of treatment per week; the American Academy of Pediatrics recommends at least 25 per week. Recent insurance legislation may make this degree of intensity of treatment more possible in Michigan and other states.

You can read the AAP’s recommendations for screening and diagnosis of ASD here.

By William Stratbucker, MD, medical director, Healthy Weight Center, Helen DeVos Children's Hospital, Grand Rapids, Michigan

Anyone with a teenager or teenaged patients knows that the best way (sometimes, the only way) to reach them is through text messages. So what about using texts to communicate important health-related messages to our patients and their families?

That's exactly the kind of thing that numerous medical professionals are investigating, including Helen DeVos Children's Hospital. While I'm confident that current studies will show patients like this mode of communication and that it contributes to several aspects of health management, including medication adherence, keeping appointments, tracking and reporting symptoms, and implementing nutritional and physical activity programs, there are some issues that need to be addressed before widespread implementation.

For instance, there is some concern that the amount of information conveyed in a short text message is not enough to communicate important medical information. It is true that some communication should be provided face to face, with plenty of time set aside. For instance, it would not be appropriate to discuss abnormal test results in a text message.

Nonetheless, I still think there are numerous ways even these short messages can be used to benefit patients, particularly with reminders and notes of encouragement. Tips for teens that are generic and without specific patient-related information are ideal. This is an important emerging strategy in my own area of obesity treatment.

For instance, I've helped launch a national research network of obesity clinicians to develop and conduct a study on the potential of texting for our patients. Among the questions we think are important to ask before implementing any texting or social media health-related program are:

• Does the teen have access to a phone with unlimited texting?
• What social media websites are they using?
• Would they like to receive messages about weight management from our teams (keep in mind privacy issues)?

It's important, however, to identify your patient's needs rather than implementing a text-based program in a vacuum. When University of Michigan researchers asked 24 overweight adolescents in a weight-management program about text-related messages, they found the teens were "very enthusiastic" about text messages, particularly those with recipe ideas, successful weight loss strategies used by peers and feedback about their progress. Teens wanted positive, encouraging and direct messages, particularly with "encouraging" symbols like exclamation points and smiley faces.

However, the respondents warned, mentioning unhealthy foods or behaviors (i.e., "Stay away from the Halloween candy!") would backfire, triggering them to eat those foods or engage in those behaviors. They also told researchers to avoid acronyms like LOL (laughing out loud), saying such language is "too informal" for messages from health care providers.

Another text-based program I'd like to highlight is the Text4baby program, provided by the National Healthy Mothers, Healthy Babies Coalition with some industry sponsorship. The program provides text messages to pregnant moms prior to delivery and during the first year of their infant's life. Content ranges from answers to common questions about pregnancy and babies, to reminders about important milestones in the infant's development. All messages are time-relevant, pegged to the mother's delivery date. And, it's free, even if the mother has a limited texting plan.

Since the medical profession has just started using text messaging as a communication vehicle, the evidence isn't in yet on its effectiveness. What is clear, however, is that we need to find ways to reach our patients and encourage healthy living beyond the traditional office visit.

Are you using text messaging in your practice? What do you think about its potential for preventive health care?

By Lisa M. Lowery, MD, adolescent medicine, Spectrum Health Medical Group, Helen DeVos Children's Hospital, Grand Rapids, Michigan

A great new study just out in Pediatrics may help you convince parents to have their daughters receive the human papillomavirus (HPV) vaccine, which I know can sometimes be a challenge. In part, this reluctance comes from the false, but still widely held belief, that the vaccine will encourage sexual activity.^[1]

In this retrospective study, researchers used longitudinal data from a large managed care organization to evaluate the composite outcome of pregnancy/sexually transmitted infection testing or diagnosis, or contraceptive counseling in 11-year-old and 12-year-old girls who received the vaccine during three years follow-up. They found no increased risk of either the composite outcome or its individual components when compared to girls who did not receive the vaccine. “If HPV vaccination was ‘a license for sex,’” the authors wrote, “we would have expected to see more adverse outcomes shortly after vaccination, when the girls were more aware of their recent vaccination status.”

These findings validate earlier surveys that found that girls receiving the HPV vaccine were not likely to change their sexual behavior because of the vaccine.^{[2], [3], [4]} I know this personally, because I’ve also asked my patients this question—and received the same answer.

Of course, as you likely know, there are other barriers to HPV vaccination, including the fact that parents are just uncomfortable talking about a vaccine for a sexually transmitted disease.

The best way around these barriers, I’ve found, is communication. Listen to the parent’s fears, do your best to address them, and explain the significant benefits and the low risks of the vaccine. Obviously, it is ultimately the parent’s decision whether to vaccinate their child, but, hopefully, your sensitive intervention can help guide them to make the right decision.

Do you find fewer parents resisting the HPV vaccine for their pre-teens? Click “Add Comment” below.

[1] United Press International. Promiscuity fears hinders HPV vaccine use. Available at: www.upi.com/Health_News/2008/12/19/

Promiscuity-fears-hinders-HPV-vaccine-use/ UPI-54571229744264/. Accessed October 28, 2011

[2] Schuler CL, Reiter PL, Smith JS, Brewer NT. Human papillomavirus vaccine and behavioural disinhibition. Sex Transm Infect. 2011;87(4): 349–353

[3] Liddon NC, Leichliter JS, Markowitz LE. Human papillomavirus vaccine and sexual behavior among adolescent and young women. Am J Prev Med. 2012;42(1):44–52

[4] Mullins TL, Zimet GD, Rosenthal SL, et al. Adolescent perceptions of risk and need for safer sexual behaviors after first human papillomavirus vaccination. Arch Pediatr Adolesc Med. 2012;166(1):82–88

By Keo Rolon, registered dietitian, Spectrum Health Medical Group, Helen DeVos Children’s Hospital, Grand Rapids, Michigan

A recent article in Pediatrics found that, on average, children get just as much sodium in their diets as adults. In other words, too much.

Researchers from the Centers for Disease Control and Prevention used data from the National Health and Nutrition Examination Survey (NHANES) from 2003–2008 to estimate sodium intake in 6,200 children 8 to 18 years old. They found that children consumed an average of 3,387 milligrams (mg) of sodium a day, a third more than recommended, and that 37 percent were overweight or obese, while 15 percent had hypertension or prehypertension. Overweight children with the highest sodium intake had triple the risk of hypertension.

Current recommendations for children 2 years and older are no more than 2,300 mg of sodium a day, less than a teaspoon, and those with hypertension should limit sodium to no more than 1,500 mg a day. However, most children only need between 1,000 mg and 1,500 mg a day. The Pediatrics study found that every 1,000 mg of sodium a day increased the risk of hypertension or prehypertension in children by 6 percent; but a whopping 74 percent for children who were already overweight or obese.

So what’s going on?

For one, cooking has gone by the wayside for many families. Often times, meals are composed of processed and fast food, both of which are very high in sodium.

Your job is to highlight the dangers of high-sodium diets for children, and educate parents about hidden sources of sodium. Most parents likely think that as long as they ditch the salt, they’re protecting their child. Make sure they know that anything that comes in a box, can, bottle or bag is likely high in sodium, unless the label specifically says “low sodium.”

Tell parents about hidden sources of sodium, such as breakfast cereal and bread and rolls, and about the highest sodium sources in a child’s diet: cold cuts and cured meats, soup, cheese, anything with tomato sauce, savory snacks like chips and pretzels, and pizza.

Also let parents know that sodium is an acquired taste. The earlier we feed kids high-sodium foods, the faster their taste buds become accustomed to salty flavors and the more they crave. Conversely, cut back on sodium and, after a few weeks, you can literally retrain those taste buds.

I also recommend other options for flavoring, such as a squeeze of lemon and fresh herbs. And, of course, urge parents to stick to “real” food as much as possible: fresh or frozen vegetables and fruit (without any sauces); unadulterated (i.e., no sauces or prepared) meat, poultry and seafood; and low-sodium or no-added-salt options if they must use prepared foods.

How do you talk to parents about sodium in their child’s diet?

By Daniel P. McGee, MD, pediatric hospitalist, Spectrum Health Medical Group, Helen DeVos Children’s Hospital, Grand Rapids, Michigan

It’s that time again—flu season. I’m sure you know the drill. Order enough vaccine, spread the word to your patients, get as many kids vaccinated as possible.

Easier said than done, right?

The biggest obstacle I see is that pediatricians wait too long to start promoting flu shots. But drugstores aren’t waiting. National pharmacy chains have more “Flu Shots Here” yard signs than politicians.

If you don’t want to lose your patients to the drugstores, you need to tout your own flu vaccine-giving abilities. The benefits are numerous, particularly the assurance that the protection kicks in before flu season does. It also provides plenty of time for the double doses many children younger than 8 years old will need.

One way to increase the percentage of your patients immunized is with special “immunization clinics” held on weekends or evenings, when it’s more convenient for many parents.

Also make sure you offer vaccination on every visit. If a patient comes in with a sprained ankle, suggest the vaccine. You can also give it along with other immunizations. Even kids with a mild fever can receive the inactivated vaccine. In fact, guidelines from the Centers for Disease Control and Prevention and the American Academy of Pediatrics note that the only children who should not receive the trivalent inactivated infuenza vaccine are infants younger than 6 months and children with a moderate-to-severe febrile illness.

While you’re at it, don’t forget your staff and yourself. A study published in the September 28 issue of “MMWR” (Morbidity and Mortality Weekly Report) found that a third of health care professionals were not vaccinated during last year’s flu season. This is an improvement, since prior to 2008 less than half of all health care providers received their influenza immunization. I guess the “swine flu” outbreak in 2009 was good for something! The more recent article found that physicians were most likely to be vaccinated, followed by nurses (Figure 1). Think about the aide who puts your patients into the exam room, takes their blood pressure, weighs them. That’s the person least likely to get vaccinated.

As far as this year’s recommendations for children, the biggest change comes in dosing instructions for children 6 months to 8 years old:

• All children 6 months and older with no contraindications should be vaccinated
• Children who received at least two doses of the trivalent seasonal vaccine since July 2010 only need one dose. Otherwise, the child should receive two doses at least four weeks apart.
• Only one dose of this year's vaccine is needed if there is clear documentation of the child having received at least two seasonal flu vaccines from any previous season in additionto at least one dose of a vaccine containing the pandemic H1N1 virus—either the monovalent vaccine released during the pandemic or the trivalent vaccine for the 2010–2011 or 2011–2012 seasons.

How do you ensure that your patients get their flu vaccines?

By Theodore D. Barber, MD, pediatric urologist, Helen DeVos Children’s Hospital, Grand Rapids, Michigan

There has been a lot of discussion about circumcision in the news lately. As the media can often sway a person’s view on a topic, it is important to discuss the risks and benefits of the procedure.

In September, the American Academy of Pediatrics updated its policy statement on the procedure, noting that its literature review “indicates that preventive health benefits of elective circumcision of male newborns outweigh the risks of the procedure,” with a rare risk of complications. However, the statement goes on to say that the “health benefits are not great enough to recommend routine circumcision for all male newborns.” Nonetheless, the new policy also notes that the “benefits of circumcision are sufficient to justify access to this procedure for families choosing it and to warrant third-party payment for circumcision of male newborns.” The American College of Obstetricians and Gynecologists endorsed the new policy statement.

Despite some evidence suggesting health benefits to infant circumcision, circumcision rates in the United States continue to decline. This decrease likely reflects increased immigration of individuals from countries in which male circumcision is the exception rather than the norm, and the growing number of state Medicaid programs that do not reimburse for the procedure (currently 18 states).

An online article from researchers at Johns Hopkins posted on the Archives of Pediatrics and Adolescent Medicine website suggests that declining rates of circumcision in this country may substantially increase lifetime health care costs. The authors predict that if circumcision rates reach those in Europe (currently 10 percent), it would add lifetime costs of $407 per male and $43 per female in this country.

The increased cost comes primarily from higher rates of sexually transmitted diseases such as HIV and herpes in men, bacterial vaginosis and trichomoniasis in women, as well as increased rates of cervical and penile cancers due to HPV infection. In the pediatric population, a higher rate of urinary tract infections (UTI)  in infants also contributes to the cost. Overall, the researchers estimate that the drop in male circumcision rates from 79 percent in the 1970s and 1980s to 55 percent today has already cost the country an estimated $2 billion or more in increased health care costs.

Despite the concerns raised, the study has several major weaknesses. Most calculations were based on studies evaluating sexually transmitted disease rates among uncircumcised men in sub-Saharan Africa, where the incidence of STDs, particularly HIV, is much higher, yet the economic calculations were based on health care costs in the United States.

Furthermore, the protective benefits of circumcision against UTIs are realized only in the first 6 months of life, primarily in infants who already have an increased risk, such as those with neurogenic bladder, high grade reflux  and ectopic ureters.

The decision on infant circumcision is not clear cut. While a growing body of data suggests medical benefits of infant circumcision, these studies had serious methodological flaws.

No wonder many primary care physicians admit that they do not understand the risks and benefits of newborn male circumcision well enough to counsel parents.¹ Such understanding is important, however, since a recent survey found that 53 percent of parents  would be more likely to circumcise their son if they received more information about the protective effect of circumcision.²

Despite the conflicting data regarding infant circumcision, the significant increase in the number of uncircumcised males makes it important that primary care physicians understand how to care for the uncircumcised penis, particularly since many were trained when circumcision rates were high.

A primary concern is the retraction of the foreskin. Although the American Academy of Pediatrics says it should retract a year after birth, the reality is that it often takes until puberty. The foreskin is physically adhered to the glans at the time of birth, so retracting it manually is painful and, ultimately, the prepuce will reattach to the glans until the keratinization process is complete (typically between the ages of 5 and 6 and puberty). So, in caring for the uncircumcised penis in a child, the best advice is to leave it alone. The foreskin will retract when it’s ready.

Although a vast majority of infant circumcisions are performed because of parental preference, a small percentage of males may require the procedure for medical reasons. These include symptomatic phimosis causing an obstruction with voiding, the need to perform self-catheterization, or genitourinary abnormalities resulting in an increased risk of febrile UTI.

But really, whether or not to circumcise a male infant comes down to a decision only the parents can make, usually based on their personal beliefs and the circumcision status of the father or other males in the family.

What questions do you have about circumcision these days?

References

1. Carbery B, Zhu J, Gust DA, et al. Need for physician education on the benefits and risks of male circumcision in the United States. AIDS Educ Prev. 2012;24(4):377-87.

2. Gust DA, Kretsinger K, Gaul Z, et al. Acceptability of newborn circumcision to prevent HIV infection in the United States. Sex Transm Dis. 2011;38(6):536-42.

By Beth Kurt, MD, pediatric oncologist, Spectrum Health Medical Group, and director, After Care and Transition Program for childhood cancer survivors, Helen DeVos Children’s Hospital, Grand Rapids, Michigan

A recent article in "Cancer" caught my attention. The authors evaluated how well the psychosocial needs of adolescents and young adults ages 14 to 29 with cancer (who we in the field call “AYAs”) are being met. The short answer, as you’ll see if you read the article, is not really, particularly those ages 20 to 29.

These individuals have psychosocial needs different from older adults. Even the settings in which they are treated—pediatric versus adult—can affect outcomes. For instance, studies find higher survival rates for patients with acute lymphoblastic leukemia who are treated in pediatric settings than those seen in adult settings.^1,2,3

The good news is that teens in the study were more likely to take advantage of programs like camps and retreat programs, mental health, religious, spiritual, and family counseling, than young adults, likely because young adults are less likely to be seen in a pediatric setting which provides such services. Still, 25 percent of teens said there was an unmet need for camps and retreat programs; 23% for infertility information; and 41 percent for information about exercise. Fourteen percent also expressed an unmet need for mental health counseling.

I can attest to the challenges involved in treating teenagers and young adults. Just consider the challenges you have in your own practice getting them to talk, to share, to listen. Well, this doesn’t magically change once they are diagnosed with cancer!

In addition, unlike younger children, whose parents serve as the primary medical historian, teenagers are their own historian. They will deny symptoms like pain, depression, despair, or certain worries in front of their parents, and “neglect” to share information unless you ask the right questions.

That’s why we always remember how important it is to treat the whole patient. Although we want to make sure our patients reach remission, we also want to make sure we’re meeting their mental health needs, including assessing and managing any anxiety or depression.

This is an important role for you, their primary care physician, as well. You see them for many of their non-cancer issues, and you’ve probably been seeing them for much of their life, so they may know you better and feel more comfortable sharing how they’re feeling. If you find they need more help than you can provide, I urge you to let us know. Most pediatric cancer centers like ours have psychologists and psychiatrists available who are trained in the unique mental health needs of cancer patients.

Interested in reading more about children with cancer? Read my blog post about the role of the primary care physician in caring for pediatric cancer patients. 

References

1. Boissel N, Auclerc MF, Lhe’ritier V. Should adolescents with acute lymphoblastic leukemia be treated as old children or young adults? Comparison of the French FRALLE-93 and LALA-94 trial. J Clin Oncol. 2003;21:774-780.
2. Stock W, La M, Sanford B. What determines the outcomes for adolescents and young adults with acute lymphoblastic leukemia treated on cooperative group protocols? A comparison of Chidlren’s Cancer Group and Cancer and Leukemia Group B studies. Blood. 2008;112:1646-1654.
3. de Bont JM, Holt B, Dekker AW, et al. Significant difference in outcome for adolescents with acute lymphoblastic leukemia treated on pediatric vs adult protocols in the Netherlands. Leukemia. 2004;18:2032-2035.

By Lisa Lowery, MD, adolescent medicine, Spectrum Health Medical Group, Helen DeVos Children’s Hospital, Grand Rapids, Michigan

A recent report from Rand Health snagged my attention. The report described previous studies from the think tank on the impact of media on adolescent behavior. Among the results highlighted:

• Teens who watch a lot of TV with sexual content are more likely to have sex the following year and more likely to get pregnant or cause a pregnancy than those exposed to less of such content.^{1, 2}
• Television shows that demonstrate the risks and consequences of pregnancy can foster beneficial dialogue between teens and parents.³
• Teens who listen to music with degrading sexual lyrics are more likely to have sex at an earlier age.⁴
• Sixth graders who view TV alcohol ads have a higher risk of drinking by the time they’re in seventh grade, while seventh grade exposure to magazines with alcohol advertisements predicted drinking onset by the ninth grade.^{5, 6}

I think these findings are right on and still relevant, even in an age of Facebook and Twitter. Sometimes we get so focused on the influence of social media that we forget that the average teenage watches three hours of TV a day. Typical teenager fare, the reported noted, “contains heavy doses of sexual content, from touching, kissing, jokes, and innuendo to conversations about sexual activity and portrayals of intercourse.”

When your most popular shows are about people living together and partying (think Jersey Shore, Real World, and 16 and Pregnant), and then we turn around and tell our kids that these aren’t the behaviors they should follow, we’re giving a lot of mixed messages. And yet it’s hard to monitor screen time these days, since teens can watch shows on their computers or phones.

Community physicians have an important role to play in warning parents about the risks of these programs, tying it into reminders about appropriate screen time and Internet safety.

You should also suggest that parents watch TV with their kids, so they know what their children are watching and can comment on inappropriate behaviors in a non-confrontational manner. For instance, a mom might casually point out to her teen that a particular program is degrading to women. Next time the show is on, the teen might remember that conversation and change the channel.

Stress to parents, however, that such conversations should not occur just once and then be crossed of the list; they need to be continual messages about appropriate and inappropriate behavior. Also stress that it’s important that parents model the behavior they’d like to see in their kids.

How do you address “screen time” with adolescents and parents in your practice?

1. Collins RL, Elliott MN, Berry SH, et al. Watching Sex on Television Predicts Adolescent Initiation of Sexual Behavior. Pediatrics. 2004;114(3):E280-E289.

2. Chandra A, Martino S, Collins R, et al. Does Watching Sex on Television Predict Teen Pregnancy? Findings from a National Longitudinal Survey of Youth. Pediatrics. 2008;122(5);1047-1054

3. Entertainment Television as a Healthy Sex Educator: The Impact of Condom-Efficacy Information in an Episode of Friends. Pediatrics. 2003;112(5):1115-1121.

4. Martino S, Collins RL, Elliott MN, et al. Exposure to Degrading Versus Nondegrading Music Lyrics and Sexual Behavior Among Youth. Pediatrics. 2006;118(2):E430-E441

5. Collins RL, Ellickson PL, McCaffrey DF, Hambarsoomian K. Early Adolescent Exposure to Alcohol Advertising and Its Relationship to Underage Drinking. J Adolesc Health. 2007;40(6):527-534

6. Ellickson PL, Collins RL, Hambarsoomian K, McCaffrey DF. Does Alcohol Advertising Promote Adolescent Drinking? Results from a Longitudinal Assessment. Addiction. 2005;100(2):235-246.

By N. Debra Simms, MD, director, Center for Child Protection, Helen DeVos Children’s Hospital

I was dismayed but not surprised to read a study in a recent issue of Pediatrics that showed an increased rate of admission for physical abuse since the recession began. The authors conducted a retrospective study of children admitted to 38 pediatric hospitals between 2000 and 2009. They found that rates of physical abuse in children under 6 and high-risk, non-motor vehicle crash-related traumatic brain injury (TBI) in infants under 1 increased by 0.8% and 3.1% a year, respectively, even as all-cause injuries dropped by 0.80%. Both physical abuse and TBI were associated with mortgage delinquency and foreclosure rates, but not with unemployment rates.

I wasn’t surprised because here at Helen DeVos Children's Hospital we saw admissions more than double from 42 in 2007 to 88 in 2009. Thankfully, that was the peak year, as it was in the Pediatrics study.

It’s important to highlight the fact that the mortgage crisis did not cause the increased rates of abuse. Instead, my guess is that the link is related to the increased financial and life stress that parents caught in the housing crisis experienced. That stress may have been particularly intense given that most of them are from middle- and upper-middle class environs (since they owned homes).

I’ve spent most of my professional career dealing with child abuse, and I can tell you that once we remove pathological abusers and sexual predators, the majority of child abuse is related to the parent or caregiver having what amounts to a  really, really bad day. That’s not to excuse what they did; it’s just trying to understand that sometimes a person reaches the abyss and, rather than being able to pull back, simply snaps.

The added stress and uncertainty of a foreclosure makes the everyday stresses we all encounter that much worse, in part because they continue over months, even years. As the Pediatrics article notes, losing your home is one of the worst things that happens to a family. It’s particularly terrible since few families have nearby support systems, and since many local and state child abuse prevention and family support programs have experienced downsizing due to lack of funding.

Community physicians are in an ideal position to identify families under unusual economic stress. First, don’t assume that just because a family appears economically well off, they still are. We’ve all read stories of people losing $800,000 homes and visiting food banks.

Second, if one of your families has been good about coming in for well-child checks or visits for children with chronic health conditions and begins missing appointments or not filling prescriptions, consider that a clue. Ask why. Probe to see if there is a problem you can help with.  Be aware of available resources. Have materials ready to hand out.

Preventing child abuse is a matter of having an open compassionate heart, being approachable, and letting your families know that you are willing to talk about—and refer them to—programs that can assist them in caring for and protecting their children. 

By Alejandro C. Quiroga Chand, MD, pediatric nephrologist, Spectrum Health Medical Group, Helen DeVos Children’s Hospital

I was gratified to see the recent study in the journal Pediatrics that concluded kids with a single healthy kidney can still play sports, even contact sports. This is something I have always advised my patients; however, as the study noted, many doctors advise such children otherwise, fearing injury to the remaining kidney. 

As with so many things in medicine, this assumption is based not on science, but on gut feeling and anecdotes. Yet when the authors of the Pediatrics study conducted a comprehensive literature review of sports-related kidney injuries in children with single kidneys, they found an incidence of kidney injury requiring nephrectomy of just 0.4 per 1 million children per year from all sports, with cycling the most common cause, followed by skiing. 

Conversely, they found that American football alone accounted for 0.9 to 5.3 fatal brain injuries and 4.9 to 7.3 irreversible spinal cord injuries per 1 million players. The most common cause of all renal injuries in a pediatric population? Motor vehicle accidents, responsible for 71% to 100% of such injuries. Yet we don’t advise kids not to ride in moving vehicles, do we?

Even though the American Academy of Pediatrics currently recommends a “qualified yes: pending individual assessment” regarding contact/collision sports for those with single kidneys, 62% of the 135 pediatric nephrologists surveyed for this study said they would “not allow” such individuals to participate in those sports. In addition, 86% of them identified football as the main sport to avoid. Both findings suggest we have a lot of education still to do.

In my opinion, it does not make sense to restrict the life of a child or adolescent so significantly for something that so rarely occurs. Even kidney lacerations in kids with two healthy kidneys are rare. In fact, in my entire career I have never seen anyone lose a kidney from a  sports-related injury.

I would, however, caution kids who want to do martial arts to arrange for extra protection over the kidneys if there is a chance of a direct blow. And I do tell my patients that becoming a rodeo clown is likely not in the cards for them.

One caveat: single pelvic kidneys are a category on their own, and I am more conservative in their management since they are sometimes very close to the skin and might be susceptible to serious injuries.

What do you think about the study? How do you counsel your single-kidney patients?

By Deborah Cloney, MD,  pediatric gastroenterologist, Spectrum Health Medical Group, Helen DeVos Children’s Hospital, Grand Rapids, Michigan

A recent article in The New York Times provides what I consider a somewhat alarmist view of the osmotic stool softener Miralax (polyethylene glycol 3350 [PEG]), often used to treat children with constipation. The article highlighted the fact that the drug (and yes, that’s what it is even though it’s available over the counter) was never tested in kids and yet is prescribed for children for months, sometimes longer.

The article asks, “What are the long-term effects of this?”

Well, since the drug was just approved in 1999, obviously we don’t know what the long-term effects are. But as a pediatric gastroenterologist who recommends the medication to many of my patients, some of whom need to be on it chronically because of motility issues related to cerebral palsy or other neurological or muscular conditions, I have not seen any ill effectives when it is used properly.

Miralax and its generic cousins are the best osmotic laxatives we have for kids because of superior palatability. Children usually will take it without complaint. Others, like Milk of Magnesia, not so much. From that perspective, it is a godsend.

In addition, there is no evidence that the product is in any way harmful to children or that they develop any kind of physical dependency. In fact, as the Times article noted, an FDA oversight board concluded in 2009 that there was no evidence that it caused severe side effects. In addition, the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition’s position statement on constipation summarizes and cites several studies that support the efficacy and safety of Miralax in this population.

I do, however, think that parents may become dependent on it to help their children have bowel movement because it’s easier to give kids some orange juice with Miralax than it is to institute the dietary and lifestyle changes recommended for constipation.

So my advice is yes, use it as needed, but develop an exit strategy as to how long you will keep the child on it and what steps you will institute while they’re taking it to address their constipation from other directions.

One word of caution about using any osmotic stool softener in a young child or one who is neurologically impaired or otherwise does not have control over their liquid intake: Watch their stool output. If it is too loose, cut back on the dose; if too dry, increase their liquid intake. Overly aggressive use of an osmotic agent, without attention to fluid status, could result in dehydration.

You can find other tips for managing pediatric constipation here.

By Steven L. Pastyrnak, PhD, division chief, pediatric psychology, Spectrum Health Medical Group, Helen DeVos Children’s Hospital

You likely heard about the recent study in Pediatrics on self-mutilation: Rates of Nonsuicidal Self-Injury in Youth: Age, Sex, and Behavioral Methods in a Community Sample. In this National Institutes of Health study, researchers from the University of Denver interviewed 665 kids ages 7 to 16 about nonsuicidal self-injury (NSSI) habits. They found an overall rate of 8% among the youth (9% of girls and 6.7% of boys), with a significant gender gap occurring after adolescence.

Most disturbing, however, is that 7.6% of third graders, 4% of sixth graders, and 12.7% of ninth graders (19% of girls and 5% of boys)  reported such behavior. While girls were most likely to cut or carve their skin, boys were most likely to hit themselves.

Other studies have found rates between 7% and 8% for middle schoolers, and 17% and 23.2% for high schoolers and college-aged youth, but this was the first such study to assess the behavior in younger (less than 11) children.^{1, 2, 3}

Overall, 1.5% of those interviewed who engaged in NSSI experienced high levels of distress and participated in the behavior at least 5 times over the past year, meeting partial criteria for a proposed DSM-5 psychiatric diagnosis of a NSSI disorder. They felt depressed, angry and consumed with negative thoughts, the researchers reported. Other data demonstrates that such behavior can significantly affect academics, relationships and social functioning.

I suspect that some of the findings are related to peer  modeling among the kids. In other words, one child does it, another finds out and follows suit. For many of these kids, this behavior is an early sign of anxiety or depression.  But there is no disputing that the problem appears to begin earlier than we suspected. Other important findings from this study include the findings on the gender disparity beginning at adolescence.

This study should be a wake-up call for us.  As the authors noted in their article, psychiatric problems in childhood and adolescence can lead to chronic obesity and substance use and abuse. Anorexia, school problems and social problems can also be evident.  Although not typically done as a suicide attempt, self mutilation may still be a precursor to suicidal thoughts. They suggest, and I agree, that identifying NSSI behavior early could help avoid these outcomes, and that routinely assessing such behavior may need to be incorporated into routine health assessments.

Although there are at least 2 screening tools that can assess for NSSI behavior, they are primarily used in research settings. Thus, clinicians must rely on more subjective evaluations to assess risk. However, as the authors write in their article, simply asking yes/no questions such as, “Have you ever cut yourself or considered cutting yourself,” is not sufficient. Open-ended questions, such as  “What do you do when you are frustrated, sad, nervous, etc.?” are more effective. Ask about any injuries you see, but in a nonjudgmental, nonthreatening manner, and if the child does admit to NSSI behavior, don’t appear shocked or disgusted.

Also look for clues of self mutilation, including wearing long sleeves and pants in hot weather; checking arms, fists, and forearms opposite the dominant hand (the most common spots) for signs of injury; the constant use of wrist bands or bracelets; and signs of depression or anxiety.

And, as always, if you have any concerns for the child’s mental health or safety please refer them to the appropriate mental health professionals.

¹Hankin BL, Abela JRZ. Nonsuicidal self-injury in adolescence: prospective rates and risk factors in a 2½ year longitudinal study. Psychiatry Res. 2011;186(1):65–70

²Muehlenkamp JJ, Gutierrez PM. An investigation of differences between self-injurious behavior and suicide attempts in a sample of adolescents. Suicide Life Threat Behav. 2004;34(1):12–23

³Whitlock J, Eckenrode J, Silverman D. Self-injurious behaviors in a college population. Pediatrics. 2006;117(6):1939–1948

By William Stratbucker, medical director, Healthy Weight Center, Grand Rapids, Michigan

We know that a child’s peer group influences their behavior, particularly teenagers. If adolescents hang out with kids who engage in risky behavior, they are more likely to engage in such behavior themselves. We also learned about the influence of social networks on adult obesity in a 2007 landmark study published in The New England Journal of Medicine. In that study, researchers found that an individual’s chance of obesity increased 57% if they had a friend who also became obese; with increased risks of 40% for someone with an obese sibling and 37% for someone with an obese spouse. It is almost as if obesity were spread like a flu virus.

Now comes evidence that similar relationships occur between school-aged children. Researchers from Vanderbilt University collected data from elementary-school aged children participating in after-school care (mean age 7.86), mapping their social networks and physical activity levels.

They found that children’s friendships “heavily” influenced their level of physical activity. In fact, it was the greatest influence on the amount of time children spent in moderate-to-vigorous physical activity during those after-school hours, with kids changing their own levels to match those of their friends. However, children did not end their friendships with children who did not match their own activity levels, nor did they deliberately choose friends whose activity levels matched their own.

I found this study fascinating. If you think about it, it suggests that if you put a physically active kid in with a group of sedentary children, the risk is that the majority rules and the active kid becomes sedentary. Conversely, if you put an inactive kid in with a group of active kids, you might see that child become more active. The problem is that if you have an active kid at home but put him/her in after-school care with a bunch of inactive friends, there is the risk that the child will not be active during that time. Thus, it becomes even more important for instructors/leaders and parents to promote physical activity in such programs.

As pediatricians, we are always looking for more behavioral strategies to use when counseling families about healthy lifestyles. So this is an important study to share with parents. They should understand the influence a child’s peer group has on his/her physical activity levels. For instance, if they have a sedentary child they might want to consider signing him/her up for a team sport, where the child can make friends who are more physically active.

The study also shows the importance of the after-school environment in kids’ activity levels. This is an incredibly important time for kids to engage in physical activity during the school week. If this “break” time is filled with inactivity like screen time followed by homework children end up with no time for activity.

As you know, screen time during the school week is an enormous problem. Estimates are that most children spend 1 to 3 hours a day watching TV, playing video games, or on their computers, and that the amount of screen time is directly related to the risk of obesity.¹

Thus, encouraging parents who need to put their children into an after-school environment, that it be one that encourages physical activity, is an important message for community pediatricians to convey.

William Stratbucker is medical director of the Helen DeVos Children’s Hospital Healthy Weight Center in Grand Rapids, Michigan.

How do you think parents can encourage their children to develop activities with more physically active children?

1. Marshall SJ, Biddle SJ, Gorely T, Cameron N, Murdey I. Relationships between media use, body fatness, and physical activity in children and youth: a meta-analysis. Int J Obes Relat Metab Disord 2004;28(10):1238-46.

By Tom Peterson, MD, Executive Director, Safety,  Quality and Community Health, Helen DeVos Children's Hospital in Grand Rapids, Michigan

There are so many reasons for the obesity crisis in our kids that it’s hard to know where to start. But a recent study in the Archives of Pediatric and Adolescent Medicine is worth highlighting because it suggests a significant role for community pediatricians in at least one of those factors.

The study, by researchers from the University of Maryland and Johns Hopkins, was a cross-sectional analysis of a sample of low-income mothers and their toddlers. Researchers showed 281 mothers of toddlers (mean age 20 months, 11.9 to 31.9) silhouette pictures of children from 0 to the 100^th weight-for-length percentile, then asked them which picture looked most like their child and which picture they wanted their child to look like.

Just one-third of the mothers chose the silhouette that accurately depicted their child’s body size. Seventy-three percent of the mothers who were inaccurate had children who were overweight compared to 35% of the mothers who were accurate (P<0.001), making them 87% less likely to accurately assess their child’s size. In addition, 82% of mothers with overweight toddlers were satisfied with their child’s size compared to a third of mothers with healthy weight children.

Given that parental perceptions of their child’s weight can be a key factor in  the lifestyle  choices they make  for their family early in life, choices that that can contribute to child’s feeding behavior (such as exhorting children of a healthy weight to eat more), this study should raise our awareness of importance of parental perceptions of their child’s weight.

Plus, as the authors noted, it is hardly the first to document parental misperceptions of their child’s weight. However, it is the first to measure perceptions of parents of such young children. As you may know, there is good evidence that toddler weight predicts later weight.¹

However, let’s not only blame parents for misperceptions of weight; pediatricians do it, too.²

This study and others like it highlight the need for objective data on the size of very young children and documentation at every well-child visit, rather than relying only on weight or only on appearance. The American Academy of Pediatrics recommends precisely this—assessing BMI in children 2 and older, and weight-for-length in younger children.

The study also highlights the need to share this information with parents and engage them in conversations about healthy lifestyles and diet, even those with very young children. Such discussions could improve the accuracy of parental perceptions of their child’s weight, as well as help parents identify opportunities to support a healthy weight in their children.

How do you routinely assess children’s body size/weight in your practice?

Tom Peterson, MD, is executive director of Safety,  Quality and Community Health at Helen DeVos Children's Hospital in Grand Rapids, Michigan

1. Reilly JJ, Armstrong J, Dorosty AR, et al. Early life risk factors for obesity in childhood: cohort study. BMJ. 2005;330(7504):1357.

2. O'Brien SH, Holubkov R, Reis EC. Identification, evaluation, and management of obesity in an academic primary care center. Pediatrics. 2004;114(2):e154-159.

By Heather L. Borders, MD, pediatric radiologist, Helen DeVos Children’s Hospital, Grand Rapids, Michigan

There’s been a lot of concern lately about the amount of radiation received from CT scans. The issue is particularly concerning when it comes to children, however, because their brains and bodies are still developing.

We just published an article in the Journal of the American College of Radiology that highlights opportunities for children’s hospitals to make CT scans safer for children. I hope all pediatric radiologists and pediatricians will read it, and that you, as a community pediatrician, will bring it to the attention of your own pediatric imaging center.

The study began with a project I initiated as a pediatric radiologist here at Helen DeVos. I knew about studies highlighting high levels of radiation with CT scans, so I started collecting information on the CT dosage and outcomes in our imaging center. Back then, pediatric and adult radiology shared a facility as well as the radiology technicians.

When we moved into the new children’s hospital in 2011 and began working in our own dedicated pediatric imaging facility, I continued collecting that information on CT dosage. We had also reconvened our ALARA (As Low As Reasonably Achievable) committee, charged with monitoring the radiation dose in pediatric radiology to ensure the use of the safest possible amount; developing ways to reduce the dose even further; and educating healthcare professionals, patients and families about the importance of keeping the dose as low as possible.

The study we published compares radiation exposure before and after we moved into the new hospital. While the best amount of radiation is no radiation at all, we were surprised (and gratified) to find that the radiation dose in the new hospital was substantially lower than that provided in the old hospital. In fact, it was often equal to or even lower than the background radiation children are regularly exposed to each year. The dosages were also much more consistent than those used under the old set up in the shared facility.

We think the difference is due to the fact that we now have a dedicated pediatric imaging department with dedicated pediatric CT technologists. This has led to better compliance with pediatric protocols and consistently lower radiation doses.

This study raises several issues, however. One is that adult and pediatric imaging departments should re-evaluate their existing protocols for pediatric imaging and provide appropriate training to ensure adherence.

Another is that just because imaging centers can get the dosage so low doesn’t mean more kids should be imaged. It is very important that pediatricians first consider why they are ordering scans and how it will affect their management of the child. If there is any question, I urge you to call a pediatric radiologist and discuss it with them. There may be other tests that could provide similar information without exposing the child to any radiation.

We’re not resting on our laurels. Here at Helen DeVos we continue to track radiation dosages and protocol adherence every month to make sure we are doing the best job possible and exposing our kids to the lowest radiation dosage possible.

What protocols do you have in place for pediatric CT scans? Have you evaluated your dosages over time?

Heather L. Borders, MD, is a pediatric radiologist at Helen DeVos Children’s Hospital in Grand Rapids, Michigan

By Michael Wood, MD, Pediatric Endocrinologist
Spectrum Health Medical Group
Helen DeVos Children’s Hospital

With the current obesity crisis in children, growing numbers of children and adolescents with dyslipidemia, and a correlation between lipoprotein disorders and the onset and severity of atherosclerosis in children and adolescents, just as in adults, you might think that a new recommendation to screen all children for dyslipidemia between the ages of 9 and 11, and then again between ages 17 and 21, would sail through the medical community like a feather in a windstorm.

Not so. The recommendation, released earlier this year by the National Heart, Lung, and Blood Institute (NHLBI) Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents, and endorsed by the American Academy of Pediatrics, has become one of the most controversial issues right now in children’s health.

In addition to the screening, the guidelines also recommend initiating statin therapy in children with LDL levels of 190 mg/dL or higher; those with LDL levels between 160 and 189 mg/dL and familial hypercholesterolemia or 2 or more moderate-level risk factors; and those with LDL levels between 130 and 159 mg/dL who also have 2 high-level risk factors, or 1 high-level and 2 or more moderate-level risk factors, or clinical CVD. Statins are approved for use in children ages 10 and older.

Given that an estimated 10% to 13% of children have elevated cholesterol levels, this screening program could result in an additional 200,000 children/adolescents being placed on statins.

The issue drew a packed audience for a debate late last month that I attended at the Pediatric Academic Society meeting between two pediatric public health heavyweights: Matthew Gilman, MD of the Harvard Medical School, who directs the obesity prevention program at the Harvard Pilgrim Health Care Institute, and Douglas S Moodie, MD, a Pediatric Cardiologist at Texas Children's Hospital in Houston.

Dr. Gilman, who served on the NHLBI committee but was one a handful of members who voted against the recommendation, also co-authored an article on the topic in The Journal of the American Medical Association critical of the recommendations. Among his concerns:

• There has not been, nor will there likely ever be, a large randomized controlled trial of screening that weighs the benefits against the harm
• Most randomized trials of lipid lowering in children/adolescents are relatively short and involve high-risk children, such as those with diabetes or familial hypercholesterolemia
• The long-term effects of children taking statins for years, possibly a lifetime, are unknown.

However, his co-author of the paper, Stephen R. Daniels, MD, PhD, of the University of Colorado School of Medicine in Aurora, noted that “universal screening and improvement of lifestyle in childhood is necessary to achieve adult low-risk status for the largest number of individuals.”

During the debate at the Society meeting, Dr. Gilman made several of the same arguments, while Dr. Moodie argued that the previous screening guidelines were ineffective, missing more than 50% of the children with a clinically significant elevation in their lipids.   Although he agreed that universal screening would lead to some false positive results and needless worry in some families (and need for more costly blood testing), the benefit of diagnosing far more children earlier would outweigh the risk.

In our clinic, we already follow the panel’s treatment guidelines, starting statin therapy in children with an LDL > 190 mg/dl, or with LDL levels between 160 and 190 mg/dL if they have other cardiovascular disease (CVD) risks, such as obesity, smoking, or a first-degree relative with a history of CVD.   We also typically start statin therapy in children with diabetes whose LDL remains greater than 130 mg/dL after a trial of dietary changes, exercise and improved diabetes control.

Nonetheless, I do have some concerns about the recommendations. One is that some doctors will place too much emphasis on the numbers, subliminally convincing parents of children with normal levels that their child is protected against CVD. These parents may then ignore the lifestyle choices that we know are so important for that protection, particularly diet and exercise.

I also worry whether pediatricians have the time and support to implement the lifestyle changes the panel recommends, including a stepped diet program and exercise and nutritional counseling.

Still, I support the recommendations.  I also applaud the panel for recommending a non-fasting cholesterol test, the Non-HDL Cholesterol (Non-HDL Cholesterol = Total Cholesterol – HDL Cholesterol), which will make the screening much easier and parents much more likely to obtain the test. If the initial screening test is high, however, children should have 2 full fasting lipid panels within 3 months before any treatment decisions are made. Those needle sticks will not be fun for parents or their children, as any pediatrician knows.

What is your opinion on universal cholesterol screening in children and adolescents? Have you implemented the guidelines in your practice? Click "Add Comment" below to join the conversation.

By Joe C. Eisenmann, PhD, Senior Translational Epidemiologist and William Stratbucker, MD, MS, Medical Director,  Healthy Weight Center, Helen DeVos Children's  Hospital, Grand Rapids Michigan

In case you were on vacation and didn’t hear, a new study from the Centers for Disease Control and Prevention predicts that by 2030, 42% of Americans will be obese. Those obese adults 18 years from now are children today, for this is where the roots of the growing obesity crisis lie. To that end, we have been operating the Healthy Weight Center at Helen DeVos Children’s Hospital since April 2009 to treat obese children and adolescents.  As part of our professional development, we conduct a monthly journal club for the entire multidisciplinary team to enhance their critical reading and research skills, and so they can stay abreast of the latest research in pediatric obesity. 

This activity made for an excellent gateway for our invited presentation of the best research papers in pediatric obesity for the National Association of Children’s Hospitals and Related Institutions (NACHRI)’s webinar series.

As you can see from the figure below, the attention paid to pediatric obesity by the research community has increased along with the epidemic.

Figure 1           Publications on Pediatric Obesity, 1940-2011



Here are some of the highlights from our presentation.

• Treatment initiation. Parent-reported adolescent health problems and a large discrepancy between a teen’s current and ideal weight actually reduced the likelihood that the patient and family would initiate treatment, while parent perception of their child’s weight category and the priority they placed on weight loss increased the likelihood of treatment initiation.¹

• Adherence with weight-loss intervention. Children who had mothers of non-white descent, a higher BMI, participated in fewer activities, did not have breakfast regularly, and did not live in families with a static adaptability structure were more likely to drop out of a lifestyle intervention for weight loss than children without those characteristics.² Key point: To reduce drop out rates, clinicians need to provide tailored interventions that target different characteristics of participants at various stages of treatment.

• Parental perceptions of weight-based terminology. This survey of 521 parents found that parents prefer the terms “weight” and “unhealthy weight” when doctors discuss their children rather than “fat,” “obese,” and “extremely obese,” which they perceive as stigmatizing, blaming, and least likely to motivate children and adolescents to lose weight.³  Key point: Watch your language when discussing weight-related issues with your patient and family.

• Exercise and cognition in overweight children. This study of 171 sedentary, overweight 7- to 11-year-old children found that those engaging in exercise (13 weeks, 20-40 minutes a day) experienced greater mental functioning improvement in areas central to cognitive development than those in a control group.⁴

• Diet types in overweight children. A low-glycemic index diet approach that used the traffic light approach (“green, yellow, red”  foods) is easy to describe to children and parents and may result in improved adherence and less hunger than the low-calorie diets typically used in most weight management centers.⁵

• Parental involvement is a must for weight loss interventions. This study compared the efficacy of a parent-centered dietary-modification program to a child-centered physical-activity program, separately and together, on various weight-related parameters in 165 overweight, prepubertal school-aged children. It found targeting calorie reduction to parents was more effective over 2 years than targeting increased physical activity interventions to children. However, either program alone or combined resulted in sustainable improvements over 2 years.⁶

• Meal replacement for overweight adolescents. Using meal replacements over 4 months significantly improved short-term weight loss compared to a conventional low-calorie diet, but the effects were short lived with no difference between the two groups at 12 months.⁷

• Text-messaging to improve weight loss in adolescents. In this qualitative study, 24 overweight adolescents in a weight management program participated in 4 focus groups to assess their action to texted weight-related messages. However, the teens also noted that mentioning unhealthy foods or behaviors would trigger them to eat those foods or engage in those behaviors. And stay away from acronyms like LOL; they were considered “too informal” for messages from healthcare providers.⁸  Key points: Teens like receiving text messages related to weight and weight loss, particularly recipe ideas, successful weight loss strategies their peers used, and requests for feedback on their progress. Keep the messages positive, encouraging, and direct, and include symbols such as exclamation points and smiley faces.

1. Dhingra et al. Predicting treatment initiation in a family-based adolescent overweight and obesity intervention. Obesity (Silver Spring). 2011;19(6):1307-10

2. de Neit J, et al. Predictors of participant dropout at various stages of a pediatric lifestyle program. Pediatrics. 2011;127(1):e164-70.

3. Puhl RM, et al. Parental perceptions of weight terminology that providers use with youth. Pediatrics. 2011;128(4):e786-793.

4. Davis CL, et al. Exercise improves executive function and achievement and alters brain activation in overweight children; A randomized, controlled trial. Health Psychol. 2011;30(1):9.

5. Siegel RM, et al. A comparison of low glycemic index and staged portion-controlled diets in improving BMI of obese children in a pediatric weight management program. Clin Ped. 2011; 50(5):459-461.

6. Collins CE, et al. Parent diet modification, child activity, or both in obese children: A randomized clinical trial. Pediatrics. 2011;127:619-627.

7. Berkowitz RI, et al. Meal replacements in the treatment of adolescent obesity; A randomized controlled trial. Obesity. 2011;19:1193-1199. 

8. Woolford SJ, et al. OMG do not say LOL: Obese adolescents’ perspectives on the content of text messages to enhance weight loss efforts. Obesity. 2011; 19(12):2382-7.

By Nancy J. Brooke, MD, pediatric allergist/immunologist

There’s a lot of excitement out there about sublingual and oral immunotherapy (SLIT and OIT), in which patients receive increasing amounts of an allergen as a liquid or tablet held under the tongue or swallowed rather than the traditional allergy shots. Patients take the therapy on a daily basis for at least 4 years.

Sublingual and oral immunotherapy has been used for years in Europe. Proponents cite the ease of use and safety record of the therapy. And, of course, what child (or parent) wouldn’t prefer an oral form of immunotherapy to multiple shots. In addition, because larger amounts of allergen are used than we use with subcutaneous immunotherapy (SCIT), patients may need fewer sessions.

The therapy has been tested in children and adults with good results, although most of the trials have been conducted in children with dust mite or grass allergies. Studies are now being conducted in children with food allergies, including cow’s milk and peanut allergies.

But I’m just not sold yet.  For one, the FDA has not approved any SLIT products, yet I know a few of my colleagues are using injectable serums off label for sublingual therapy.

Also, the European studies show best results when SLIT is used for nonsensitized patients, i.e., single grass pollen.  Unfortunately, most patients in North America are sensitized to multiple aeroallergens and the results are not as encouraging.

Compliance is also an issue, in that SLIT has to be administered on a daily basis to ensure the best outcome.  If doses are regularly missed, patients will have less than satisfactory results.

Although there are fewer reactions to SLIT, there have been serious reactions, including some that were life-threatening.  This is particularly concerning since SLIT is administered at home, and could be particularly dangerous is the patient has asthma.

Finally, given that there are no commercially available allergen preparations in the United States for SLIT, it is not generally reimbursed by insurance payors, placing the financial responsibility on the patient.

Other concerns include: 

• Few trials have compared SCIT to SLIT/OIT, so I’m hard pressed to say that one is better than the other.
• We just don’t know which patients should receive SLIT/OIT and which should stay with SCIT. For instance, can it be used in patients with asthma? What about those with multiple allergies?
• Can it prevent the development of asthma in young children as SCIT can?
• Which should be used, SLIT or OIT? A recently published study on the safety and efficacy of each for children with milk allergy found that while OIT worked better at desensitizing children to cow’s milk than SLIT alone, children receiving OIT had more systemic side effects and some lost desensitization within 1 week of stopping therapy.[1]
• How long will the effects of SLIT/OIT last after therapy ends? We know with SCIT that the effects last for years, possibly a lifetime, after discontinuation.

At this time, I do not feel comfortable instituting SLIT or OIT in my patients until there are more positive trials, the FDA approves it, and there are commercial preparations approved for its use.

What do you think about SLIT/OIT versus SCIT? Are you using them in your practice?

Nancy J. Brooke, MD, is a pediatric allergist/immunologist on staff at Helen DeVos Children’s Hospital, Grand Rapids, Michigan.

By Sharon Palma RNC IBCLC, lactation consultation in the neonatal intensive care unit at Helen DeVos Children's Hospital in Grand Rapids, MI

Yet another study on yet more benefits of breastfeeding. The study comes from researchers in Switzerland and the United Kingdom and was published online ahead of print publication in the American Thoracic Society's American Journal of Respiratory and Critical Care Medicine. The researchers analyzed data from a nested sample of 1,458 children born between 1993 and 1997 in the UK whose lung function was measured at age 12. They found that breastfeeding four to six months was associated with greater forced expiratory volume 50 (FEV50) in all children (P=0.48), even more in those breastfed for more than six months (P=0.41).

However, the greatest improvement came in the children of mothers with asthma, with those breastfed four to six months demonstrating FEV50 increases of 0.375 L/sec (P=0.15) and those breastfed longer than six months improvements of 0.468 L/sec (P-0.99) compared to children who were not breastfed.

These were also the only children to demonstrate significant improvements in forced vital capacity (FVC) or forced expiratory volume at 1 second (FEV1). Even adjusting for respiratory infections in infancy and asthma and atopy in early childhood did not change the results.

These are particularly interesting findings given other work suggesting that breastfeeding might actually be harmful in children of women with asthma.¹

So, in addition to sharing this news with the mothers in your practice, particularly those with asthma, what more can you do?

The most important thing is to provide support. Emotional and educational. If your practice doesn’t have a lactation consultant on site, refer them out. Even the Women, Infants, and Children (WIC) nutritional program offers support through trained peer counselors in breastfeeding.

It is so easy for women to become discouraged about breastfeeding, particularly when formula is so readily available. Thus, it is important that they have realistic expectations from the beginning.

For instance, many women turn to formula because they think their infant isn’t getting enough milk. Remind them that frequent nursing is normal. Breast milk is digested more quickly than formula and a sudden surge in nursing frequency is the baby’s way of increasing your supply during a growth spurt.

Also remind them that babies cry for other reasons besides hunger.

Also ask mom how many wet diapers baby has, a clear sign that he/she is getting enough nutrition.

Many women (and some doctors) worry that breastfed babies don’t grow as fast as formula-fed babies. While it is true that breastfed babies may initially track lower on the growth chart, they eventually catch up.

If women try to quit nursing or cut back because the father wants to be “more involved,” remind them of the multitude of ways dad can be involved, including playing with baby, bathing baby, and, every woman’s favorite, changing baby’s diaper.

And if they want to stop nursing because they’re tired of getting up in the middle of the night to nurse, and someone told them that formula or, even worse, formula thickened with cereal, will help baby sleep through the night, remind them that infants are not supposed to sleep through the night.

So let’s review. Key messages you can provide:

• Babies are hard wired to breastfeed, so you can do this. And if you need it, help is available.
• There is nothing wrong with you; baby is most likely getting enough milk.
• There are plenty of ways for dad to be involved beyond giving bottles.
• Babies are supposed to wake up in the night for nursing.

And then tell them about this study—and the hundreds of other studies—that show breastfeeding is best.

Sharon Palma, RNC, IBCLC, is a lactation consultant in the neonatal intensive care unit at Helen DeVos Children's Hospital in Grand Rapids, MI

1. Guilbert TW, Stern DA, Morgan WJ, Martinez FD, Wright AL. Effect of breastfeeding on lung function in childhood and modulation by maternal asthma and atopy. Am J Respir Crit Care Med 2007;176:843-848.

By Kyle Morrison, program manager and pediatric exercise physiologist at Helen DeVos Children’s Hospital Healthy Weight Center

How many times do you ask parents of very young children about their development? Are they crawling? Trying to walk? Can they push a ball? Throw a ball? Skip?

Now, how many times do you ask a parent if they are teaching their child to do these activities? Actively engaging them in those activities?

If my question caught you off guard, you’re not alone. We’re primed to believe that most children just naturally develop these skills just as they naturally learn to breathe, eat and eventually become potty trained. But the reality (and what the science shows) is that while kids will likely still develop in these ways, they will do so much better if they have a parent or other adult actively engaging them in the standard physical activities of infancy and the toddler years above and beyond what naturally occurs.

While it might seem that toddlers and babies are in continual motion, that’s not true, particularly for first babies who tend to be held more during the first six to nine months of their lives compared to siblings that may follow.

The importance of physical activity during these years is so important that major national organizations like the American Alliance for Health, Physical Education, Recreation and Dance have guidelines regarding infant interactions and physical activities, and recommending that toddlers engage in at least 30 minutes of structured physical activity each day.

More recently, the Canadian Society for Exercise Physiology (CSEP) developed two sets of guidelines designed to improve the health and activity levels of infants and toddlers. The recommendations, published in the April 2012 issue of the journal Applied Physiology, Nutrition and Metabolism, call for children ages 1 to 4 to accumulate at least 180 minutes of physical activity in a variety of free play and structured settings throughout the day. The guidelines go on to recommend that parents and caregivers limit prolonged sitting for more than an hour a time, as well as limit “excessive screen time.”

So how should parents ensure their young children get this amount of physical activity? You should encourage them to deliberately engage in activities by carrying infants into new environments and putting them down on the floor to explore; standing over them when the stepping reflex kicks in, holding their hands, and helping them make practice steps; putting a ball or toy in front of them and encouraging them to scoot or crawl towards it, or littering their path with blocks or toys so they learn to circumnavigate obstacles.

As children get older, parents should engage in more active play, such as tossing a ball, riding a tricycle or scooter, going for walks. You might also recommend parents see if the Start Smart Sports Development Program is available in their community. This program, from the National Alliance for Youth Sports, is a developmentally appropriate introductory sports program for children 3 to 5 years old.

When parents participate in physical activity with young, developing children, they improve the likelihood that this modeling will help promote future activity levels. These early opportunities for physical activity also help build the skill sets and confidence kids need to be active in the later stages of childhood through adulthood.

Kyle Morrison is a program manager and pediatric exercise physiologist at Helen DeVos Children’s Hospital’s Healthy Weight Center in Grand Rapids, Michigan.

By Beth Kurt, MD, pediatric oncologist with the Spectrum Health Medical Group and director of the After Care and Transition program for childhood cancer survivors at Helen DeVos Children’s Hospital

I was intrigued by a recent article in the Journal of Pediatric Psychology published online in early February. The article reports the results of the first prospective study of the cognitive, physical and social development of infants and toddlers undergoing cancer treatment.

The researchers conducted age-appropriate neuropsychological testing in 61 children with non-central nervous system cancers who were 42 months or younger and compared the results to similar testing in matched controls. The testing occurred while the children were in the midst of treatment.

The study sponsored by the National Institute of Child Health and Development, was conducted on children in Italy. Based on the test scores, the researchers found that the cancer cohort tended to have significant development deficits in cognitive aspects such as attention and memory, and in motor skills, compared to the control group (P<0.001), although there were no differences between groups in terms of social and emotional development.

This study is important because it adds to an area of research that is relatively thin: the effects of cancer and its treatment on neurocognitive development. Still, I would like to see data on these children’s neurocognitive and motor milestones after they finish their treatment, data I’m sure will be forthcoming.

Nonetheless, this study reminds us—both oncologists and primary care physicians, who provide a great deal of non-cancer-related care to young children—that we can’t ignore cognitive, motor, and social development in these children just because they are sick. We need to treat the whole child, not just the illness.

As community physicians, you play an important role in this. You can encourage parents to engage their children in non-medically related activities that they would be doing if the child weren’t sick. Reading out loud. Drawing pictures. Playing games. Taking walks. Tossing a ball. You can also connect them with community resources available to support development, including  programs through Part C of the Individuals with Disabilities Education Act (IDEA). In Michigan, the program is called Early On.

The big takeaway from this study is that we could all be better at placing emphasis on getting these kids into developmental services earlier rather than later. As the authors of the study noted: “If not addressed adequately, the effects of early problems can spread, affecting many aspects of children’s development in significant ways.”

Stephen Albrecht, PhD, Pediatric Psychology
Spectrum Health Medical Group
Helen DeVos Children’s Hospital

A recently published paper entitled “Physical Punishment of Children: Lessons from 20 Years of Research” should give any parent pause when it comes to lifting a hand against their child. The paper, from researchers Joan Durrant, PhD, and Ron Ensom, MSW, of the University of Manitoba in Canada, highlights the risks associated with physical punishment of children, namely, that there is a substantially higher risk of negative development outcomes when corporate punishment is used.

As the authors note in their paper: “Physicians familiar with the research can now confidently encourage parents to adopt constructive approaches to discipline and can comfortably use their unique influence to guide other aspects of children’s healthy development.”

Which brings me to the point of this blog posting: What can you, as a community pediatrician or family practitioner, do to encourage these constructive approaches? What do these constructive approaches look like? Here is some advice to provide parents with a “toolbox” from which to manage their child’s behavior.

• Use the concept of a “toolbox” approach. Obviously, the reaction to a child running into a busy street or hitting his sister should differ from the response to a child who won’t eat her peas.
• Emphasize what the child should do rather than what the child shouldn’t do. Instead of saying, “You better not leave your peas again tonight,” say, “Eating vegetables is such a cool thing to do; it not only fills you up, but gives you lots of energy.”
• Encourage parents to praise the good behavior rather than focus on the bad behavior. You may know this as “catch them doing good.” Over time, research shows, this approach can result in behavioral changes in the child and improved parent/child dynamics.
• For children who are “acting out,” try to understand what triggers the behavior and then work to avoid or change those triggers. Perhaps the child tends to “act out” when he’s tired or hungry—triggers that can be addressed. We call this the ABC approach:
  • Identify the Antecedent
  • Target the Behavior
  • Provide the Consequences
• Have the parent list behaviors they can and cannot ignore, the classic “pick your battle” approach. For instance, maybe they can ignore or only mildly reprimand a child who doesn’t make his bed, but not doing homework requires a bigger “tool” from the toolbox. 

What’s important to remember is that every family is different and every family needs different tools in their disciplinary toolbox. One tool they don’t need, however, is physical punishment.

Resources:

 I recommend the following resources to my patients’ parents; you might want to do the same.

• Parenting the Strong-Willed Child: The Clinically Proven Five-Week Program for Parents of Two- to Six-Year-Olds, by Rex Forehand and Nicholas Long
• 1-2-3 Magic: Effective Discipline for Children 2-12, by Thomas W. Phelan, PhD
• SOS: Help for Parents, by Lynn Clark, PhD
• Your Defiant Child: Eight Steps to Better Behavior, by Russell A. Barkley

What tools do you recommend to parents? Click "Add Comment" below to join the conversation.

John Huntington, MD, Anesthesiologist
Helen DeVos Children’s Hospital

A new study published in February in the journal Mayo Clinic Proceedings brings the anesthesia in children issue back into the spotlight. I last wrote about this topic in August, when an FDA panel was meeting to evaluate concerns about cognitive problems and learning disabilities from general anesthesia in young children.

The Mayo Clinic study was conducted by the same group that reported on the increased risk for learning disabilities in children receiving anesthesia before age 2.^1,2 As with that earlier report, this one evaluated a large database of all children born between January 1, 1976 and December 31, 1982 in Rochester, MN who were still living in the city at age 5. The researchers identified 341 cases of attention deficit hyperactivity disorder (ADHD) and 497 total procedures involving anesthesia among 350 children. Comparing the two groups, they found that undergoing 2 or more procedures requiring anesthesia before age 2 significantly increased the risk of ADHD, even after controlling for sex, birth weight, and gestational age (hazard ratio 1.95; 95% confidence interval, 1.03-3.71). They also found an increased risk for ADHD without learning disabilities among the multiple anesthesia cohort. There was no association between length of anesthesia and ADHD risk.

The researchers did acknowledge that factors associated with the procedure itself could be related to the increased ADHD and learning disorder risk identified in this and other studies, as well and pre- and postnatal stress and inflammation, which, of course, can be caused by surgery. This is important, since patients who require 2 or more procedures before age 2 that require anesthesia are generally less healthy and might also have additional co-morbidities. The medical conditions or co-morbidities as well as the procedures themselves might be contributing to the increased risk of developing ADHD/LD, as could the increased pain and physiological stress associated with their medical conditions, the procedures themselves, and recovery from the procedures, not simply exposure to anesthetic agents.

What we must keep in mind is that the cause and effect link between requiring 2 or more anesthetics and developing ADHD or learning disorders has not been established. In other words, while the use of 2 anesthetics prior to age 2 is a marker for an increased risk of ADHD/LD, it is not proven as the cause of that increased risk. 

The most important fact to keep in mind at this time is that there is no acceptable alternative to anesthesia. We should not—indeed, we cannot—withhold anesthetics and pain medicines from patients who require them.

Are the parents of your patients concerned about anesthesia during procedures? Click "Add Comment" at the end of this post.  

1. Wilder RT, Flick RP, Sprung J, et al. Early exposure to anesthesia and learning disabilities in a population-based birth cohort. Anesthesiology. 2009;110(4):796-804.

2. Flick RP, Katusic SK, Colligan RC, et al. Cognitive and behavioral outcomes after early exposure to anesthesia and surgery. Pediatrics. 2011;128(5):e1053-e1061

Deborah Cloney, MD, Pediatric Gastroenterology
Spectrum Health Medical Group
Helen DeVos Children’s Hospital in Grand Rapids, Michigan

I last wrote about the use of proton pump inhibitors (PPI) in children in July 2011. Back then, I highlighted research showing an incredibly large increase in PPI prescriptions for infants under age 1, even though none of the PPIs are approved for use in that age group. I noted that there was still not enough data to establish the efficacy of PPIs in children, but that this conundrum was common in pediatrics.

So I wanted to draw your attention to a new article recently published in the Journal of the American Medical Association evaluating the use of lansoprazole (Prevacid) in children with asthma, with or without gastroesophageal reflux (GER).¹ The 2 conditions often coexist, and PPIs can be effective in managing asthma in adults with symptomatic GERD.^2-4

Researchers from the American Lung Association’s Asthma Clinical Research Centers conducted a randomized, masked, placebo-controlled, parallel clinical trial comparing lansoprazole with placebo in 306 children (mean age 11) with poorly controlled asthma and no GER symptoms who were receiving inhaled corticosteroid treatment.

They found no significant differences between the two groups in the Asthma Control Questionnaire (ACQ) score, which was the primary outcome. Nor were there any significant differences in secondary outcomes of mean difference in change for forced expiratory volume in the first second, asthma-related quality of life, or rate of episodes of poor asthma control (relative risk, 1.2; 95% CI, 0.9-1.5).

In a subset of children (n=115) who received esophageal pH studies, they found a GER prevalence of 43%, but also observed no statistically significant improvements for any of the asthma outcomes. In fact, they found a higher rate of respiratory infections (relative risk, 1.3 [95% CI, 1.1-1.6]) in the lansoprazole group.

This study certainly raises some interesting questions. How often is acid reflux a contributing factor in pediatric patients with poorly controlled asthma? Is non-acid reflux an issue?  How can we best identify those patients who may benefit from treatment? Is empiric treatment with a PPI in this patient population potentially more harmful than beneficial? If we choose to treat, how can we assess response?

This study did exclude patients with symptoms of GER or who had already been treated with a PPI or other reflux medication. Perhaps the population studied was not the group most likely to respond simply because of these exclusions.

No doubt further studies can help answer some of these difficult questions. In the meantime, my advice is to be thoughtful in your selection of patients to be treated and give careful consideration as to the outcome parameters you will use to determine response to therapy. Putting an asthmatic patient on a PPI “just in case” will likely result in significant PPI over use.

I’d like some feedback from you. Do you prescribe PPIs for your patients with asthma? Do you see any benefit? What are your thoughts about this study? Scroll down to click the "Add Comment" button at the end of this post. 

References

1. Writing Committee for the American Lung Association Asthma Clinical Research Centers. Lansoprazole for Children With Poorly Controlled Asthma: A Randomized Controlled Trial. JAMA. 2012;307(4);373-381.
2. Kiljander TO, Harding SM, Field SK, et al. Effects of esomeprazole 40 mg twice daily on asthma: a randomized placebo-controlled trial. AmJ Respir Crit Care Med. 2006;173(10):1091-1097.
3. Kiljander TO, Junghard O, Beckman O, Lind T. Effect of esomeprazole 40 mg once or twice daily on asthma: a randomized, placebo-controlled study. Am J Respir Crit Care Med. 2010;181(10):1042-1048.
4. Mastronarde JG, Anthonisen NR, Castro M, et al; American Lung Association Asthma Clinical Research Centers. Efficacy of esomeprazole for treatment of poorly controlled asthma. N Engl J Med. 2009;360(15):1487-1499.
5. Khoshoo V, Haydel R Jr. Effect of antireflux treatment on asthma exacerbations in nonatopic children. J Pediatr Gastroenterol Nutr. 2007;44(3):331-335.

Steven L. Pastyrnak, PhD, Pediatric Psychology
Spectrum Health Medicial Group
Helen DeVos Children's Hospital

Morgan R. Cole, PharmD, BCPS, Pharmacy Manager
Helen DeVos Children’s Hospital, Grand Rapids, MI

In case you (or, more likely, the parents in your practice) haven’t heard, new guidelines from the Food and Drug Administration (FDA) on dosing for infant acetaminophen are finally hitting the shelves. The new recommendations came after reports of overdosing in children who received high doses of the more concentrated infant formulation, leading to liver toxicity.

The take-home message - infant and children’s acetaminophen are now the same concentration: 160 mg/5 ml (32mg/ml). With the concentration change, infants will receive more liquid by the same amount of active ingredient. So, for instance, children weighing 6 to 11 pounds receiving a 40 mg dose will now receive 1.25 ml in the syringe versus the half dropper (0.4 ml) they would receive with the more concentrated formulation. This new, unconcentrated formulation is easy to spot—it’s packaged with a syringe dosing device instead of a dropper.

It’s important that parents hear about this change from you since they may not read the small print on the bottles. Plus, the switch is voluntary—not all manufacturers may do it. Even if they all conform, it may still be confusing for a while as stores carry both dosages while switching over. Plus, parents may have old products available at home they’re still using.

The concern is that if you prescribe a 5-ml dose of the less-concentrated liquid acetaminophen but parents administer a 5-ml dose of the more concentrated liquid acetaminophen, the child could receive a potentially fatal overdose; conversely, if the dose is based on the “old” formulation and the child receives the new formulation, the effective medication may not be enough to fight a fever.

The FDA also required a labeling change noting that the maximum dose per day should be 3,000 mg, down from the previous 4000 mg. Thus, while children may still receive up to five doses a day, the total amount should not exceed 3,000 mg/day.

Brand names for children’s acetaminophen include Tylenol^®, Little Fevers^®, Triaminic Infant/Pain Reliever, Pedia Care^®, and Triaminic Infants’ Syrup Fever Reducer Pain Reliever^®. The ruling also affects all store brands (Rite Aid, CVS, Walgreens, etc.).

You can read more about the FDA’s decision and recommendations here.

Acetaminophen Change at Spectrum Health
On January 16, 2012, Helen DeVos Children’s Hospital and Spectrum Health made our conversion to the new product.

Morgan R. Cole, PharmD, BCPS, is the pharmacy manager at Helen DeVos Children’s Hospital in Grand Rapids, MI

Wendy Burdo-Hartman, MD, Neurodevelopmental Pediatrics
Spectrum Health Medical Group
Helen DeVos Children’s Hospital

I don’t know if you saw the article in The New York Times a few weeks ago about how babies sort out language, but it got me thinking. The article, by pediatrician and writer Perri Klass, highlighted the growing propensity (particularly among high-income families) to start bilingual language development in children earlier, as well as the growing number of bilingual households immigrant families bring to this country. Could children exposed to more than one language early develop “language confusion?”

I don’t think so. In my experience, normally developing children will learn both languages just fine, something that is supported by the research. For instance, Klass highlighted an EEG study that found infants exposed to two languages in the first year are able to discriminate between sounds in each language by 10 to 12 months.¹ Other research suggests that language recognition even occurs prenatally, with babies born to bilingual mothers preferring the languages heard in utero over other languages, and registering differences between the two languages. There is even some suggestion that bilingual children may have an advantage when it comes to early executive control.²

However, children with other developmental delays, or language delays in general, should not be pushed to learn a new language. For these families, you should gently recommend letting the child focus on one language at a time.

Do you see more children learning a second language earlier?

1. Adrian Garcia-Sierra, Maritza Rivera-Gaxiola, Cherie R. Percaccio, et al. Bilingual language learning: An ERP study relating early brain responses to speech, language input, and later word production. J Phonetics. 2011.

2. Byers-Heinlein K, Burns TC, Werker JF. The roots of bilingualism in newborns. Psychol Sci. 2010;21(3):343-8.

Alejandro Quiroga, MD, Pediatric Nephrologist
Spectrum Health Medical Group
Helen DeVos Children’s Hospital

In late August, the American Academy of Pediatrics released the first update in more than a decade to its guidelines for the treatment of pediatric urinary tract infections (UTI) in children 2 to 24 months and the changes are significant.¹ I’ve highlighted the key changes in the table below.

The most significant change is that you no longer need to order a VCUG after a first UTI to rule out vesicoureteral reflux (VUR). There are several reasons for this change. The first is how we have traditionally treated VUR: with low-dose, prophylactic antibiotics. Yet, just as prophylactic antibiotics replaced surgical ureteral reimplantation as the primary treatment for VUR after we recognized the surgery was not effective, today we find little-to-no evidence demonstrating the effectiveness of prophylactic antibiotics to prevent UTIs and renal scarring in patients with VUR.^2-6 In addition, it appears that pyelonephritis can occur without the presence of VUR by VCUG.¹

Second, an analysis of recent studies on VCUG found that it would require 100 infants with febrile UTIs to identify 1 infant with grade V VUR. After a second UTI, however, just 10 infants would need to undergo the procedure to identify the 1 with the VUR, and that one child might have already been identified after the RBUS.¹

Finally, a VUR is not a benign procedure. It is invasive; most centers, including ours, sedate children; and it creates a significant amount of parental anxiety, as well.

The new guidelines do raise one interesting question: What do you do if you are treating a child who is taking prophylactic antibiotics? I recommend referring them back to the pediatric nephrologist for assessment.

Questions about the new guidelines? Post them here and I will respond. 

References

1. Committee On Quality Improvement And Management and Subcommittee On Urinary Tract Infection. Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months. Pediatrics. 2011. 128(3): 595-610.
2. Montini G, Rigon L, Zucchetta P, et al. Prophylaxis after first febrile urinary tract infection in children? A multicenter, randomized, controlled, noninferiority trial. Pediatrics. 2008;122(5):1064 –1071
3. Roussey-Kesler G, Gadjos V, Idres N, et al. Antibiotic prophylaxis for the prevention of recurrent urinary tract infection in children with low grade vesicoureteral reflux: results from a prospective randomized study. J Urol. 2008;179(2):674–679
4. Craig J, Simpson J, Williams G. Antibiotic prophylaxis and recurrent urinary tract infection in children. N Engl J Med. 2009; 361(18):1748 –1759
5. Pennesi M, Travan L, Peratoner L, et al. Is antibiotic prophylaxis in children with vesicoureteral reflux effective in preventing pyelonephritis and renal scars? A randomized, controlled trial. Pediatrics. 2008; 121(6). Available at: www.pediatrics.org/cgi/content/full/121/6/e1489
6. Garin EH, Olavarria F, Garcia Nieto V, Valenciano B, Campos A, Young L. Clinical significance of primary vesicoureteral reflux and urinary antibiotic prophylaxis after acute pyelonephritis: a multicenter, randomized, controlled study. Pediatrics. 2006;117(3):626–63

Karen M. Dahl, MD, Infectious Disease Specialist
Spectrum Health Medical Group
Helen DeVos Children’s Hospital

In early October, the state of Michigan became only the third state in the country to fully implement mandatory screening of newborns for Severe Combined Immunodeficiency (SCID). It is important that community physicians educate families about the new screening and the potential implications of an abnormal result.

You should tell families that we’re looking for a very rare immune deficiency, and that treatment is far more effective if the defect is identified early, before the baby becomes sick. Left undiagnosed, most infants with SCID die within their first year from an infection that their compromised immune system is unable to fight off. A hematopoietic stem cell transplant is a curative treatment, with outcomes significantly better when performed in an otherwise healthy child with no sign of infection.¹

Since the screening program just went into effect in October, you may still see patients in your practice with undiagnosed SCID. These infants are typically fine at birth, but within the first few months develop problems. Infectious complications include viral respiratory or gastrointestinal disease, and recurrent bacterial infections (otitis media and pneumonia). Other problems include failure to thrive and severe eczema, which may be attributed to dietary causes.  Atypical SCID may present after 1 year with similar symptoms, as well as autoimmune cytopenias, granulomatous cutaneous lesions, and lymphopenia.²

Only Wisconsin and New York also routinely screen all newborns for SCIDS.  That will soon change, however, since Connecticut, Delaware, Illinois, Minnesota, Mississippi, Rhode Island, and West Virginia have passed laws requiring the testing but have not yet implemented them. Massachusetts and California universally offer SCID testing, although it is not mandated, while Arizona , Pennsylvania, and Texas offer it to a select population, or by request.³

The screening test is not diagnostic; but if you receive a positive on the screening, we make a point of seeing the child within 48 hours for additional lab work, or you can order the labs yourself with our support. Our first patient to screen positive had the positive screen results reported on a Friday, we saw the patient on Monday in Infectious Disease clinic, and by Wednesday, we knew it was a false positive.  

In Michigan, three sites are on call to follow up on the newborn screening results: our group at Helen Devos Children’s Hospital in Grand Rapids; Children’s of Michigan in Detroit; and C.S. Mott Children’s Hospital in Ann Arbor. 

Do you have any questions/concerns/comments about SCID newborn screening?

1. Brown L, Xu-Bayford J, Allwood Z, et al.  Neonatal diagnosis of severe combined immunodeficiency leads to significantly improved survival outcome: the case for newborn screening. Blood. 2012. 117(11):3243–3246.
2. van der Burg M, Gennery AR. The expanding clinical and immunological spectrumof severe combined immunodeficiency. Eur J Pediatr. 2011;170:561–571.
3. National Newborn Screening Status Report. Updated November 21, 2011. Available at: genes-r-us.uthscsa.edu/nbsdisorders.pdf. Accessed November 28, 2011.

Anthony J. Richtsmeier, Jr., MD, Behavioral Pediatrician
Spectrum Health Medical Group
Helen DeVos Children’s Hospital

You may have seen the recent study in Pediatrics about the risk of recurrence for autism spectrum disorder (ASD) in families who already have a child with ASD. To the surprise of many, the recurrence rate in this relatively large sample (664 infants) was 18.7%. This is much higher than the 3% to 10% suggested by smaller studies and may even be an underestimation because the study evaluated children at 36 months; higher functioning ASD may not manifest obvious symptoms so early.

The early identification of children with an autism spectrum disorder is not always easy. Problems with social and emotional development, important in suspecting ASD, are generally less obvious than other developmental differences.   

This study reminds us of the importance of being sensitive to developmental differences  at every visit, and of screening at 18 and 24 months with the Modified Checklist for Autism in Toddlers (M-CHAT), as recommended by the American Academy of Pediatrics. You can download the M-CHAT free here.

Interestingly, an article published in the July issue of Pediatrics questioned the value of such routine screening, concluding that there may not be enough sound evidence to support its implementation. I would take issue with the authors of that article. We are learning that children with autism who receive specific early intervention show more improvement than children who do not—at least in clinical studies. One problem is that in real life, “early intervention” may merely consist of weekly appointments with speech and/or occupational therapy. These may be helpful but much more is likely needed.

There is tremendous variation among children with symptoms along the autism continuum, thus generalizing about treatment is difficult.  The vast majority of families I see report benefits from available therapies and behaviorally based treatments. But I also see children who receive a lot of therapy demonstrate minimal improvement, while other children improve with minimal formal intervention. This may be the child’s particular therapeutic and/or environmental influences, or it may be the way the brain is programmed – or both. More research is needed to understand how to help each child optimally develop.

I would submit that the burden of proof against routine screening lies with those who say there is more potential harm than benefit. Data are limited, but the risk of ignoring delays and allowing families to struggle relatively unsupported and children’s autistic features to be ingrained seems higher to me than any risks that may be associated with screening. If any problems are identified, pediatricians can provide families with basic information about the findings and potential implications; share information regarding the child’s strengths as well as challenges; express commitment to help families navigate through choices; refer to Early On for evaluation and intervention; offer general behavioral recommendations; and share information about specialty referral and resource opportunities.

This brings me back to the sibling study. If you hear from parents concerned about having another child with ASD, remind them that even while the study showed about a 19% risk, that is a group statistic and individual risks could vary. It also means that in the aggregate there was more than 80% likelihood that the subsequent siblings studied did not have ASD. Even if a future sibling is affected, there may be a different severity.

There are many different findings and conditions that can be associated with autism. Children with ASD should receive thorough pediatric evaluation for abnormal findings and possible conditions that can be associated with ASD, have those issues pursued diagnostically and be referred as indicated. Chromosomal microarray has replaced high-resolution chromosome analysis as test of choice in the evaluation of autism.  An underlying abnormality is more likely to be uncovered in ASD children with intellectual disabilities and/or abnormal physical issues than in those without.  In most cases of autism today, a cause cannot be found.

When it comes to ASD, I believe that you, as pediatricians, should promote a realistic element of hope in these families for several reasons:  A positive outlook can help promote a more positive outcome; some children develop very unique abilities ; and, most importantly, developmental gains are common, with some being dramatic.

Anthony J. Richtsmeier, Jr., MD, is a behavioral pediatrician with the Spectrum Health Medical Group who practices at Helen DeVos Children’s Hospital in Grand Rapids, Michigan.

Susan Millard, MD, Pediatric Pulmonology
Spectrum Health Medical Group
Helen DeVos Children’s Hospital

If you’re of a certain generation, the scent of Vicks VapoRub can have the same effect as a Snickerdoodle cookie my mom used to make—sending you hurtling back to your childhood when mom rubbed the goop on your chest to “loosen” up congestion during coughs and colds. And as long as the mentholated gel remains on the chest—and isn’t used in children under 2—there may not be a problem.

But in the past few years, I have heard and read reports from colleagues throughout the country about respiratory distress and hypoxemia in infants and toddlers who aspirated the salve after it was placed under their nose. In fact, a case published in Chest in 2009 highlighted this very situation, in which a grandmother rubbed Vicks under her toddler grandchild’s nose. The child recovered after hospital observation.¹

The physicians who treated that child then conducted studies in ferrets, whose airways mimic those of humans. Their work found that nasal Vicks exposure induced inflammation and mucus hypersecretion, increasing mucus production 63 percent compared to controls while reducing the function of hair cells in the lining of the airways (cilia) by 35 percent. In other words, it was counterproductive to improving the health of the nose and other air passages.¹

I expect this effect is not unique to Vicks, but could be induced by other volatile aromatics, particularly those that contain menthol. In addition to menthol, Vicks contains turpentine oil, eucalyptus oil, and cedar leaf oil. There is at least one published report of a child who developed contact dermatitis while using the salve, and another of a skin color change in an elderly woman after its use.^2,3

The other potentially harmful household product parents should be aware of is petroleum jelly. Parents often put it in a child’s nose to relieve irritation during cold or allergy season. We also see parents of children who are on oxygen using it to relieve dried mucus inside the nose. However, there have been published case reports of lipoid pneumonia resulting from long-term aspiration of this substance.⁴ Instead, we recommend that parents use an over-the-counter water-based product. These are made by the same companies that make the salt water nasal sprays. 

Bottom line: remind parents that they should check with you before using over-the-counter products, particularly when using them in very young children.

References 

1. Abanses JC, Arina S, Rubin BK. Vicks VapoRub induces mucin secretion, decreases ciliary beat frequency, and increases tracheal mucus transport in the ferret trachea. Chest. 2009;135:143-148.
2. Noiles K, Pratt M. Contact dermatitis to Vicks VapoRub. Dermatitis. 2010 Jun;21(3):167-9.
3. Boyse KE, Zirwas MJ. Chemical Leukoderma Associated with Vicks VapoRub. J Clin Aesthet Dermatol. 2008; 1(4): 34–35.
4. Brown AC, Slocum PC, Putthoff SL, et al. Exogenous lipoid pneumonia due to nasal application of petroleum jelly. Chest. 1994;104:968-969.

Alejandro Quiroga, MD, Pediatric Nephrologist
Spectrum Health Medical Group
Helen DeVos Children’s Hospital

I’m sure that few primary care physicians have the time or inclination to read the Clinical Journal of the American Society of Nephrology, but there was a very interesting editorial in the most recent issue about glomerular filtration rate (GFR) in children. We see quite a few patients referred to us for abnormal GFRs when, in fact, their GFR is normal. The challenge comes with the fact that figuring the estimated GFR (eGFR) in a child requires a calculation that isn’t required in normal adults (you can estimate the GFR in adults using the MDRD formula). Thus, the values you receive back from the lab may show the result as high or low because the lab does not perform that calculation and busy pediatricians may also forget to do it.

In addition, as the editorial by Fadrowski and Furth noted, today there are two commonly used estimating equations for children. There is the Schwartz equation, on which most of us trained, and the newer CKiD equation developed the ongoing National Institutes of Health-sponsored Chronic Kidney Disease in Children (CKiD) Study. (Full disclosure: Helen DeVos Children’s Hospital participates in the CKiD study).

I still recommend the Schwartz formula, since it is what most of us are familiar with. In addition, there is some suggestion that the CKiD misclassifies or underestimates median GFR (mGFR) in children with normal or mildly decreased kidney function^1-3

As you may recall, with the Schwartz formula you multiply the height of the child against a constant that depends on the age (infant 0.45, child 0.55) then divide the result by the serum creatine mg/dL (you can always train your staff to use an online calculator http://www-users.med.cornell.edu/~spon/picu/calc/crclschw.htm).  A result of ³90 ml/min per 1.73 m² is generally considered “normal” kidney function. The “normal” kidney function using the CKiD equation requires further validation, noted the authors of the aforementioned editorial.

Confused? Don’t be. When in doubt—and before sending a child to the emergency department—check with a pediatric nephrologist. We’re happy to help.

Alejandro Quiroga, MD, is a pediatric nephrologist at Helen DeVos Children’s Hospital, Grand Rapids, Michigan

References

1. Staples A, LeBlond R, Watkins S, Wong C, Brandt J: Validation of the revised Schwartz estimating equation in a predominantly non-CKD population. Pediatr Nephrol 25: 2321–2326, 2010
2. Pottel H, Mottaghy FM, Zaman Z, Martens F: On the relationship between glomerular filtration rate and serum creatinine in children. Pediatr Nephrol 25: 927–934, 2010
3. Qayed M, Thompson A, Applegate K, Haight A, Rogatko A, Chiang KY, Horan J: Is the updated Schwartz formula appropriate for assessing renal function prior to hematopoietic stem cell transplantation? Pediatr Blood Cancer 55: 199–201, 2010

Morgan R. Cole, PharmD, BCPS, manager, pharmacy, Helen DeVos Children's Hospital

As if there weren't enough challenges when it comes to pediatric medications, add the taste factor to the list. The reality is that it is difficult, at times impossible, to get a child to swallow foul-tasting medicine. Yet, as a recent FDA Update published in Pediatrics noted, the challenges facing drug companies when it comes to developing pediatric formulations means that kids are often required to swallow drugs designed for adults. (The Best Pharmaceuticals for Children Act web page has more information on pediatric pharmaceutical development efforts). 

Unfortunately, I see a lot of parents address the taste problem by grinding up pills and hiding the powder in ice cream or applesauce, or mixing bad tasting liquids with juice or milk. 

As pediatric clinicians, it is important that we do whatever we can to ensure that our patients take the medication  prescribed as directed-and that we warn parents about the potential dangers of mixing or manipulating those medications.

The first step is to order the medication from a compounding pharmacy or local retail pharmacy that carries commercially available flavoring agents.  For example, FLAVORx^®, a flavoring agent developed to improve the taste of medication without affecting its efficacy. You can read more about it here.

However, discourage parents from mixing liquid medications, pills, or crushed pills with their own food and drink. To often this can have unintended consequences, including erratic absorption. For instance, the drug could bind to the food or drink ingredients and become unavailable for absorption. One such drug is the antibiotic levofloxacin (Levaquin) oral solution. It binds to heavy metals (calcium, iron, and magnesium). That means hiding it in ice cream or milk renders it unavailable because it binds to calcium and/or iron.

In fact, we don't like to see juice, particularly citrus juices, used with medication in any situation, even to wash down the drug. You probably know that grapefruit juice can have multiple interactions with medications, including competing for or inhibiting enzymes required to metabolize medications; but other citrus juices, including orange, also contain compounds that can affect the bioavailability of certain medications.

If a parent has no other way to get a medication into a child (and no flavoring is available),  one possible option could be to mix the drug with chocolate syrup. It masks the bitterness but generally does not bind to the  active ingredients. 

As for crushing pills, counsel your patients that they should only take that step if their pharmacist agrees, as there are many dangerous effects when a medication is crushed when it should be administered whole. We are trained to know which medications can be crushed and which ones cannot be crushed. We even maintain Do Not Crush lists. 

Bottom line: When in doubt, turn to a pharmacist, particularly one with pediatric experience.

Morgan R. Cole, PharmD, BCPS, is the manager of the pharmacy at Helen DeVos Children's Hospital in Grand Rapids, Michigan.

John Huntington, MD, Anesthesiologist

Ever since news articles appeared last spring about an FDA federal panel meeting to evaluate concerns about cognitive problems or learning disabilities from general anesthesia in young children, I, like other anesthesiologists, have been fielding questions from concerned parents about the safety of anesthesia for their children. I'm sure you, as primary care physicians, are receiving similar questions. 

The concern about the possible effects of anesthesia on children's cognitive development began with animal studies published several years ago that demonstrated brain neuron death and long-term cognitive issues in 7-day-old rats given a combination of anesthesia drugs early in life. The FDA held a meeting in 2007 to discuss that research, concluding that anesthesia did not appear to cause similar issues in children but urging continued research. 

Much of the research since then has also been done in animals. However, several retrospective studies do suggest that children who receive repeated exposure to anesthesia before age 4 are more likely to have cognitive problems.^1,2,3,4

The study from Wilder et al, I think, is the one that has raised the current concerns. The authors looked at a cohort of 5,347children, approximately 600 of who had received general anesthesia before age 4 between 1976 and 1982. After 15 years, the authors found a correlation between two or more early anesthesia exposures and learning disabilities (hazard ratio [HR] =1.59, 95% CI 1.06-2.37 for two exposures; and HR 2.60, 95% CI 1.60-4.24, for three or more).⁴

Keep in mind that this is a correlation; we do not know if the anesthesia itself caused the learning deficits. Also consider, as we all know, that children who require two or more surgeries with general anesthesia before age 4 likely have other medical problems that could have contributed to those cognitive deficits. 

Still, if you combine retrospective studies like the one from Wilder et al with the animal studies, you can see how the current firestorm began. Thus, it's not surprising that the FDA felt it had act. 

The bottom line is that, at present, there is no alternative to general anesthesia for young children who require invasive procedures and such treatment is a must; we know even neonates feel pain. However, we always err on the side of caution, such as reserving elective procedures until children are older and limiting the number of anesthetics we give. If a child needs several procedures, we try to combine them into a single surgical session if possible. 

Also, if a child under 4 needs surgery it is likely related to a serious medical condition. So while I'm seeing more questions from parents in the past few months, none have cancelled surgeries. My advice is to take the time to counsel parents about the reality of the studies and our knowledge, and help them, as we do in so many things related to pediatric medicine, weigh the potential risks and benefits of the procedure.  

What are your thoughts about general anesthesia for young children? What are you hearing from parents?

John Huntington, MD, is an anesthesiologist at Helen DeVos Children's Hospital 

References

1. DiMaggio C, Sun LS, Kakavouli A, Byrne MW, Li G. A retrospective cohort study of the association of anesthesia and hernia repair surgery with behavioral and developmental disorders in young children. J Neurosurg Anesthesiol. 2009;21:286-91. 

2. Kalkman CJ, Peelen L, Moons KG, et al. Behavior and development in children and age at the time of first anesthetic exposure. Anesthesiology. 2009;110:805-12.

3. Backman ME, Kopf AW. Iatrogenic effects of general anesthesia in children: considerations in treating large congenital nevocytic nevi. J Dermatol Surg Oncol. 1986;12:363-7. 

4. Wilder RT, Flick RP, Sprung J, et al. Early exposure to anesthesia and learning disabilities in a population-based birth cohort. Anesthesiology. 2009;110:796-804.

Brooke E. Geddie, DO, Pediatric Ophthalmologist
Spectrum Health Medical Group
Helen DeVos Children's Hospital 

The Nintendo 3-D gaming systems had barely hit store shelves last Christmas before the scary headlines began. "3-D Games Can Ruin Children's Eyes, Nintendo Warns;"  Well, I'm here to tell you that you-and your patients' parents-you can breathe easy.   There is absolutely no justification for the hysteria as confirmed by numerous pediatric ophthalmologists and a policy statement from the American Academy of Ophthalmology (AAO) released in January.

The interesting thing about this whole issue is that it was Nintendo itself that issued a warning about the 3D device, urging parents to prevent children under age 6 from prolonged viewing so as to avoid possible damage to their visual development. This is a similar warning that manufacturers of other 3-D devices have been issuing.  

If only they'd asked the experts first. The reality, as the AAO statement noted, is that there are no conclusive studies on the effects of these devices. The other reality? Normal 3-D development is largely completed by the time children turn 3. And there isn't any evidence to support the idea that 3D images-or games of any kind-interferes with this development.  So although there are probably many valid reasons why young children should have their video game playing time limited, damage to the child's visual potential is not one of them!  

Parents should also be aware that children with amblyopia, strabismus, or other vision problems that affect focusing, depth perception, or normal 3-D vision may have trouble viewing the 3-D images; that doesn't mean the gaming system caused the problems. So, in fact, 3D movies and games have actually served as a "vision screening tool" for children. If a child is unable to see the 3D images of such movies or games, it is a red flag for strabismus or amblyopia, and he or she should be evaluated by a pediatric ophthalmologist.  And, as you might expect, prolonged exposure regardless of vision quality, can cause headaches and/or eye fatigue.

Brooke E. Geddie, D.O., is a pediatric ophthalmologist at Helen DeVos Children's Hospital in Grand Rapids, MI. 

Deborah Cloney, MD, Pediatric Gastroenterologist

I've been getting some questions lately about whether we should be prescribing acid-suppressing drugs like Prilosec (omeprazole)  and Prevacid (lansoprazole) for infants with troublesome acid reflux or even for older children and teenagers. The concern stems from a review article published in Pediatrics earlier this year that assessed 12 clinical trials evaluating the effectiveness of proton pump inhibitors (PPIs) for gastroesophageal reflux (GERD) in children. The authors concluded that there wasn't enough evidence to show that the medications effectively treated GERD in infants, although they were more effective at resolving symptoms in children. 

In addition, an FDA hearing last year found that the number of prescriptions for PPIs dispensed for children from birth through age 17 between 2002 and 2009 had tripled, from 875,000 to 2.6 million, with similar increases in the number of patients prescribed the drug (332,000 in 2002 to 885,000 in 2009).

The committee was particularly struck by the 11-fold increase in PPI prescriptions for infants under age 1 during the same period, from 37,000 to 403,000, with an eight-fold increase in the number of patients prescribed the drug. That's despite the fact that none of the PPIs are approved for use in that age group. Expect to see more on this as the FDA looks deeper into the issue.

My take on the Pediatrics article is not that the drugs shouldn't be prescribed for children, but that there is just not enough data to establish their efficacy in children-which is the case with a lot of the medications we use. Even when it comes to infants, I still have some babies with reflux in whom a PPI seems to help. 

The message? Be judicious (as always) in your use of medications; select patients whose symptoms seem to support a diagnosis of reflux; and set parameters on what your patients and their families should expect with treatment. For instance, we know that children with chronic abdominal pain will experience some reduction in symptoms when they start on medication because of a high placebo response. So when the time comes to take them off the drug, they often resist. Because we don't know what the long-term effects of these acid suppressors are on children, it is best to set expectations up front in terms regarding the length of therapy. 

Conversely, if the patient's reflux-like symptoms do not respond to a PPI, it is probably time for a referral to a pediatric gastroenterologist for an endoscopy to see if anything else is going on. For instance, an allergic form of esophagitis can mimic the signs of reflux. 

How often do you prescribe PPIs for kids with reflux-like symptoms? What kind of response do you see?

Lisa Lowery, MD, MPH, Adolescent Medicine 
Spectrum Health Medical Group
Helen DeVos Children's Hospital

The recent vote to allow gay marriage in New York state brought to mind the challenges that we, as healthcare professionals, face when our young patients have questions about or are struggling with issues related to their own sexual identity. 

As an adolescent medicine specialist, dealing with these issues is not uncommon. To encourage patients to share their concerns, it's important to create an environment in which your patients feel comfortable having such conversations. In my office, that means pamphlets and posters that demonstrate our support of our patients regardless of their sexual orientation. 

Why does this matter? Because as a primary caregiver part of your job is to ensure the safety of your patients. Yet a recent report from the Centers for Disease Control and Prevention found that gay, lesbian, and bisexual high school students were far more likely to engage in risky behavior such as smoking, drinking alcohol, and carrying guns than straight teens. The study of 156,000 high school students should be a "wake up call for families, schools and communities that we need to do a much better job of supporting these young people" said Howell Wechsler, the director of the CDC's Division of Adolescent and School Health. In an article on the study, Laura McGinnis, of the Trevor Project, said the teens are often driven to such risky behavior because they are "rejected by their families and other support groups."

As clinicians bound by our professional ethics to meet our patients wherever they are in order to provide the best possible care for them-regardless of our personal views on homosexuality. The American Academy of Pediatrics (AAP) issued its first statement on homosexuality and adolescents in 1983, revising it in 1993 and, more recently, in 2004. You can read it here. 

It notes that "Health care professionals should provide factual, current, nonjudgmental information in a confidential manner . . . The pediatrician should be attentive to various potential psychosocial difficulties, offer counseling or refer for counseling when necessary and ensure that every sexually active youth receives a thorough medical history, physical examination, immunizations, appropriate laboratory tests, and counseling about sexually transmitted infections (including human immunodeficiency virus infection) and appropriate treatment if necessary."

I try to stay away from gender-specific terms like "boyfriend" or "girlfriend." Allowing the teen to self identify provides you with the opportunity to ask more probing questions as needed. I find that asking if they have a special "friend" can help start the conversation. Another good way to start a conversation is to ask about bullying or if the teen is getting picked on. Also be alert to family issues around the teen's sexuality that could become divisive if not downright dangerous. And keep an eye out for signs of depression and other mood disorders, which are also extremely prevalent in this population.

If you're not comfortable talking about homosexuality with your patients, make sure you can refer patients to other community resources or even to another who can provide such support. This is also a recommendation from the AAP: "Any pediatrician who is unable to care for and counsel nonheterosexual youth should refer these patients to an appropriate colleague."

How do you get your patients to discuss concerns related to their sexual orientation?

Lisa Lowery, MD, MPH is an adolescent medicine specialist at Helen DeVos Children's Hospital in Grand Rapids, Michigan.

Bryan Judge, MD, Emergency Medicine and Medical Toxicology
Helen DeVos Children's Hospital
Grand Rapids, Michigan

I was pleased to see the new policy paper from the American Academy of Pediatrics on chemical exposure in children. The paper, published online in late April, basically says that federal authorities are not doing enough to protect kids from dangerous chemicals and recommends that chemical management policy in the United States be revised to protect children, pregnant women, and other populations.

The fact is, regulatory processes in the United States are far behind where they should be in terms of monitoring the thousands of harmful chemicals we're exposed to each year. We simply don't know enough about these chemicals and the long-term health effects. The Toxic Substances Control Act was passed more than 30 years ago to protect the public against exposure to hazardous chemicals, and yet has only been used to regulate five chemicals. 

On the flip side, we are exposed to dozens of potentially toxic chemicals every day and we're not all dying, which makes it difficult to get the importance of this issue across. Yet you know as well as I do that we've seen significant increases in rates of neurological conditions like  attention deficit hyperactivity disorder, in asthma, and in male genital deformities. 

So what does this have to do with you, the community-based pediatrician? Your role is to help patients and their families identify potential toxins present in the environment, household products, and toys that children are exposed to. You can also become involved in the policy issues around toxins at a local, state, and federal level, and/or through the AAP. For instance, there is now a bill pending in the Senate to reform the Toxic Substances Control Act. The American Medical Association, American Public Health Association, American Nurses Association, and now the APA endorse changes to the Act.

You can also work to educate yourself on toxins your patients may be exposed to, such as bisphenol A (BPA), which was recently eliminated from most baby bottles, and phthalates, used in many plastic items. Another good area to warn about are flame retardants in clothing like pajamas. There is no evidence that they are very effective and more evidence that the chemicals used can be harmful. 

A good reference is the APA's Pediatric Environmental Health, the third edition of which will be available later this year. Other good references include the Environmental Health and Toxicology pages of the National Library of Medicine web site. You can also call the Poison Control Center at 800.222.1222 for answers to many questions about chemicals and children. If they can't answer your question, they can refer you to environmental health experts or medical toxicologists.

What are your thoughts about chemical exposure in our world and the its affects on the health of children?

Susan Millard, MD, Pediatric Pulmonologist
Helen DeVos Children's Hospital
Grand Rapids, Michigan

As if the risks of marijuana, cocaine, prescription pain medication, and other drugs weren't enough, we, as pediatric physicians, also need to worry about another threat: inhalant abuse. Although that's not what the kids doing it call it; to them it's huffing, sniffing, bagging, glading or dusting. 

No matter what you call it, however, it still means inhaling toxic chemicals (think glue, paint thinner, gasoline, spray paint, even the nitrous oxide from whipped cream canisters and the compressed air used to clean keyboards) to get high. It's also a practice that is rampant among pre-teens and adolescents, particularly in hard economic times. As the author of a 2009 article on the topic noted: "A $2.50 container of air freshener is more affordable than a 'dime bag' of marijuana and users get a similar experience."¹

The 2009 National Survey on Drug Use and Health estimated that about 1% of youths ages 12 to 17 have used inhalants, but that it was the first illicit drug 10% of drug users tried. A study evaluating its use among juvenile offenders in Michigan found that nearly 40% reported lifetime inhalant use.² Boys are far more likely to use inhalants than girls.³

I bring this up because, as a pediatric pulmonologist, I don't want to see another kid in the PICU as a result of inhalant abuse. And you, as community pediatricians, are in a position to help prevent it. I recommend you begin talking about the dangers to kids and their parents before they hit adolescence. Tell parents to look for signs their kids are using, such as: 

• Disappearing aerosols
• Sores around or within a child's mouth
• Paint stains on clothing (from spray paint cans)
• Finding paraphernalia like plastic bags in the child's possession (used for bagging)
• Slurred or slow speech
• Mood changes

Clinical signs of inhalant abuse include unexplained coughing up of blood and/or recurrent pneumonia. Although either could be signs of tuberculosis or HIV infection, you should consider inhalant abuse in your differential diagnosis. 

Other signs include:

• throat edema
• changes in kidney and/or liver enzyme levels
• unexplained vomiting
• nausea
• hallucinations
• dizziness
• seizures

Long-term users may demonstrate neuronal damage manifesting as difficulty walking and talking, and loss of hearing and memory.¹ Routine use can also cause arrhythmias, kidney and liver damage, while even a single use can  result in cardiac arrest and death. Children using inhalants also become less inhibited and are more likely to take risks.⁴

So, please, educate yourself on the signs and symptoms of inhalant use and take a few minutes to educate your patients and their parents. 

Are you seeing inhalant abuse in your practice? How do you talk to parents and patients about this threat?

Susan Millard, MD, is a pediatric pulmonologist at Helen DeVos Children's Hospital in Grand Rapids, Michigan.

References

1. Criss L. Huffing: prehospital identification & treatment of inhalant abuse. JEMS. 2009 May;34(5):42-3, 45, 47 passim.

Jennifer Hoekstra
Safe Kids Greater Grand Rapids
Helen DeVos Children's Hospital

Of all the things that you, as a primary care physician for young children, have to deal with, car seats might seem relatively innocuous compared to immunizations, respiratory syncytial virus (RSV), and weight/height charts. But nothing kills more children under age 5 than automobiles accidents.¹ In fact, using the appropriate child safety seats can reduce the risk of death for infants by 71 percent; by 54 percent in toddlers ages 1 to 4.

So the new policy statement from the American Academy of Pediatrics on "Child Passenger Safety" is important information to communicate to the families of the infants and young children in your practice.

In a  nutshell:

Rear facing until age 2. Kids need to remain in a rear-facing car seat far longer than we used to recommend. That means until age 2 or until the child reaches the height and weight recommended by the seat manufacturer. This is the biggest change in the AAP recommendations, and comes as a result of data demonstrating that children who ride in a car facing forward before age 2 are far more likely to receive neck and spinal injuries during an accident. Backward-facing car seats protect still-developing neck and spines far more than seats facing forward. Most of these seats today can work for children up to 35 pounds.

Forward facing car seat until booster seat ready. Children 2 and older, or younger children who have outgrown the rear-facing seat, should remain in a forward-facing seat with a harness for as long as possible, up to the highest weight or height allowed by the manufacturer of their child safety seat.

Booster seat until big enough for seatbelts only. Children who no longer meet the height and weight requirements for a child safety seat should be in a booster seat that uses a belt until they are big enough to properly  use the lap-and-shoulder belts in cars. This typically occurs at 4-feet, 9-inches and between 8 and 12 years of age.

Back seat only until age 13 or later. At this point, children should remain in the back seat using the lap and shoulder belt until at least age 13.

Yo might hear parents complain their child simply hates facing backwards. Suggest that they adjust the angle of the car seat rather than turning it around. Newborns should be reclined at a 45-degree incline to protect their airway; but as they get older, the incline can be shifted upwards so the child can see out the windows. 

It is also important that the seats be properly installed. Feel free to refer your parents to their local Safe Kids Coalition, where they can receive hands-on support to make sure that their car seats are properly installed.

Reference:

¹Centers for Disease Control and Prevention. Web-based Injury Statistics Query and Reporting System [online]. National Center for Injury Prevention and Control, Centers for Disease Control and Prevention (producer). http://cdc.gov/ncipc/wisqars. Accessed May 11, 2011.

It's time to register for the annual Pediatric Update Conference, sponsored by Helen DeVos Children's Hospital and Grand Rapids Medical Partners in Grand Rapids, Michigan. The conference is designed to increase the knowledge of regional physicians on current trends and treatments in pediatric medicine. Objectives include:

• Provide enhanced care to pediatric patients by increasing the ability to diagnose and manage patients in pediatric and subspecialty areas
• Discuss  and explore current advances and treatments in pediatric medicine
• Serve as an educational resource to regional pediatricians and family practice physicians

This one-day educational conference occurs at the new Helen DeVos Children's Hospital and includes a guided tour and a post-conference reception at the adjacent Van Andel Institute. 

The conference will be held May 25 from 8:30 a.m., to 7:30 p.m.*

Among the speakers:

Daniel Arndt, MD: "Neurology Update: Epileptology"

Who would have thought you could safely remove up to half of the brain and cure a patient from medically refractory epilepsy with a very favorable benefit-to-risk ratio? From the first epilepsy surgery that occurred in 1886 at the National Hospital for the Paralyzed and Epileptic at Queen's Square in London to the epilepsy surgeries that took hold in the 1940s with the invention of electroencephalography (EEG), to the "third wave" of epilepsy surgeries beginning in the 1970s, this talk will focus current efforts to treat epilepsy surgically. It will cover the appropriate identification of surgical candidates who, ideally, would be referred much earlier in the disease than we see today, presurgical evaluation and surgical options, and post-surgical outcomes. 






Chad Afman, MD: "Tonsillectomy and Adenoidectomy: New Guidelines"

This talk will cover the first-ever guidelines for tonsillectomy and adenoidectomy, including indications for and risks and benefits of the procedure. You can read more here about the topic.

 







Brooke Geddie, DO: "Pediatric Ophthalmology Update"

What are the latest recommendations for vision screening in your office? What ocular presentations necessitate immediate versus routine referral to a pediatric ophthalmologist? These questions and more will be addressed during this concise pediatric ophthalmology update. 

Theodore Barber, MD: "Urology Update: Hypospadias and Neurogenic Bladder"

Paradigms of management for both hypospadias and the neurogenic bladder have undergone a dramatic shift. Previously, hypospadias repair was performed using a variety of flap techniques, resulting in suboptimal functional as well as cosmetic outcomes and high complication rates. These techniques are now being replaced by free grafts and the tubularized incised plate (Snodgrass) repair. 

Until recently, deterioration of the neurogenic bladder with the ultimate requirement for bladder augmentation, and its significant associated complications, was viewed as inevitable. However, recent data has challenged this teaching, making a compelling argument for a more conservative approach to these challenging patients.  





William Stratbucker, MD: "Bright Futures: The Front Door to Your Pediatric Medical Home"

Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Third Edition, provides a model of practice that helps providers prevent dangerous illnesses, manage developmental concerns, educate parents and address the unique needs of children with special health needs in the child's medical home. Information provided will help providers distinguish their services from retail-based clinics, urgent care centers, and the Internet while improving pediatric care. The implementation of Bright Futures Guidelines within a pediatric practice can impact both financial reimbursement for services provided and the provision of best practice, high-quality pediatric medical care. Finding a way to work these recommendations into an already busy practice is challenging but offers the possibility of significant reward.

 

 
You can view the entire agenda here and register for the conference here.

*Grand Rapids Medical Partners is accredited by the Michigan State Medical Society Committee on CME Accreditation to provide continuing medical education for physicians. Grand Rapids Medical Education Partners designates this educational activity for a maximum of 8.25 AMA PRA Category 1 Credit(s) TM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Bradford W. Betz, MD, Medical Director, Pediatric Radiology  
Helen DeVos Children's Hospital

A recent study in the journal Radiology reported on an analysis of 14 years of data on more than 7,300 emergency department (ED) visits. The authors found that during that time the number of children getting CT scans increased fivefold. One reason, the authors suggested, is that most visits were to non-pediatric EDs, where kids were overseen by radiologists with no specialty training in pediatrics. The children may also have received unnecessarily high CT doses since many general hospitals do not always recognize the need to reduce radiation dosages for children. 

Other reasons for the high rate of CTs, the authors suggest, are parents who push for them and emergency department physicians who are afraid of missing a diagnosis. Importantly, the vast majority of the CTs performed were normal. 

There are three components to appropriately using CT for children seen in the ED. First, ED physicians need to be comfortable with kids and their unique medical issues. This level of confidence reduces the need for CT scans.  Second, if a CT scan is necessary, it is important that the radiologist and CT technologist keep the dose as low as possible to obtain the required diagnostic information. And, finally, the radiologist who interprets pediatric studies needs to be knowledgeable about the medical differences between children and adults.

Parents may not always be aware of the way their health care facility safeguards CT utilization and dose, especially when their child develops an acute illness and requires emergency care. One quick way to gauge their level of concern is to make sure the ordering ED physician is able to clearly explain the reason for the CT scan and how that information will affect the care of their child.

For more on diagnostic radiation safety in children,  you can read an earlier blog posting here.