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|Tuesday, June 29, 2010
|New AAP Mental Health Screening Guidelines Released
|by Pediatric Perspectives at 09:26 AM
Steven L. Pastyrnak, PhD, Psychology, Division Chief
Helen DeVos Children's Hospital
Did you catch the special supplement that came with your June issue of Pediatrics? If not, here are the headlines:
- Pediatricians should screen children for possible mental health issues at every doctor visit
- Pediatricians should develop a network of mental-health professionals in the community to whom they can send patients if they suspect a child needs further evaluation
Given that an estimated 21% of US children and adolescents have a diagnosable mental illness, with only one-fifth receiving treatment, I see these recommendations as long overdue. We know that the earlier we intervene in mental health issues, the greater the benefit; screening kids every time you see them provides many more such opportunities for early intervention.
So how do you add one more thing to an office visit?
As with so many things we do, it requires asking the right questions and looking for clues.
For very young children, you'll obviously need to ask the parent or guardian questions about the child, particularly about their recent behavior. Key clues that children may be struggling with anxiety, for instance, include stomach problems, acting out, or becoming withdrawn. Clues to depression include increased irritability and/or lack of interest in activities the child previously enjoyed.
Kids who are acting out are, most likely, expressing an outward clue to an underlying emotional problem. For instance, if a child is bullying a sibling, he may be getting bullied himself at school.
One way to get at issues with older children is to ask if they are feeling happy, mad, sad, or scared. Even adolescents will give you a specific answer to this question, which helps them categorize how they're feeling. This then opens the door for more discussion.
It is also important to recognize that anxiety and depression in children do not necessarily manifest the same as in adult. A depressed child may not be sad, but irritable and angry. A child who appears withdrawn or, as noted earlier, is acting out may have some anxiety issues.
If you suspect depression, it is also important that you assess suicidality. Just ask the question: "Have you thought about hurting yourself?" Kids are generally inclined to give an honest answer. And the question will not make the child think about suicide; we have years of data showing that asking about suicide doesn't trigger the act.
In many instances, you may be able to assess and treat the child yourself. But if you feel that the child's condition is creating a dysfunction in their life, such as affecting school performance and friendships, or if you simply don't feel comfortable dealing with such issues, you should refer.
Check out the June supplement. It includes an algorithm for assessment; sources for specialty services; and an overview of evidence-based interventions. There is even an article on proper coding for the mental health algorithm.
You might also be interested in this recent article from the Wall Street Journal about the issue of mental health problems in adolescents.
How do you screen your kids for mental health issues? What questions do you have for me on this topic?
Steven L. Pastyrnak, PhD, is the division chief of psychology services at Helen DeVos Children's Hospital in Grand Rapids, Michigan.
|Monday, June 21, 2010
|AAP Changes Swim Lessons Recommendation
|by Pediatric Perspectives at 12:58 PM
Daniel McGee, MD
Pediatric Hospitalist, Helen DeVos Children's Hospital
Just in time for summer, the American Academy of Pediatrics announced new guidelines related to swimming lessons. The headline: Swimming lessons for children between ages 1 and 4 are now recommended. Previously, the AAP discouraged teaching children under 4 to swim.
I say it's about time. As the father of two children, both of whom were competitive swimmers (one of my sons was swimming competitively at age 4) I've seen firsthand the benefits of teaching children early to swim. But don't go by my anecdotal evidence; consider the same evidence the AAP Committee on Injury, Violence and Poison Prevention reviewed in making its recommendation. Namely, that better swimming ability is associated with a reduced risk of drowning (citations below).
While your patients' parents have likely heard about the new guidelines (they received wide distribution on TV, in print, and on the Internet) make sure they understand that swimming lessons is no substitute for good parenting. Remind them of other precautions they should take, including:
Install a four-foot high, locked fence around all pools, even above-ground pools and large inflatable pools that remain filled. Studies find such fences can slash the number of pool-related drownings and other injuries by more than half. Although pool alarms are helpful, they are not a substitute for supervising your child or for a full barrier around the poo, neither are pool covers.
Remove all containers of standing water. A child can drown in as little as 2 inches of water. We recently had a 20-month-old stick his head in the bucket of water older kids had put out for filling squirt guns.
Never take your eyes off your child when he/she is swimming, no matter how good a swimmer you think they are. I also don't recommend relying on the lifeguard unless you know what level of training and certification he/she has received.
Never let children, even teenagers, swim alone.
Make sure all children in boats wear a flotation device. Ninety percent of boat-related drownings occur in children who did not wear such devices.
Be particularly vigilant if your child has an underlying medical condition, such as seizure disorder, which can increase the risk of drowning.
Daniel McGee, MD, is a pediatric hospitalist at Helen DeVos Children's Hospital in Grand Rapids, Michigan.
Smith GS. Drowning prevention in children: the need for new strategies. Inj Prev. 1995; 1(4):216 -217
Brenner R, Suluja G, Smith GS. Swimming lessons, swimming ability, and the risk of drowning. Inj Control Saf Promot. 2003;10(4):211-216
Rodgers GB. Factors contributing to child drownings and near-drownings in residential swimming pools. Hum Factors. 1989;31(2):123-132
Brenner R, Taneja G, Haynie D, et al. The association between swimming lessons and drowning in childhood: a case-control study. Arch Pediatr Adolesc Med. 2009; 163(3):203-210
US Coast Guard. Recreational Boating Statistics 2008. Washington, DC: US Coast Guard; 2009. COMDTPUB P16754.21. Available at: www.safeboatingcampaign.com/
2008_statistics.pdf. Accessed May 13, 2010
Diekema DS, Quan L, Holt VL. Epilepsy as a risk factor for submersion injury in children. Pediatrics. 1993;91(3):612- 616
Kemp AM, Sibert JR. Epilepsy in children and the risk of drowning. Arch Dis Child. 1993; 68(5):684-685
Shavelle RM, Strauss DJ, Pickett J. Causes of death in autism. J Autism Dev Disord. 2001; 31(6):569 -576
|Monday, June 14, 2010
|When the Going Gets Tough: Managing Pediatric Constipation
|by Pediatric Perspectives at 01:28 PM
Deborah Cloney, MD
Helen DeVos Children's Hospital
Constipation is one of the most common complaints seen in pediatric practices and no, it's not your imagination-you really are seeing more of it. A recent analysis from the National Ambulatory Medical Care Survey (NAMCS) found the rate of ambulatory visits for constipation in children 0-14 years of age increased from 16.2 per 1,000 population during 1993-1996 to nearly 40 per 1,000 population during 2001-2004. As a result patient visits to pediatricians for constipation have nearly doubled, from 12.8% of all visits during 1993-1996 to nearly 21% during 2001-2004.
Which begs the question: What is the best way to treat constipation in children?
Start by asking the right questions.
What are you bowel movements like?
How often are you having one?
How big is it?
How firm is it?
Does it hurt?
Then listen for clues. Children may not always present with large, hard, painful bowel movements. Instead, they might complain of abdominal pain or, in some cases, of diarrhea because stool has leaked around an impaction. If a child says she's only going every five days and has to flush the toilet twice, then constipation is probably the problem. It's time for a rectal exam, particularly for overweight children in whom it may be difficult to feel a fecal mass with abdominal palpation.
Also remember that what's "normal" for a child depends on the child. Most children pass a bowel movement somewhere between three and four times a day and once every three or four days. The key is determining the normal pattern for that child, and any significant deviation from that pattern.
Before referring for a GI consultation, try following:
- Prescribe large doses of stool softeners. The standard dose of stool softener often has no affect on a child with impacted bowels. They need a 'cleanout' to flush out their system. Try a double dose (17 g bid) of polyethylene glycol (MiraLax, GlycoLax, etc) for two or three days until the child has a bowel movement. Adding mineral oil during the cleanout (1 ounce per year of age divided tid, maximum 9 ounces/day) can also help (suggest mixing it with yogurt, pudding or a milkshake to improve palatability). Once the child has a bowel movement, titrate down to the maintenance dose.
- Give the full maintenance dose. Too often, parents try to reduce the dose on their own once their child begins stooling. Then the constipation returns. Remind parents that the goal is to have pain-free bowel movements at least every two to three days with stool that resembles "mashed potatoes."
- Continue the stool softener for three to six months. Remember that the child wasn't constipated for only two days. Often, it has been weeks or even months. In toddlers, the pain associated with bowel movements quickly becomes a control issue. Once they recognize that a bowel movement hurts, they refuse to have one. So it's important to keep it soft long enough so they forget that it was painful. Another reason to continue the medication for months is that a child who has been chronically constipated may have developed a dilated rectum and colon, which makes it easier to hold stool. This may require weeks or even months to normalize. Weaning the stool softener slowly (over four to eight weeks) is appropriate.
- Support the family. Consider providing the parents with guidelines to adjust the stool softener if it's not working and ask them to call if the child gets diarrhea or isn't improving. A good protocol is to schedule a follow-up visit one month after beginning the cleanout regimen or in three months if the child was less constipated. It's important to make sure the child is well-regulated before reducing the stool softener.
- Explain the basics to the parents. That means nutritional information on the importance of a high-fiber diet and fluid, and, if the family needs additional support, referral to a dietician. It is also important that parents learn the importance of regular toilet time and train the child to sit on the toilet twice a day for 5 minutes at a time. If the child has any encopresis, it is important to stress the importance of good hygiene, including baths, to reduce the risk of skin breakdown.
So when should you refer to a specialist? If the child is vomiting along with constipation, has an apparent obstruction, or has a very early history of constipation, such as a newborn that has not passed meconium, consider referral. Other issues that warrant referral include genital abnormalities, suspicion of Hirschsprung's disease, and failure-to-thrive comorbid with constipation. Or when an attempted cleanout and aggressive use of stool softener hasn't worked and you feel you've hit the wall.
Tell us about your own experiences with constipation in infants and children. (Click "Add Comment" below.)
Deborah Cloney, MD, is a pediatric gastroenterologist with Helen DeVos Children's Hospital in Grand Rapids, Michigan.
Shah ND, Chitkara DK, Locke GR, Meek PD, Talley NJ.Ambulatory Care for Constipation in the United States, 1993-2004. Am J Gastroenterol. 2008 Jun 12.