Melinda Tanzola

MIAMI — The first goal of treatment in patellofemoral pain syndrome is to reduce and eventually discontinue NSAIDs, Dr. Joseph Congeni said at a meeting on pediatric sports medicine sponsored by the American Academy of Pediatrics.

Patellofemoral pain syndrome is the most common sports-related overuse injury in young athletes, occurring at least once in an estimated 30%–40% of female athletes. Also known as runner's knee, the syndrome is usually caused by improper tracking of the kneecap in the patellofemoral groove. Instead of riding smoothly in the groove, the malaligned patella is shifted, a condition that causes pain and inflammation. A few cases result from compression of the kneecap, which can develop if the hamstring muscle is significantly stronger than the quadriceps, a situation seen in younger children who have just gone through their growth spurt or teenage boys.

The incidence of tracking PFS is about five times greater in girls than in boys. Several anatomical factors contribute to PFS, including femoral anteversion, kneecaps pointing toward each other (“squinting patella”), genu varum (bowleg), and tibia varum. The feet compensate for the malalignment by pronating, and these factors together result in the pain associated with PFS.

In many cases of PFS, a lateral-view x-ray will show that the kneecap rides high (patella alta). “When the kneecap rides this high, it's not as deep a groove and the kneecap tends to slide in and out of that groove readily,” said Dr. Congeni, medical director of the sports medicine center at the Children's Hospital Medical Center of Akron (Ohio). Children with tracking PFS present with pain around the knee that emerges without any specific injury. They may or may not have swelling around the kneecap. Clinicians may see that the patella tracks in a “J” pattern when the leg is extended, because the patella moves inward as it moves up along the knee. Increased ligament laxity or instability also is common.

The functional tests of a minisquat and a catcher's squat, which will likely be painful in PFS, can help in the diagnosis.

Aside from having a thorough patellar exam, athletes with suspected PFS should undergo a full structural exam—including a careful examination of the hip—to rule out a slipped capital femoral epiphysis (SCFE). Dr. Congeni recommended, at the very least, clinical evaluation of the internal and external rotation of the hip in these children, as vague knee pain is one of the signs of SCFE. PFS is usually a straightforward clinical diagnosis based on history and physical exam, and does not require additional tests. Dr. Congeni recommended x-rays for children who do not improve after a month to rule out other causes and to assess the state of the kneecap.

Dr. Congeni explained that the clinical course of PFS is likely to be a roller coaster of good and bad days, weeks, or months, as activity levels change. Sitting for long periods and walking on stairs or hills can aggravate symptoms.

Treating PFS is a slow process that involves rest and rehabilitation through strengthening (quadriceps and gluteals) and increasing flexibility (quadriceps, hamstrings, and iliotibial band).

Orthotics can be more helpful than bracing for correcting mechanical issues, he said. Chronic self-medication with over-the-counter NSAIDs is common.

MIAMI — The first goal of treatment in patellofemoral pain syndrome is to reduce and eventually discontinue NSAIDs, Dr. Joseph Congeni said at a meeting on pediatric sports medicine sponsored by the American Academy of Pediatrics.

Patellofemoral pain syndrome is the most common sports-related overuse injury in young athletes, occurring at least once in an estimated 30%–40% of female athletes. Also known as runner's knee, the syndrome is usually caused by improper tracking of the kneecap in the patellofemoral groove. Instead of riding smoothly in the groove, the malaligned patella is shifted, a condition that causes pain and inflammation. A few cases result from compression of the kneecap, which can develop if the hamstring muscle is significantly stronger than the quadriceps, a situation seen in younger children who have just gone through their growth spurt or teenage boys.

The incidence of tracking PFS is about five times greater in girls than in boys. Several anatomical factors contribute to PFS, including femoral anteversion, kneecaps pointing toward each other (“squinting patella”), genu varum (bowleg), and tibia varum. The feet compensate for the malalignment by pronating, and these factors together result in the pain associated with PFS.

In many cases of PFS, a lateral-view x-ray will show that the kneecap rides high (patella alta). “When the kneecap rides this high, it's not as deep a groove and the kneecap tends to slide in and out of that groove readily,” said Dr. Congeni, medical director of the sports medicine center at the Children's Hospital Medical Center of Akron (Ohio). Children with tracking PFS present with pain around the knee that emerges without any specific injury. They may or may not have swelling around the kneecap. Clinicians may see that the patella tracks in a “J” pattern when the leg is extended, because the patella moves inward as it moves up along the knee. Increased ligament laxity or instability also is common.

The functional tests of a minisquat and a catcher's squat, which will likely be painful in PFS, can help in the diagnosis.

Aside from having a thorough patellar exam, athletes with suspected PFS should undergo a full structural exam—including a careful examination of the hip—to rule out a slipped capital femoral epiphysis (SCFE). Dr. Congeni recommended, at the very least, clinical evaluation of the internal and external rotation of the hip in these children, as vague knee pain is one of the signs of SCFE. PFS is usually a straightforward clinical diagnosis based on history and physical exam, and does not require additional tests. Dr. Congeni recommended x-rays for children who do not improve after a month to rule out other causes and to assess the state of the kneecap.

Dr. Congeni explained that the clinical course of PFS is likely to be a roller coaster of good and bad days, weeks, or months, as activity levels change. Sitting for long periods and walking on stairs or hills can aggravate symptoms.

Treating PFS is a slow process that involves rest and rehabilitation through strengthening (quadriceps and gluteals) and increasing flexibility (quadriceps, hamstrings, and iliotibial band).

Orthotics can be more helpful than bracing for correcting mechanical issues, he said. Chronic self-medication with over-the-counter NSAIDs is common.

MIAMI — The first goal of treatment in patellofemoral pain syndrome is to reduce and eventually discontinue NSAIDs, Dr. Joseph Congeni said at a meeting on pediatric sports medicine sponsored by the American Academy of Pediatrics.

Patellofemoral pain syndrome is the most common sports-related overuse injury in young athletes, occurring at least once in an estimated 30%–40% of female athletes. Also known as runner's knee, the syndrome is usually caused by improper tracking of the kneecap in the patellofemoral groove. Instead of riding smoothly in the groove, the malaligned patella is shifted, a condition that causes pain and inflammation. A few cases result from compression of the kneecap, which can develop if the hamstring muscle is significantly stronger than the quadriceps, a situation seen in younger children who have just gone through their growth spurt or teenage boys.

The incidence of tracking PFS is about five times greater in girls than in boys. Several anatomical factors contribute to PFS, including femoral anteversion, kneecaps pointing toward each other (“squinting patella”), genu varum (bowleg), and tibia varum. The feet compensate for the malalignment by pronating, and these factors together result in the pain associated with PFS.

In many cases of PFS, a lateral-view x-ray will show that the kneecap rides high (patella alta). “When the kneecap rides this high, it's not as deep a groove and the kneecap tends to slide in and out of that groove readily,” said Dr. Congeni, medical director of the sports medicine center at the Children's Hospital Medical Center of Akron (Ohio). Children with tracking PFS present with pain around the knee that emerges without any specific injury. They may or may not have swelling around the kneecap. Clinicians may see that the patella tracks in a “J” pattern when the leg is extended, because the patella moves inward as it moves up along the knee. Increased ligament laxity or instability also is common.

The functional tests of a minisquat and a catcher's squat, which will likely be painful in PFS, can help in the diagnosis.

Aside from having a thorough patellar exam, athletes with suspected PFS should undergo a full structural exam—including a careful examination of the hip—to rule out a slipped capital femoral epiphysis (SCFE). Dr. Congeni recommended, at the very least, clinical evaluation of the internal and external rotation of the hip in these children, as vague knee pain is one of the signs of SCFE. PFS is usually a straightforward clinical diagnosis based on history and physical exam, and does not require additional tests. Dr. Congeni recommended x-rays for children who do not improve after a month to rule out other causes and to assess the state of the kneecap.

Dr. Congeni explained that the clinical course of PFS is likely to be a roller coaster of good and bad days, weeks, or months, as activity levels change. Sitting for long periods and walking on stairs or hills can aggravate symptoms.

Treating PFS is a slow process that involves rest and rehabilitation through strengthening (quadriceps and gluteals) and increasing flexibility (quadriceps, hamstrings, and iliotibial band).

Orthotics can be more helpful than bracing for correcting mechanical issues, he said. Chronic self-medication with over-the-counter NSAIDs is common.

Interferon alfa-2a appears to provide some benefit as a second-line treatment for uveitis in patients who relapse after treatment with corticosteroids and immunosuppressants, according to a study published online on October 18 in the British Journal of Ophthalmology.

Among 45 patients (median age, 32 years), 19 of 23 patients with Behçet's disease (BD) and 13 of 22 patients with other conditions achieved control of their uveitis with interferon therapy during a median follow-up of 30 months, wrote Dr. Bahram Bodaghi and colleagues in their report (Br. J. Ophthalmol. DOI:10.1136/bjo.2006.101550).

In the retrospective, single-center study, patients received subcutaneous interferon alfa-2a at 3 million U three times/week, with intravenous pulses of methylprednisolone, followed by oral prednisone. Oral acetaminophen was administered to prevent interferon-associated side effects.

Patients continued on interferon until they had been in complete remission for at least 9 months, according to Dr. Bodaghi and colleagues at the University of Paris.

Overall, 10 patients with BD and 4 patients without BD discontinued interferon; of these, 4 patients with BD and 1 patient without BD had subsequent relapses.

All five of these patients responded to reintroduction of interferon with an initially increased steroid dose.

Multiple relapses occurred in four patients with BD and one patient without BD during treatment, indicating that the treatment was not effective in these patients.

The median oral prednisone threshold, which reflects the dose that leads to relapse during tapering, decreased significantly from 23.6 mg/day at baseline to 10 mg/day at the end of the period of follow-up.

The most common side effect was a flu-like syndrome at treatment initiation.

Two patients had major side effects from interferon treatment, including one case of severe depression requiring treatment discontinuation and one case of major neutropenia requiring temporary interruption.

The authors concluded that controlled studies are needed to further investigate the optimal dose and duration of interferon treatment in patients with uveitis.

Interferon alfa-2a appears to provide some benefit as a second-line treatment for uveitis in patients who relapse after treatment with corticosteroids and immunosuppressants, according to a study published online on October 18 in the British Journal of Ophthalmology.

Among 45 patients (median age, 32 years), 19 of 23 patients with Behçet's disease (BD) and 13 of 22 patients with other conditions achieved control of their uveitis with interferon therapy during a median follow-up of 30 months, wrote Dr. Bahram Bodaghi and colleagues in their report (Br. J. Ophthalmol. DOI:10.1136/bjo.2006.101550).

In the retrospective, single-center study, patients received subcutaneous interferon alfa-2a at 3 million U three times/week, with intravenous pulses of methylprednisolone, followed by oral prednisone. Oral acetaminophen was administered to prevent interferon-associated side effects.

Patients continued on interferon until they had been in complete remission for at least 9 months, according to Dr. Bodaghi and colleagues at the University of Paris.

Overall, 10 patients with BD and 4 patients without BD discontinued interferon; of these, 4 patients with BD and 1 patient without BD had subsequent relapses.

All five of these patients responded to reintroduction of interferon with an initially increased steroid dose.

Multiple relapses occurred in four patients with BD and one patient without BD during treatment, indicating that the treatment was not effective in these patients.

The median oral prednisone threshold, which reflects the dose that leads to relapse during tapering, decreased significantly from 23.6 mg/day at baseline to 10 mg/day at the end of the period of follow-up.

The most common side effect was a flu-like syndrome at treatment initiation.

Two patients had major side effects from interferon treatment, including one case of severe depression requiring treatment discontinuation and one case of major neutropenia requiring temporary interruption.

The authors concluded that controlled studies are needed to further investigate the optimal dose and duration of interferon treatment in patients with uveitis.

Interferon alfa-2a appears to provide some benefit as a second-line treatment for uveitis in patients who relapse after treatment with corticosteroids and immunosuppressants, according to a study published online on October 18 in the British Journal of Ophthalmology.

Among 45 patients (median age, 32 years), 19 of 23 patients with Behçet's disease (BD) and 13 of 22 patients with other conditions achieved control of their uveitis with interferon therapy during a median follow-up of 30 months, wrote Dr. Bahram Bodaghi and colleagues in their report (Br. J. Ophthalmol. DOI:10.1136/bjo.2006.101550).

In the retrospective, single-center study, patients received subcutaneous interferon alfa-2a at 3 million U three times/week, with intravenous pulses of methylprednisolone, followed by oral prednisone. Oral acetaminophen was administered to prevent interferon-associated side effects.

Patients continued on interferon until they had been in complete remission for at least 9 months, according to Dr. Bodaghi and colleagues at the University of Paris.

Overall, 10 patients with BD and 4 patients without BD discontinued interferon; of these, 4 patients with BD and 1 patient without BD had subsequent relapses.

All five of these patients responded to reintroduction of interferon with an initially increased steroid dose.

Multiple relapses occurred in four patients with BD and one patient without BD during treatment, indicating that the treatment was not effective in these patients.

The median oral prednisone threshold, which reflects the dose that leads to relapse during tapering, decreased significantly from 23.6 mg/day at baseline to 10 mg/day at the end of the period of follow-up.

The most common side effect was a flu-like syndrome at treatment initiation.

Two patients had major side effects from interferon treatment, including one case of severe depression requiring treatment discontinuation and one case of major neutropenia requiring temporary interruption.

The authors concluded that controlled studies are needed to further investigate the optimal dose and duration of interferon treatment in patients with uveitis.

ATLANTA — Several strategies have been shown to increase vaccination coverage in children, Dr. Jeanne M. Santoli said at a meeting on clinical vaccinology sponsored by the National Foundation for Infectious Diseases.

Five interventions have been recommended by the Task Force on Community Preventive Services on the basis of strong evidence of their effectiveness in increasing vaccination rates (Am. J. Prev. Med. 2000;18[1 Suppl.]:97–140).

One of these strategies that clinicians may be able to implement in practice is a client reminder-recall system, in which families are informed by mail or by telephone that the child is due or overdue for a vaccination.

A 1999 study involving 2,000 children younger than age 2 showed that immunization rates increased 20% by the end of a reminder, recall, and outreach immunization program (Pediatrics 1999;103:31–8). The researchers observed spillover benefits of the program, including an 11% increase in preventive visits, a 12% increase in anemia screening, and an 8% increase in lead screening.

“Despite this proven benefit [of recall systems], the use of this strategy is not nearly what we might hope,” said Dr. Santoli, deputy director of the Immunization Services Division for the National Center for Immunization and Respiratory Diseases, a part of the Centers for Disease Control and Prevention. Self-reported use of recall systems by pediatricians remains low, at less than 25% across multiple studies.

Providers might not see the need for such systems, she said, because most tend to overestimate vaccination coverage in their practices. Variations in the degree of computerization and the organization of medical records also can affect the feasibility of implementing such a program.

Out-of-pocket cost reductions are other interventions with strong evidence to back them. Dr. Santoli said the cost to fully vaccinate children, with fees calculated based on federal vaccine contracts, has increased dramatically, from $45 in 1985 to $894 in 2006. The addition of the human papillomavirus vaccine would bring the total cost up to $1,182, not including vaccine administration fees.

The CDC's Vaccines for Children program is a comprehensive intervention for reducing costs, under which providers receive vaccine replacements to immunize eligible children. Dr. Santoli estimated that 40 million children in the United States under the age of 18 are eligible for the program. Studies of program participation suggest that “the program is reaching the children that it was intended to serve,” she noted at the meeting, which was also sponsored by Emory University.

Other interventions recommended on the basis of strong evidence include provider reminder-recall systems and assessment, feedback for providers, and multicomponent interventions.

Interventions with “sufficient” evidence include vaccination requirements for child care, school, and college; school vaccination programs (when focused on new vaccines); vaccination programs in Women, Infants, and Children settings; and home visits. “When there are state requirements [for entry into school] and when they are enforced, they can have an important impact on vaccination rates,” Dr. Santoli said.

Other interventions have not demonstrated sufficient increases in vaccine coverage: education-only programs, vaccination programs in child care centers, family incentives, and client-held medical records.

It also is important to keep barriers to vaccination in mind. Parental attitudes, provider attitudes, and access to care were previously considered the primary barriers, said Dr. Santoli. However, the literature indicates that socioeconomic factors, a late start on vaccinations, an information gap, provider practices, and clinic factors are the key barriers. By addressing these barriers with proven interventions, clinicians may be able to improve vaccination rates in their own practices.

ATLANTA — Several strategies have been shown to increase vaccination coverage in children, Dr. Jeanne M. Santoli said at a meeting on clinical vaccinology sponsored by the National Foundation for Infectious Diseases.

Five interventions have been recommended by the Task Force on Community Preventive Services on the basis of strong evidence of their effectiveness in increasing vaccination rates (Am. J. Prev. Med. 2000;18[1 Suppl.]:97–140).

One of these strategies that clinicians may be able to implement in practice is a client reminder-recall system, in which families are informed by mail or by telephone that the child is due or overdue for a vaccination.

A 1999 study involving 2,000 children younger than age 2 showed that immunization rates increased 20% by the end of a reminder, recall, and outreach immunization program (Pediatrics 1999;103:31–8). The researchers observed spillover benefits of the program, including an 11% increase in preventive visits, a 12% increase in anemia screening, and an 8% increase in lead screening.

“Despite this proven benefit [of recall systems], the use of this strategy is not nearly what we might hope,” said Dr. Santoli, deputy director of the Immunization Services Division for the National Center for Immunization and Respiratory Diseases, a part of the Centers for Disease Control and Prevention. Self-reported use of recall systems by pediatricians remains low, at less than 25% across multiple studies.

Providers might not see the need for such systems, she said, because most tend to overestimate vaccination coverage in their practices. Variations in the degree of computerization and the organization of medical records also can affect the feasibility of implementing such a program.

Out-of-pocket cost reductions are other interventions with strong evidence to back them. Dr. Santoli said the cost to fully vaccinate children, with fees calculated based on federal vaccine contracts, has increased dramatically, from $45 in 1985 to $894 in 2006. The addition of the human papillomavirus vaccine would bring the total cost up to $1,182, not including vaccine administration fees.

The CDC's Vaccines for Children program is a comprehensive intervention for reducing costs, under which providers receive vaccine replacements to immunize eligible children. Dr. Santoli estimated that 40 million children in the United States under the age of 18 are eligible for the program. Studies of program participation suggest that “the program is reaching the children that it was intended to serve,” she noted at the meeting, which was also sponsored by Emory University.

Other interventions recommended on the basis of strong evidence include provider reminder-recall systems and assessment, feedback for providers, and multicomponent interventions.

Interventions with “sufficient” evidence include vaccination requirements for child care, school, and college; school vaccination programs (when focused on new vaccines); vaccination programs in Women, Infants, and Children settings; and home visits. “When there are state requirements [for entry into school] and when they are enforced, they can have an important impact on vaccination rates,” Dr. Santoli said.

Other interventions have not demonstrated sufficient increases in vaccine coverage: education-only programs, vaccination programs in child care centers, family incentives, and client-held medical records.

It also is important to keep barriers to vaccination in mind. Parental attitudes, provider attitudes, and access to care were previously considered the primary barriers, said Dr. Santoli. However, the literature indicates that socioeconomic factors, a late start on vaccinations, an information gap, provider practices, and clinic factors are the key barriers. By addressing these barriers with proven interventions, clinicians may be able to improve vaccination rates in their own practices.

ATLANTA — Several strategies have been shown to increase vaccination coverage in children, Dr. Jeanne M. Santoli said at a meeting on clinical vaccinology sponsored by the National Foundation for Infectious Diseases.

Five interventions have been recommended by the Task Force on Community Preventive Services on the basis of strong evidence of their effectiveness in increasing vaccination rates (Am. J. Prev. Med. 2000;18[1 Suppl.]:97–140).

One of these strategies that clinicians may be able to implement in practice is a client reminder-recall system, in which families are informed by mail or by telephone that the child is due or overdue for a vaccination.

A 1999 study involving 2,000 children younger than age 2 showed that immunization rates increased 20% by the end of a reminder, recall, and outreach immunization program (Pediatrics 1999;103:31–8). The researchers observed spillover benefits of the program, including an 11% increase in preventive visits, a 12% increase in anemia screening, and an 8% increase in lead screening.

“Despite this proven benefit [of recall systems], the use of this strategy is not nearly what we might hope,” said Dr. Santoli, deputy director of the Immunization Services Division for the National Center for Immunization and Respiratory Diseases, a part of the Centers for Disease Control and Prevention. Self-reported use of recall systems by pediatricians remains low, at less than 25% across multiple studies.

Providers might not see the need for such systems, she said, because most tend to overestimate vaccination coverage in their practices. Variations in the degree of computerization and the organization of medical records also can affect the feasibility of implementing such a program.

Out-of-pocket cost reductions are other interventions with strong evidence to back them. Dr. Santoli said the cost to fully vaccinate children, with fees calculated based on federal vaccine contracts, has increased dramatically, from $45 in 1985 to $894 in 2006. The addition of the human papillomavirus vaccine would bring the total cost up to $1,182, not including vaccine administration fees.

The CDC's Vaccines for Children program is a comprehensive intervention for reducing costs, under which providers receive vaccine replacements to immunize eligible children. Dr. Santoli estimated that 40 million children in the United States under the age of 18 are eligible for the program. Studies of program participation suggest that “the program is reaching the children that it was intended to serve,” she noted at the meeting, which was also sponsored by Emory University.

Other interventions recommended on the basis of strong evidence include provider reminder-recall systems and assessment, feedback for providers, and multicomponent interventions.

Interventions with “sufficient” evidence include vaccination requirements for child care, school, and college; school vaccination programs (when focused on new vaccines); vaccination programs in Women, Infants, and Children settings; and home visits. “When there are state requirements [for entry into school] and when they are enforced, they can have an important impact on vaccination rates,” Dr. Santoli said.

Other interventions have not demonstrated sufficient increases in vaccine coverage: education-only programs, vaccination programs in child care centers, family incentives, and client-held medical records.

It also is important to keep barriers to vaccination in mind. Parental attitudes, provider attitudes, and access to care were previously considered the primary barriers, said Dr. Santoli. However, the literature indicates that socioeconomic factors, a late start on vaccinations, an information gap, provider practices, and clinic factors are the key barriers. By addressing these barriers with proven interventions, clinicians may be able to improve vaccination rates in their own practices.

ATLANTA — Providing the influenza vaccine to as many eligible schoolchildren as possible might reduce the burden of influenza in the entire community, Dr. Kathleen M. Neuzil said at a meeting on clinical vaccinology sponsored by the National Foundation for Infectious Diseases.

The current risk-based recommendations for vaccination are complicated, said Dr. Neuzil, with 12 influenza vaccination target groups currently identified by the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP). Adults may have a difficult time determining whether they are at high risk. Alternative strategies have been evaluated as a way to increase vaccination coverage.

Dr. Neuzil explained that while older adults are most likely to develop complications from influenza, children aged 5–14 years are the group most likely to have clinical disease.

In fact, absenteeism from school is the first marker of an influenza epidemic, and a 10% absenteeism rate is an effective marker for an epidemic (N. Engl. J. Med. 1987;298:587–92).

Given this epidemiology, several studies have investigated vaccinating all schoolchildren as a mechanism for protecting the whole community from influenza.

Starting in 1962, Japan vaccinated most children against influenza. The vaccination program was associated with a decrease in excess mortality, and when the program was discontinued in 1987, mortality increased (N. Engl. J. Med. 2001;344:889–96).

A schoolchild vaccination study involving 28 schools in the United States found a reduced influenza burden during the peak influenza week in the households of the 2,717 schoolchildren who received the live attenuated influenza vaccine during the 2004–2005 season, compared with children in control schools.

The results of the study, presented at the 2006 Pediatric Academic Society meeting, showed fewer episodes of influenza-like illnesses, fewer related physician visits, less frequent use of medications, and fewer school and work days missed in households of vaccinated children. Interestingly, 73% of children in the study were receiving influenza vaccine for the first time, indicating that the program was meeting an unmet need.

Between 30% and 56% of children in the target schools opted to receive the vaccination, with rates correlating with socioeconomic status.

This study “supports the theory that kids are integral in spreading flu,” commented Dr. Neuzil of the University of Washington in Seattle. She said that improving vaccination of existing target groups might be achieved through improved public awareness and provider education. The ACIP also is looking into establishing a universal vaccination recommendation, beginning with children.

At the meeting, which was also sponsored by Emory University, Dr. Katherine A. Poehling offered some additional suggestions for increasing influenza vaccinations in children. Providers should specifically recommend the vaccine to parents and educate them on when and why to vaccinate.

She told the story of a local practice that mentions the vaccine at three different points during a visit. They report that it's very hard to refuse after being told the same information three times, said Dr. Poehling of the Monroe Carell Jr. Children's Hospital at Vanderbilt University, Nashville, Tenn.

Dr. Poehling also suggested that clinicians educate parents about influenza vaccine throughout the year, because not all children will have a well-child visit between October and January.

Steps also should be taken to enhance access to the vaccine, such as reducing out-of-pocket costs and vaccinating children at all visits.

Walk-in clinics or flu shot clinics also can improve access, although the best strategies for each practice may vary.

ATLANTA — Providing the influenza vaccine to as many eligible schoolchildren as possible might reduce the burden of influenza in the entire community, Dr. Kathleen M. Neuzil said at a meeting on clinical vaccinology sponsored by the National Foundation for Infectious Diseases.

The current risk-based recommendations for vaccination are complicated, said Dr. Neuzil, with 12 influenza vaccination target groups currently identified by the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP). Adults may have a difficult time determining whether they are at high risk. Alternative strategies have been evaluated as a way to increase vaccination coverage.

Dr. Neuzil explained that while older adults are most likely to develop complications from influenza, children aged 5–14 years are the group most likely to have clinical disease.

In fact, absenteeism from school is the first marker of an influenza epidemic, and a 10% absenteeism rate is an effective marker for an epidemic (N. Engl. J. Med. 1987;298:587–92).

Given this epidemiology, several studies have investigated vaccinating all schoolchildren as a mechanism for protecting the whole community from influenza.

Starting in 1962, Japan vaccinated most children against influenza. The vaccination program was associated with a decrease in excess mortality, and when the program was discontinued in 1987, mortality increased (N. Engl. J. Med. 2001;344:889–96).

A schoolchild vaccination study involving 28 schools in the United States found a reduced influenza burden during the peak influenza week in the households of the 2,717 schoolchildren who received the live attenuated influenza vaccine during the 2004–2005 season, compared with children in control schools.

The results of the study, presented at the 2006 Pediatric Academic Society meeting, showed fewer episodes of influenza-like illnesses, fewer related physician visits, less frequent use of medications, and fewer school and work days missed in households of vaccinated children. Interestingly, 73% of children in the study were receiving influenza vaccine for the first time, indicating that the program was meeting an unmet need.

Between 30% and 56% of children in the target schools opted to receive the vaccination, with rates correlating with socioeconomic status.

This study “supports the theory that kids are integral in spreading flu,” commented Dr. Neuzil of the University of Washington in Seattle. She said that improving vaccination of existing target groups might be achieved through improved public awareness and provider education. The ACIP also is looking into establishing a universal vaccination recommendation, beginning with children.

At the meeting, which was also sponsored by Emory University, Dr. Katherine A. Poehling offered some additional suggestions for increasing influenza vaccinations in children. Providers should specifically recommend the vaccine to parents and educate them on when and why to vaccinate.

She told the story of a local practice that mentions the vaccine at three different points during a visit. They report that it's very hard to refuse after being told the same information three times, said Dr. Poehling of the Monroe Carell Jr. Children's Hospital at Vanderbilt University, Nashville, Tenn.

Dr. Poehling also suggested that clinicians educate parents about influenza vaccine throughout the year, because not all children will have a well-child visit between October and January.

Steps also should be taken to enhance access to the vaccine, such as reducing out-of-pocket costs and vaccinating children at all visits.

Walk-in clinics or flu shot clinics also can improve access, although the best strategies for each practice may vary.

ATLANTA — Providing the influenza vaccine to as many eligible schoolchildren as possible might reduce the burden of influenza in the entire community, Dr. Kathleen M. Neuzil said at a meeting on clinical vaccinology sponsored by the National Foundation for Infectious Diseases.

The current risk-based recommendations for vaccination are complicated, said Dr. Neuzil, with 12 influenza vaccination target groups currently identified by the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP). Adults may have a difficult time determining whether they are at high risk. Alternative strategies have been evaluated as a way to increase vaccination coverage.

Dr. Neuzil explained that while older adults are most likely to develop complications from influenza, children aged 5–14 years are the group most likely to have clinical disease.

In fact, absenteeism from school is the first marker of an influenza epidemic, and a 10% absenteeism rate is an effective marker for an epidemic (N. Engl. J. Med. 1987;298:587–92).

Given this epidemiology, several studies have investigated vaccinating all schoolchildren as a mechanism for protecting the whole community from influenza.

Starting in 1962, Japan vaccinated most children against influenza. The vaccination program was associated with a decrease in excess mortality, and when the program was discontinued in 1987, mortality increased (N. Engl. J. Med. 2001;344:889–96).

A schoolchild vaccination study involving 28 schools in the United States found a reduced influenza burden during the peak influenza week in the households of the 2,717 schoolchildren who received the live attenuated influenza vaccine during the 2004–2005 season, compared with children in control schools.

The results of the study, presented at the 2006 Pediatric Academic Society meeting, showed fewer episodes of influenza-like illnesses, fewer related physician visits, less frequent use of medications, and fewer school and work days missed in households of vaccinated children. Interestingly, 73% of children in the study were receiving influenza vaccine for the first time, indicating that the program was meeting an unmet need.

Between 30% and 56% of children in the target schools opted to receive the vaccination, with rates correlating with socioeconomic status.

This study “supports the theory that kids are integral in spreading flu,” commented Dr. Neuzil of the University of Washington in Seattle. She said that improving vaccination of existing target groups might be achieved through improved public awareness and provider education. The ACIP also is looking into establishing a universal vaccination recommendation, beginning with children.

At the meeting, which was also sponsored by Emory University, Dr. Katherine A. Poehling offered some additional suggestions for increasing influenza vaccinations in children. Providers should specifically recommend the vaccine to parents and educate them on when and why to vaccinate.

She told the story of a local practice that mentions the vaccine at three different points during a visit. They report that it's very hard to refuse after being told the same information three times, said Dr. Poehling of the Monroe Carell Jr. Children's Hospital at Vanderbilt University, Nashville, Tenn.

Dr. Poehling also suggested that clinicians educate parents about influenza vaccine throughout the year, because not all children will have a well-child visit between October and January.

Steps also should be taken to enhance access to the vaccine, such as reducing out-of-pocket costs and vaccinating children at all visits.

Walk-in clinics or flu shot clinics also can improve access, although the best strategies for each practice may vary.

ATLANTA – Anxiety, depression, and pain are often overlooked in older cancer survivors, according to results of a study presented at the annual meeting of the American Society of Clinical Oncology.

In this study of 150 men who had been diagnosed with cancer an average of 3 years prior, pain, anxiety, and depression were common, occurring in 64%, 26%, and 21% of men, respectively, according to prospective analysis of responses to a questionnaire.

Despite the high frequency of these issues, in many cases, oncologists did not discuss pain and well-being with their patients. According to blinded chart reviews, oncologists did not inquire about pain in 22% of the men. Inquiries about mental health were more infrequent: 95% of men were not asked about anxiety, and 88% of men were not asked about depression.

Because of this failure to inquire about pain and mental health, a significant proportion of men with each condition was overlooked, including 18% of men with pain, 85% with anxiety, and 75% with depression.

In an interview during his poster presentation, Dr. Harvey Jay Cohen said this information is very relevant for primary care physicians. “People need to be aware that cancer survivors, older ones at least, not infrequently are anxious and showing signs of depression,” said Dr. Cohen, professor and interim chair in the department of medicine and director of the Center for the Study of Aging and Human Development at Duke University Medical Center in Durham, N.C. “That's something people at least need to inquire about.”

In the study, Dr. Cohen and his colleagues evaluated 153 male patients who visited a single oncology clinic at a Veterans Affairs Medical Center. The men filled out questionnaires reporting pain using the pain thermometer and mental health using the Hospital Anxiety and Depression Scale.

The patients averaged 68 years old, and 40% were African American. Most of the men (64%) were married, though 22% lived alone. They had, on average, about five comorbidities. The most common cancers involved were prostate (47%), head and neck (19%), and lung (12%).

A total of 147 men were evaluable for the pain component of the study, 128 for anxiety, and 136 for depression, based on the presence of responses to each segment of the evaluation and available chart information.

The investigators looked for any notes about mood, anxiety, depression, other psychological or psychiatric conditions, notes about treatment, and suggestions for psychiatric referrals in the chart. They analyzed a 3-month period of charts to rule out that they had not overlooked the appointment where the issues were discussed.

“We looked for anything that in the chart would've indicated that [the oncologist] had noticed anything–they said something, treated the patients–we took absolutely anything,” Dr. Cohen said.

ATLANTA – Anxiety, depression, and pain are often overlooked in older cancer survivors, according to results of a study presented at the annual meeting of the American Society of Clinical Oncology.

In this study of 150 men who had been diagnosed with cancer an average of 3 years prior, pain, anxiety, and depression were common, occurring in 64%, 26%, and 21% of men, respectively, according to prospective analysis of responses to a questionnaire.

Despite the high frequency of these issues, in many cases, oncologists did not discuss pain and well-being with their patients. According to blinded chart reviews, oncologists did not inquire about pain in 22% of the men. Inquiries about mental health were more infrequent: 95% of men were not asked about anxiety, and 88% of men were not asked about depression.

Because of this failure to inquire about pain and mental health, a significant proportion of men with each condition was overlooked, including 18% of men with pain, 85% with anxiety, and 75% with depression.

In an interview during his poster presentation, Dr. Harvey Jay Cohen said this information is very relevant for primary care physicians. “People need to be aware that cancer survivors, older ones at least, not infrequently are anxious and showing signs of depression,” said Dr. Cohen, professor and interim chair in the department of medicine and director of the Center for the Study of Aging and Human Development at Duke University Medical Center in Durham, N.C. “That's something people at least need to inquire about.”

In the study, Dr. Cohen and his colleagues evaluated 153 male patients who visited a single oncology clinic at a Veterans Affairs Medical Center. The men filled out questionnaires reporting pain using the pain thermometer and mental health using the Hospital Anxiety and Depression Scale.

The patients averaged 68 years old, and 40% were African American. Most of the men (64%) were married, though 22% lived alone. They had, on average, about five comorbidities. The most common cancers involved were prostate (47%), head and neck (19%), and lung (12%).

A total of 147 men were evaluable for the pain component of the study, 128 for anxiety, and 136 for depression, based on the presence of responses to each segment of the evaluation and available chart information.

The investigators looked for any notes about mood, anxiety, depression, other psychological or psychiatric conditions, notes about treatment, and suggestions for psychiatric referrals in the chart. They analyzed a 3-month period of charts to rule out that they had not overlooked the appointment where the issues were discussed.

“We looked for anything that in the chart would've indicated that [the oncologist] had noticed anything–they said something, treated the patients–we took absolutely anything,” Dr. Cohen said.

ATLANTA – Anxiety, depression, and pain are often overlooked in older cancer survivors, according to results of a study presented at the annual meeting of the American Society of Clinical Oncology.

In this study of 150 men who had been diagnosed with cancer an average of 3 years prior, pain, anxiety, and depression were common, occurring in 64%, 26%, and 21% of men, respectively, according to prospective analysis of responses to a questionnaire.

Despite the high frequency of these issues, in many cases, oncologists did not discuss pain and well-being with their patients. According to blinded chart reviews, oncologists did not inquire about pain in 22% of the men. Inquiries about mental health were more infrequent: 95% of men were not asked about anxiety, and 88% of men were not asked about depression.

Because of this failure to inquire about pain and mental health, a significant proportion of men with each condition was overlooked, including 18% of men with pain, 85% with anxiety, and 75% with depression.

In an interview during his poster presentation, Dr. Harvey Jay Cohen said this information is very relevant for primary care physicians. “People need to be aware that cancer survivors, older ones at least, not infrequently are anxious and showing signs of depression,” said Dr. Cohen, professor and interim chair in the department of medicine and director of the Center for the Study of Aging and Human Development at Duke University Medical Center in Durham, N.C. “That's something people at least need to inquire about.”

In the study, Dr. Cohen and his colleagues evaluated 153 male patients who visited a single oncology clinic at a Veterans Affairs Medical Center. The men filled out questionnaires reporting pain using the pain thermometer and mental health using the Hospital Anxiety and Depression Scale.

The patients averaged 68 years old, and 40% were African American. Most of the men (64%) were married, though 22% lived alone. They had, on average, about five comorbidities. The most common cancers involved were prostate (47%), head and neck (19%), and lung (12%).

A total of 147 men were evaluable for the pain component of the study, 128 for anxiety, and 136 for depression, based on the presence of responses to each segment of the evaluation and available chart information.

The investigators looked for any notes about mood, anxiety, depression, other psychological or psychiatric conditions, notes about treatment, and suggestions for psychiatric referrals in the chart. They analyzed a 3-month period of charts to rule out that they had not overlooked the appointment where the issues were discussed.

“We looked for anything that in the chart would've indicated that [the oncologist] had noticed anything–they said something, treated the patients–we took absolutely anything,” Dr. Cohen said.

Part of the problem with addressing bullying is that it is accepted as a normative behavior, Dr. Joseph L. Wright said at the annual meeting of the American Academy of Pediatrics.

“In the United States, we are quite behind the eight ball in terms of recognizing this problem,” he said.

The issue of bullying is gaining recognition with the recent increase in school-based violent events involving multiple victims. A Secret Service report on 37 such incidents confirms conventional wisdom on these incidents: “Most attackers felt bullied or persecuted and had engaged in behavior that worried others before the attack,” said Dr. Wright, executive director of Child Health Advocacy Institute at the Children's National Medical Center in Washington.

A 2003 study showed that children who were bullied often and those who frequently bullied others were more likely to carry a weapon or bring a weapon to school (Arch. Pediatr. Adolesc. Med. 2003;157:348–53). The effects of bullying increased with the frequency of bullying.

In this study of 15,686 children surveyed, those who reported being bullied weekly at school were about 50% more likely than other children to carry a weapon or to bring a weapon to school. Children being bullied weekly away from school were about four times more likely to carry a weapon or bring one to school. The highest incidence of weapon carrying was seen among youths who bullied others away from school on a weekly basis. These children were six times more likely than others to carry a weapon and five times more likely to bring a weapon to school.

Bullying behaviors differ between the sexes: Studies show that boys are more likely to carry out direct or physical bullying (pushing, slapping, punching, spitting, or tripping), and girls are more likely to carry out indirect bullying (threats, teasing, rumors, stealing or extortion, or shunning). But Dr. Wright pointed out the disturbing trend that girls are now engaging in more physical bullying.

Being bullied carries long-term risks. According to a study of 4,811 children in the Netherlands, bullied children are more likely to have depression and suicidal ideation, and this association is stronger for indirect rather than direct bullying (Pediatrics 2003;111:1312–17).

Among girls, frequent direct bullying increased the risk of depression and suicidal ideation by 3.3-fold and 2.6-fold, respectively, while frequent indirect bullying raised the risks by 8.9-fold and 3.6-fold, respectively.

Overall, 43% of all frequently directly bullied girls reported depression, compared with 6% of girls who were almost never directly bullied.

The effects of direct bullying on boys were not significant after controlling for confounding factors, although frequent indirect bullying in boys increased the risk of depression by 11-fold and the risk of suicidal ideation by 5.6-fold.

Dr. Wright urged physicians to engage with families of young children to help prevent the later development of bullying behavior.

'In the United States, we are quite behind the eight ball in terms of recognizing this problem.' DR. WRIGHT

Part of the problem with addressing bullying is that it is accepted as a normative behavior, Dr. Joseph L. Wright said at the annual meeting of the American Academy of Pediatrics.

“In the United States, we are quite behind the eight ball in terms of recognizing this problem,” he said.

The issue of bullying is gaining recognition with the recent increase in school-based violent events involving multiple victims. A Secret Service report on 37 such incidents confirms conventional wisdom on these incidents: “Most attackers felt bullied or persecuted and had engaged in behavior that worried others before the attack,” said Dr. Wright, executive director of Child Health Advocacy Institute at the Children's National Medical Center in Washington.

A 2003 study showed that children who were bullied often and those who frequently bullied others were more likely to carry a weapon or bring a weapon to school (Arch. Pediatr. Adolesc. Med. 2003;157:348–53). The effects of bullying increased with the frequency of bullying.

In this study of 15,686 children surveyed, those who reported being bullied weekly at school were about 50% more likely than other children to carry a weapon or to bring a weapon to school. Children being bullied weekly away from school were about four times more likely to carry a weapon or bring one to school. The highest incidence of weapon carrying was seen among youths who bullied others away from school on a weekly basis. These children were six times more likely than others to carry a weapon and five times more likely to bring a weapon to school.

Bullying behaviors differ between the sexes: Studies show that boys are more likely to carry out direct or physical bullying (pushing, slapping, punching, spitting, or tripping), and girls are more likely to carry out indirect bullying (threats, teasing, rumors, stealing or extortion, or shunning). But Dr. Wright pointed out the disturbing trend that girls are now engaging in more physical bullying.

Being bullied carries long-term risks. According to a study of 4,811 children in the Netherlands, bullied children are more likely to have depression and suicidal ideation, and this association is stronger for indirect rather than direct bullying (Pediatrics 2003;111:1312–17).

Among girls, frequent direct bullying increased the risk of depression and suicidal ideation by 3.3-fold and 2.6-fold, respectively, while frequent indirect bullying raised the risks by 8.9-fold and 3.6-fold, respectively.

Overall, 43% of all frequently directly bullied girls reported depression, compared with 6% of girls who were almost never directly bullied.

The effects of direct bullying on boys were not significant after controlling for confounding factors, although frequent indirect bullying in boys increased the risk of depression by 11-fold and the risk of suicidal ideation by 5.6-fold.

Dr. Wright urged physicians to engage with families of young children to help prevent the later development of bullying behavior.

'In the United States, we are quite behind the eight ball in terms of recognizing this problem.' DR. WRIGHT

Part of the problem with addressing bullying is that it is accepted as a normative behavior, Dr. Joseph L. Wright said at the annual meeting of the American Academy of Pediatrics.

“In the United States, we are quite behind the eight ball in terms of recognizing this problem,” he said.

The issue of bullying is gaining recognition with the recent increase in school-based violent events involving multiple victims. A Secret Service report on 37 such incidents confirms conventional wisdom on these incidents: “Most attackers felt bullied or persecuted and had engaged in behavior that worried others before the attack,” said Dr. Wright, executive director of Child Health Advocacy Institute at the Children's National Medical Center in Washington.

A 2003 study showed that children who were bullied often and those who frequently bullied others were more likely to carry a weapon or bring a weapon to school (Arch. Pediatr. Adolesc. Med. 2003;157:348–53). The effects of bullying increased with the frequency of bullying.

In this study of 15,686 children surveyed, those who reported being bullied weekly at school were about 50% more likely than other children to carry a weapon or to bring a weapon to school. Children being bullied weekly away from school were about four times more likely to carry a weapon or bring one to school. The highest incidence of weapon carrying was seen among youths who bullied others away from school on a weekly basis. These children were six times more likely than others to carry a weapon and five times more likely to bring a weapon to school.

Bullying behaviors differ between the sexes: Studies show that boys are more likely to carry out direct or physical bullying (pushing, slapping, punching, spitting, or tripping), and girls are more likely to carry out indirect bullying (threats, teasing, rumors, stealing or extortion, or shunning). But Dr. Wright pointed out the disturbing trend that girls are now engaging in more physical bullying.

Being bullied carries long-term risks. According to a study of 4,811 children in the Netherlands, bullied children are more likely to have depression and suicidal ideation, and this association is stronger for indirect rather than direct bullying (Pediatrics 2003;111:1312–17).

Among girls, frequent direct bullying increased the risk of depression and suicidal ideation by 3.3-fold and 2.6-fold, respectively, while frequent indirect bullying raised the risks by 8.9-fold and 3.6-fold, respectively.

Overall, 43% of all frequently directly bullied girls reported depression, compared with 6% of girls who were almost never directly bullied.

The effects of direct bullying on boys were not significant after controlling for confounding factors, although frequent indirect bullying in boys increased the risk of depression by 11-fold and the risk of suicidal ideation by 5.6-fold.

Dr. Wright urged physicians to engage with families of young children to help prevent the later development of bullying behavior.

'In the United States, we are quite behind the eight ball in terms of recognizing this problem.' DR. WRIGHT

The hepatitis A vaccine is immunogenic and generally well tolerated in healthy 12-month-old children and can be administered concomitantly with certain other vaccines, Dr. Fernando A. Guerra of the San Antonio Metropolitan Health District and his associates said.

“The immunogenicity and safety data collected in this study support the administration of hepatitis A vaccine as early as 12 months of age, regardless of initial hepatitis A serostatus, … concomitantly with measles, mumps, and rubella vaccine and poliovirus vaccines,” wrote Dr. Guerra and his colleagues (Pediatr. Infect. Dis. J. 2006;25:912–9). “The study is insufficient to assess the immunogenicity of varicella vaccine and DTaP [diphtheria-tetanus-acellular pertussis] vaccine when administered concomitantly with hepatitis A vaccine.”

In the open-label study, the researchers randomized 503 healthy 12-month-old children to receive hepatitis A vaccine with or without measles, mumps, and rubella (MMR) and varicella zoster virus (VZV) vaccines (with dose one) and diphtheria-tetanus-acellular pertussis (DTaP) vaccine (with dose two). Children in the concomitant vaccine group could have also optionally received oral or inactivated poliovirus vaccine with dose two.

The immunogenicity of the hepatitis A vaccine was acceptable in this young population. With observed seropositive rates of 98.3% and 100% after the first and second doses, respectively, the vaccine appeared as immunogenic in 12-month-old children as it is in children 2–3 years of age.

Geometric mean antibody titers were similar among the 40 initially seropositive children (6,207 mIU/mL) and the 259 initially seronegative children (6,810 mIU/mL), which suggested that the presence of maternal antibodies does not affect responses to the vaccine. However, the researchers noted that many factors, including the concentration of maternal antibodies at vaccination, could affect immunogenicity outcomes.

Concomitant administration of hepatitis A and MMR vaccines did not appear to affect seropositive rates or geometric mean titers to either vaccine in either combination. The seropositive rates were 95.5% for hepatitis A, 98.8% for measles, 99.6% for mumps, and 100% for rubella.

Although the concomitant administration of hepatitis A and DTaP vaccines yielded acceptable response rates to hepatitis A (100%), diphtheria (98.6%), tetanus (100%), and filamentous hemagglutinin (83.3%), the response rate for pertussis toxoid (PT) was 76%, which is lower than the historical rate of 85%. The investigators hypothesized that early timing of the prevaccination blood draw resulted in higher preboost antibody titers, which could have prevented them from seeing an adequate increase for PT.

Study-related problems may have contributed to a failure to detect adequate responses to the VZV vaccine. Only 79% of children concomitantly immunized with hepatitis A and VZV vaccines developed antibody responses to VZV, a rate lower than the 90% historical rate.

Polio antibody response rates of 98%–100% were reported after 4 weeks in the 189 subjects who received both vaccinations. Antibody titers increased at least 30-fold after administration of the poliovirus vaccine booster dose at age 18 months.

The researchers reported two potentially vaccine-related serious clinical adverse events; both were febrile seizures that occurred 9 days after vaccination. One child had received hepatitis A, MMR, and varicella vaccines, whereas the other had received MMR and varicella vaccines. Neither child discontinued participation in the study.

The most common injection site adverse events reported in the first 4 days after the first hepatitis A vaccine dose were pain, tenderness, and soreness, which occurred in 1.3%–4.8% of children across the treatment groups. Between 2.7% and 6.2% of children in each group developed a temperature higher than 102 ° F within that period.

The most common systemic adverse events that were reported across treatment groups in the 42 days following the first dose of hepatitis A vaccine were fever (22%–25%), upper respiratory tract infection (8%–16%), and otitis media (6%–12%). About one-third of children with systemic adverse events were considered to have vaccine-related events.

Safety outcomes were similar after the second dose of hepatitis A vaccine.

The hepatitis A vaccine is immunogenic and generally well tolerated in healthy 12-month-old children and can be administered concomitantly with certain other vaccines, Dr. Fernando A. Guerra of the San Antonio Metropolitan Health District and his associates said.

“The immunogenicity and safety data collected in this study support the administration of hepatitis A vaccine as early as 12 months of age, regardless of initial hepatitis A serostatus, … concomitantly with measles, mumps, and rubella vaccine and poliovirus vaccines,” wrote Dr. Guerra and his colleagues (Pediatr. Infect. Dis. J. 2006;25:912–9). “The study is insufficient to assess the immunogenicity of varicella vaccine and DTaP [diphtheria-tetanus-acellular pertussis] vaccine when administered concomitantly with hepatitis A vaccine.”

In the open-label study, the researchers randomized 503 healthy 12-month-old children to receive hepatitis A vaccine with or without measles, mumps, and rubella (MMR) and varicella zoster virus (VZV) vaccines (with dose one) and diphtheria-tetanus-acellular pertussis (DTaP) vaccine (with dose two). Children in the concomitant vaccine group could have also optionally received oral or inactivated poliovirus vaccine with dose two.

The immunogenicity of the hepatitis A vaccine was acceptable in this young population. With observed seropositive rates of 98.3% and 100% after the first and second doses, respectively, the vaccine appeared as immunogenic in 12-month-old children as it is in children 2–3 years of age.

Geometric mean antibody titers were similar among the 40 initially seropositive children (6,207 mIU/mL) and the 259 initially seronegative children (6,810 mIU/mL), which suggested that the presence of maternal antibodies does not affect responses to the vaccine. However, the researchers noted that many factors, including the concentration of maternal antibodies at vaccination, could affect immunogenicity outcomes.

Concomitant administration of hepatitis A and MMR vaccines did not appear to affect seropositive rates or geometric mean titers to either vaccine in either combination. The seropositive rates were 95.5% for hepatitis A, 98.8% for measles, 99.6% for mumps, and 100% for rubella.

Although the concomitant administration of hepatitis A and DTaP vaccines yielded acceptable response rates to hepatitis A (100%), diphtheria (98.6%), tetanus (100%), and filamentous hemagglutinin (83.3%), the response rate for pertussis toxoid (PT) was 76%, which is lower than the historical rate of 85%. The investigators hypothesized that early timing of the prevaccination blood draw resulted in higher preboost antibody titers, which could have prevented them from seeing an adequate increase for PT.

Study-related problems may have contributed to a failure to detect adequate responses to the VZV vaccine. Only 79% of children concomitantly immunized with hepatitis A and VZV vaccines developed antibody responses to VZV, a rate lower than the 90% historical rate.

Polio antibody response rates of 98%–100% were reported after 4 weeks in the 189 subjects who received both vaccinations. Antibody titers increased at least 30-fold after administration of the poliovirus vaccine booster dose at age 18 months.

The researchers reported two potentially vaccine-related serious clinical adverse events; both were febrile seizures that occurred 9 days after vaccination. One child had received hepatitis A, MMR, and varicella vaccines, whereas the other had received MMR and varicella vaccines. Neither child discontinued participation in the study.

The most common injection site adverse events reported in the first 4 days after the first hepatitis A vaccine dose were pain, tenderness, and soreness, which occurred in 1.3%–4.8% of children across the treatment groups. Between 2.7% and 6.2% of children in each group developed a temperature higher than 102 ° F within that period.

The most common systemic adverse events that were reported across treatment groups in the 42 days following the first dose of hepatitis A vaccine were fever (22%–25%), upper respiratory tract infection (8%–16%), and otitis media (6%–12%). About one-third of children with systemic adverse events were considered to have vaccine-related events.

Safety outcomes were similar after the second dose of hepatitis A vaccine.

The hepatitis A vaccine is immunogenic and generally well tolerated in healthy 12-month-old children and can be administered concomitantly with certain other vaccines, Dr. Fernando A. Guerra of the San Antonio Metropolitan Health District and his associates said.

“The immunogenicity and safety data collected in this study support the administration of hepatitis A vaccine as early as 12 months of age, regardless of initial hepatitis A serostatus, … concomitantly with measles, mumps, and rubella vaccine and poliovirus vaccines,” wrote Dr. Guerra and his colleagues (Pediatr. Infect. Dis. J. 2006;25:912–9). “The study is insufficient to assess the immunogenicity of varicella vaccine and DTaP [diphtheria-tetanus-acellular pertussis] vaccine when administered concomitantly with hepatitis A vaccine.”

In the open-label study, the researchers randomized 503 healthy 12-month-old children to receive hepatitis A vaccine with or without measles, mumps, and rubella (MMR) and varicella zoster virus (VZV) vaccines (with dose one) and diphtheria-tetanus-acellular pertussis (DTaP) vaccine (with dose two). Children in the concomitant vaccine group could have also optionally received oral or inactivated poliovirus vaccine with dose two.

The immunogenicity of the hepatitis A vaccine was acceptable in this young population. With observed seropositive rates of 98.3% and 100% after the first and second doses, respectively, the vaccine appeared as immunogenic in 12-month-old children as it is in children 2–3 years of age.

Geometric mean antibody titers were similar among the 40 initially seropositive children (6,207 mIU/mL) and the 259 initially seronegative children (6,810 mIU/mL), which suggested that the presence of maternal antibodies does not affect responses to the vaccine. However, the researchers noted that many factors, including the concentration of maternal antibodies at vaccination, could affect immunogenicity outcomes.

Concomitant administration of hepatitis A and MMR vaccines did not appear to affect seropositive rates or geometric mean titers to either vaccine in either combination. The seropositive rates were 95.5% for hepatitis A, 98.8% for measles, 99.6% for mumps, and 100% for rubella.

Although the concomitant administration of hepatitis A and DTaP vaccines yielded acceptable response rates to hepatitis A (100%), diphtheria (98.6%), tetanus (100%), and filamentous hemagglutinin (83.3%), the response rate for pertussis toxoid (PT) was 76%, which is lower than the historical rate of 85%. The investigators hypothesized that early timing of the prevaccination blood draw resulted in higher preboost antibody titers, which could have prevented them from seeing an adequate increase for PT.

Study-related problems may have contributed to a failure to detect adequate responses to the VZV vaccine. Only 79% of children concomitantly immunized with hepatitis A and VZV vaccines developed antibody responses to VZV, a rate lower than the 90% historical rate.

Polio antibody response rates of 98%–100% were reported after 4 weeks in the 189 subjects who received both vaccinations. Antibody titers increased at least 30-fold after administration of the poliovirus vaccine booster dose at age 18 months.

The researchers reported two potentially vaccine-related serious clinical adverse events; both were febrile seizures that occurred 9 days after vaccination. One child had received hepatitis A, MMR, and varicella vaccines, whereas the other had received MMR and varicella vaccines. Neither child discontinued participation in the study.

The most common injection site adverse events reported in the first 4 days after the first hepatitis A vaccine dose were pain, tenderness, and soreness, which occurred in 1.3%–4.8% of children across the treatment groups. Between 2.7% and 6.2% of children in each group developed a temperature higher than 102 ° F within that period.

The most common systemic adverse events that were reported across treatment groups in the 42 days following the first dose of hepatitis A vaccine were fever (22%–25%), upper respiratory tract infection (8%–16%), and otitis media (6%–12%). About one-third of children with systemic adverse events were considered to have vaccine-related events.

Safety outcomes were similar after the second dose of hepatitis A vaccine.

A practical toolkit and policy statement to help pediatricians build a system to bill for telephone care in their practices are now available from the American Academy of Pediatrics.

Dr. Peter Dehnel discussed practical considerations for implementing a telephone care billing system at the annual meeting of the American Academy of Pediatrics.

“The most important reason [to bill for telephone care] is so that we in primary care, as well as all pediatrics, can provide a higher quality of service for our families in a way that's more timely and effective and efficient to them,” said Dr. Dehnel, medical director of the Children's Physician Network's Nurse Triage Program in Minneapolis.

The toolkit, available from the Member Center at the academy's Web site, www.aap.org

Pediatricians also are encouraged to review the policy statement on telephone care published in the October issue of Pediatrics (Pediatrics 2006;118:1768–73). The statement, written by members of the AAP's Section on Telephone Care and the Committee on Child Health Financing, discusses the function of telephone care and the current state of billing for phone care and gives practical recommendations for instituting a billing system.

Dr. Dehnel recommended that practices adopt a consensus or majority vote and not allow one naysayer to sway the office against adopting a telephone care billing system.

After the decision is made to initiate billing, Dr. Dehnel suggests that one physician and one administrator in each practice should act as the local telephone care experts, which can help the practices adopt a smooth-running telephone care system.

Finally, it is important for pediatricians to adequately prepare families for the change in billing by notifying them of the new policy, what calls will be included, and how the insurance process will work. “It is extremely important to use more than one means to notify your families,” Dr. Dehnel said. He suggested using office posters, an article in the office newsletter, and certainly mailings as ways to inform families about the change.

A practical toolkit and policy statement to help pediatricians build a system to bill for telephone care in their practices are now available from the American Academy of Pediatrics.

Dr. Peter Dehnel discussed practical considerations for implementing a telephone care billing system at the annual meeting of the American Academy of Pediatrics.

“The most important reason [to bill for telephone care] is so that we in primary care, as well as all pediatrics, can provide a higher quality of service for our families in a way that's more timely and effective and efficient to them,” said Dr. Dehnel, medical director of the Children's Physician Network's Nurse Triage Program in Minneapolis.

The toolkit, available from the Member Center at the academy's Web site, www.aap.org

Pediatricians also are encouraged to review the policy statement on telephone care published in the October issue of Pediatrics (Pediatrics 2006;118:1768–73). The statement, written by members of the AAP's Section on Telephone Care and the Committee on Child Health Financing, discusses the function of telephone care and the current state of billing for phone care and gives practical recommendations for instituting a billing system.

Dr. Dehnel recommended that practices adopt a consensus or majority vote and not allow one naysayer to sway the office against adopting a telephone care billing system.

After the decision is made to initiate billing, Dr. Dehnel suggests that one physician and one administrator in each practice should act as the local telephone care experts, which can help the practices adopt a smooth-running telephone care system.

Finally, it is important for pediatricians to adequately prepare families for the change in billing by notifying them of the new policy, what calls will be included, and how the insurance process will work. “It is extremely important to use more than one means to notify your families,” Dr. Dehnel said. He suggested using office posters, an article in the office newsletter, and certainly mailings as ways to inform families about the change.

A practical toolkit and policy statement to help pediatricians build a system to bill for telephone care in their practices are now available from the American Academy of Pediatrics.

Dr. Peter Dehnel discussed practical considerations for implementing a telephone care billing system at the annual meeting of the American Academy of Pediatrics.

“The most important reason [to bill for telephone care] is so that we in primary care, as well as all pediatrics, can provide a higher quality of service for our families in a way that's more timely and effective and efficient to them,” said Dr. Dehnel, medical director of the Children's Physician Network's Nurse Triage Program in Minneapolis.

The toolkit, available from the Member Center at the academy's Web site, www.aap.org

Pediatricians also are encouraged to review the policy statement on telephone care published in the October issue of Pediatrics (Pediatrics 2006;118:1768–73). The statement, written by members of the AAP's Section on Telephone Care and the Committee on Child Health Financing, discusses the function of telephone care and the current state of billing for phone care and gives practical recommendations for instituting a billing system.

Dr. Dehnel recommended that practices adopt a consensus or majority vote and not allow one naysayer to sway the office against adopting a telephone care billing system.

After the decision is made to initiate billing, Dr. Dehnel suggests that one physician and one administrator in each practice should act as the local telephone care experts, which can help the practices adopt a smooth-running telephone care system.

Finally, it is important for pediatricians to adequately prepare families for the change in billing by notifying them of the new policy, what calls will be included, and how the insurance process will work. “It is extremely important to use more than one means to notify your families,” Dr. Dehnel said. He suggested using office posters, an article in the office newsletter, and certainly mailings as ways to inform families about the change.

ATLANTA — Maintaining proper hygienic practices appears to substantially reduce the spread of shigellosis in day care centers, according to an investigation of a widespread shigellosis outbreak affecting at least 645 individuals in Missouri in 2005.

The results of the case-control study were presented at the annual meeting of the American Academy of Pediatrics.

In an analysis of 39 day care centers, those with at least one sink per room reduced by 80% the likelihood of having a higher attack rate of shigellosis among children. Overall, 3 of the 18 day care centers which had a high attack rate for the disease (case centers) had at least one sink per room, compared with 13 of the 21 centers with low attack rates of shigellosis (control centers).

The presence of a diapering station in all rooms with diapered children reduced the likelihood of a widespread outbreak by 90%. Diapering stations were present in all rooms where diapered children are present in 6 of 18 day care centers with high attack rates and in 15 of 21 day-care centers with low attack rates.

“Outbreaks in day care centers can be difficult to control … Shigella can be transmitted from person to person and through contact with contaminated objects,” explained the study's lead investigator, Dr. Wences Arvelo of the Centers for Disease Control and Prevention in Atlanta.

This makes attention to hand washing and hygiene particularly important, he said.

The Shigella sonnei responsible for the outbreaks was resistant to multiple antibiotics, according to in vitro analysis of 31 randomly selected isolates. Overall, 28 isolates (90%) were resistant to ampicillin and trimethoprim-sulfamethoxazole.

These high resistance rates reflect the nationwide increase toward multidrug-resistant shigellosis.

Among 210 children in which treatment choices were analyzed, 44% were treated with azithromycin, 27% with cephalosporin, 15% with trimethoprim-sulfamethoxazole, 5% with fluoroquinolones, 2% with ampicillin, and 7% with other antibiotics.

The American Academy of Pediatrics recommends using azithromycin, ceftriaxone, or fluoroquinolones to treat multidrug-resistant shigellosis, though there are no standardized methods for monitoring for resistance to azithromycin, and the safety profile of fluoroquinolones in children is uncertain.

Dr. Arvelo suggested that changing licensure requirements for hygiene infrastructure might ensure good hygiene practices and help prevent transmission of shigellosis, therefore reducing the need for antibiotic treatment.

He noted that physicians choosing to treat children with shigellosis should test for antibiotic resistance, given the high resistance rates.

Finally, he encouraged clinicians to consider the risks and benefits of antimicrobial treatment of shigellosis.

Although effective antibiotic treatment improves severe symptoms and decreases the duration of shedding the bacteria, it alters the normal flora, is costly, and can lead to increased antibiotic resistance.

Expectant management—in which children are not treated but rather are kept at home or “cohorted” with other infected children within day care centers—might be a feasible alternative to antibiotic treatment.

A report on the Missouri outbreak as well as outbreaks in Kansas and Kentucky was published in the October 6 issue of Morbidity and Mortality Weekly Report (MMWR 2006;55:1068–70).

Information about patient exposures to day care settings was not collected in Kansas, the CDCsaid.

In Fayette County, Kentucky, there were 148 confirmed cases of S. sonnei, median age 4 years.

Ninety-three percent of cases occurred among attendees, family members, or staff at 16 day care centers.

ATLANTA — Maintaining proper hygienic practices appears to substantially reduce the spread of shigellosis in day care centers, according to an investigation of a widespread shigellosis outbreak affecting at least 645 individuals in Missouri in 2005.

The results of the case-control study were presented at the annual meeting of the American Academy of Pediatrics.

In an analysis of 39 day care centers, those with at least one sink per room reduced by 80% the likelihood of having a higher attack rate of shigellosis among children. Overall, 3 of the 18 day care centers which had a high attack rate for the disease (case centers) had at least one sink per room, compared with 13 of the 21 centers with low attack rates of shigellosis (control centers).

The presence of a diapering station in all rooms with diapered children reduced the likelihood of a widespread outbreak by 90%. Diapering stations were present in all rooms where diapered children are present in 6 of 18 day care centers with high attack rates and in 15 of 21 day-care centers with low attack rates.

“Outbreaks in day care centers can be difficult to control … Shigella can be transmitted from person to person and through contact with contaminated objects,” explained the study's lead investigator, Dr. Wences Arvelo of the Centers for Disease Control and Prevention in Atlanta.

This makes attention to hand washing and hygiene particularly important, he said.

The Shigella sonnei responsible for the outbreaks was resistant to multiple antibiotics, according to in vitro analysis of 31 randomly selected isolates. Overall, 28 isolates (90%) were resistant to ampicillin and trimethoprim-sulfamethoxazole.

These high resistance rates reflect the nationwide increase toward multidrug-resistant shigellosis.

Among 210 children in which treatment choices were analyzed, 44% were treated with azithromycin, 27% with cephalosporin, 15% with trimethoprim-sulfamethoxazole, 5% with fluoroquinolones, 2% with ampicillin, and 7% with other antibiotics.

The American Academy of Pediatrics recommends using azithromycin, ceftriaxone, or fluoroquinolones to treat multidrug-resistant shigellosis, though there are no standardized methods for monitoring for resistance to azithromycin, and the safety profile of fluoroquinolones in children is uncertain.

Dr. Arvelo suggested that changing licensure requirements for hygiene infrastructure might ensure good hygiene practices and help prevent transmission of shigellosis, therefore reducing the need for antibiotic treatment.

He noted that physicians choosing to treat children with shigellosis should test for antibiotic resistance, given the high resistance rates.

Finally, he encouraged clinicians to consider the risks and benefits of antimicrobial treatment of shigellosis.

Although effective antibiotic treatment improves severe symptoms and decreases the duration of shedding the bacteria, it alters the normal flora, is costly, and can lead to increased antibiotic resistance.

Expectant management—in which children are not treated but rather are kept at home or “cohorted” with other infected children within day care centers—might be a feasible alternative to antibiotic treatment.

A report on the Missouri outbreak as well as outbreaks in Kansas and Kentucky was published in the October 6 issue of Morbidity and Mortality Weekly Report (MMWR 2006;55:1068–70).

Information about patient exposures to day care settings was not collected in Kansas, the CDCsaid.

In Fayette County, Kentucky, there were 148 confirmed cases of S. sonnei, median age 4 years.

Ninety-three percent of cases occurred among attendees, family members, or staff at 16 day care centers.

ATLANTA — Maintaining proper hygienic practices appears to substantially reduce the spread of shigellosis in day care centers, according to an investigation of a widespread shigellosis outbreak affecting at least 645 individuals in Missouri in 2005.

The results of the case-control study were presented at the annual meeting of the American Academy of Pediatrics.

In an analysis of 39 day care centers, those with at least one sink per room reduced by 80% the likelihood of having a higher attack rate of shigellosis among children. Overall, 3 of the 18 day care centers which had a high attack rate for the disease (case centers) had at least one sink per room, compared with 13 of the 21 centers with low attack rates of shigellosis (control centers).

The presence of a diapering station in all rooms with diapered children reduced the likelihood of a widespread outbreak by 90%. Diapering stations were present in all rooms where diapered children are present in 6 of 18 day care centers with high attack rates and in 15 of 21 day-care centers with low attack rates.

“Outbreaks in day care centers can be difficult to control … Shigella can be transmitted from person to person and through contact with contaminated objects,” explained the study's lead investigator, Dr. Wences Arvelo of the Centers for Disease Control and Prevention in Atlanta.

This makes attention to hand washing and hygiene particularly important, he said.

The Shigella sonnei responsible for the outbreaks was resistant to multiple antibiotics, according to in vitro analysis of 31 randomly selected isolates. Overall, 28 isolates (90%) were resistant to ampicillin and trimethoprim-sulfamethoxazole.

These high resistance rates reflect the nationwide increase toward multidrug-resistant shigellosis.

Among 210 children in which treatment choices were analyzed, 44% were treated with azithromycin, 27% with cephalosporin, 15% with trimethoprim-sulfamethoxazole, 5% with fluoroquinolones, 2% with ampicillin, and 7% with other antibiotics.

The American Academy of Pediatrics recommends using azithromycin, ceftriaxone, or fluoroquinolones to treat multidrug-resistant shigellosis, though there are no standardized methods for monitoring for resistance to azithromycin, and the safety profile of fluoroquinolones in children is uncertain.

Dr. Arvelo suggested that changing licensure requirements for hygiene infrastructure might ensure good hygiene practices and help prevent transmission of shigellosis, therefore reducing the need for antibiotic treatment.

He noted that physicians choosing to treat children with shigellosis should test for antibiotic resistance, given the high resistance rates.

Finally, he encouraged clinicians to consider the risks and benefits of antimicrobial treatment of shigellosis.

Although effective antibiotic treatment improves severe symptoms and decreases the duration of shedding the bacteria, it alters the normal flora, is costly, and can lead to increased antibiotic resistance.

Expectant management—in which children are not treated but rather are kept at home or “cohorted” with other infected children within day care centers—might be a feasible alternative to antibiotic treatment.

A report on the Missouri outbreak as well as outbreaks in Kansas and Kentucky was published in the October 6 issue of Morbidity and Mortality Weekly Report (MMWR 2006;55:1068–70).

Information about patient exposures to day care settings was not collected in Kansas, the CDCsaid.

In Fayette County, Kentucky, there were 148 confirmed cases of S. sonnei, median age 4 years.

Ninety-three percent of cases occurred among attendees, family members, or staff at 16 day care centers.

MIAMI — Although the overall risk of injury in cheerleading is low, the activity accounts for more than half of all catastrophic sports injuries in females, Dr. Teri McCambridge said at a meeting on pediatric sports medicine sponsored by the American Academy of Pediatrics.

In the last 25 years, cheerleading has progressed from a spirit-raising sideline activity to an exacting athletic endeavor, and with that change, there has been an increase in the number of injuries among cheerleaders.

Partner stunts, particularly basket tosses and pyramids, account for the greatest number of cheerleading injuries. In a basket toss, three or four “bases” toss a “flier” into the air. The flier reaches heights of 6–20 feet before falling into the arms of the bases. Most basket toss injuries occur indoors, when cheerleaders perform them in a gymnasium during winter sports.

Performing stunts on an improper surface during a game or practice session is one common yet preventable cause of serious injury. According to surveys completed by 425 high school cheerleaders in the Midwest, 10% of cheerleading practices are held in the cafeteria or hallway, where the concrete floors offer minimal padding. Other contributors include performing stunts on wet floors, forming pyramids without mats or spotters, trying to perform stunts in a short time frame, and cheerleading too close to the field or court, said Dr. McCambridge, a pediatrician at Johns Hopkins University, Baltimore.

The American Association of Cheerleading Coaches and Administrators (AACCA) has published safety guidelines, including pyramid restrictions of two levels in high school and 2.5 levels in college. Following these guidelines can prevent cheerleaders from attempting skills beyond their developmental abilities.

In a larger context, a primary issue with cheerleading is the lack of standardized rules and regulations. Various cheerleading associations have published guidelines, but universal guidelines do not exist. Moreover, cheerleading coaches are not required to obtain a universal safety certification; as of 2003, only 30% of coaches were certified.

Some states require coaches to be AACCA safety-certified before they can teach children stunts, however, and beginning this year, the National Collegiate Athletic Association (NCAA) will require all coaches to have AACCA safety certifications. Some insurance companies are also requiring coaches to be AACCA-certified before they can obtain liability insurance.

These issues of nonregulation likely stem from the fact that cheerleading in most cases is not considered a sport according to the NCAA definition, and it is thus not as well regulated as other sports. This exclusion makes cheerleading squads ineligible for funding that can help pay for coaches, equipment, and other expenses, but it also frees them from constraints of sports such as having a defined competitive season. The debate on whether to classify cheerleading as a sport is ongoing.

“It would help us as primary care providers to have it be a sport,” Dr. McCambridge said, “because then the NCAA would track their injuries, and we could make more educated changes in their safety requirements.” She predicted that the nonregulated state of cheerleading would likely end if cheerleading becomes an official sport.

Pediatricians can do their part to help ensure cheerleaders' safety by providing guidance to their own cheerleading patients. (See box.)

Dr. McCambridge encouraged those who provide sports coverage to high schools to advocate for safety certification requirements in their schools.

Padding, Matting, and Lighting Spell Safety

Dr. McCambridge recommended that physicians discuss the following questions with families of cheerleaders:

▸ Is a separate practice area available?

▸ Is there sufficient space—floor space and ceiling height—for the type of stunts being performed?

▸ Are there enough spotters present for the stunt being performed?

▸ Are nearby objects properly padded?

▸ Is there adequate matting?

▸ Is there adequate lighting?

▸ Are the cheerleaders practicing and performing on an appropriate flooring surface?

▸ Are the cheerleaders in appropriate attire (tennis shoes, tight-fitting clothes, no dangly earrings or facial piercings)?

MIAMI — Although the overall risk of injury in cheerleading is low, the activity accounts for more than half of all catastrophic sports injuries in females, Dr. Teri McCambridge said at a meeting on pediatric sports medicine sponsored by the American Academy of Pediatrics.

In the last 25 years, cheerleading has progressed from a spirit-raising sideline activity to an exacting athletic endeavor, and with that change, there has been an increase in the number of injuries among cheerleaders.

Partner stunts, particularly basket tosses and pyramids, account for the greatest number of cheerleading injuries. In a basket toss, three or four “bases” toss a “flier” into the air. The flier reaches heights of 6–20 feet before falling into the arms of the bases. Most basket toss injuries occur indoors, when cheerleaders perform them in a gymnasium during winter sports.

Performing stunts on an improper surface during a game or practice session is one common yet preventable cause of serious injury. According to surveys completed by 425 high school cheerleaders in the Midwest, 10% of cheerleading practices are held in the cafeteria or hallway, where the concrete floors offer minimal padding. Other contributors include performing stunts on wet floors, forming pyramids without mats or spotters, trying to perform stunts in a short time frame, and cheerleading too close to the field or court, said Dr. McCambridge, a pediatrician at Johns Hopkins University, Baltimore.

The American Association of Cheerleading Coaches and Administrators (AACCA) has published safety guidelines, including pyramid restrictions of two levels in high school and 2.5 levels in college. Following these guidelines can prevent cheerleaders from attempting skills beyond their developmental abilities.

In a larger context, a primary issue with cheerleading is the lack of standardized rules and regulations. Various cheerleading associations have published guidelines, but universal guidelines do not exist. Moreover, cheerleading coaches are not required to obtain a universal safety certification; as of 2003, only 30% of coaches were certified.

Some states require coaches to be AACCA safety-certified before they can teach children stunts, however, and beginning this year, the National Collegiate Athletic Association (NCAA) will require all coaches to have AACCA safety certifications. Some insurance companies are also requiring coaches to be AACCA-certified before they can obtain liability insurance.

These issues of nonregulation likely stem from the fact that cheerleading in most cases is not considered a sport according to the NCAA definition, and it is thus not as well regulated as other sports. This exclusion makes cheerleading squads ineligible for funding that can help pay for coaches, equipment, and other expenses, but it also frees them from constraints of sports such as having a defined competitive season. The debate on whether to classify cheerleading as a sport is ongoing.

“It would help us as primary care providers to have it be a sport,” Dr. McCambridge said, “because then the NCAA would track their injuries, and we could make more educated changes in their safety requirements.” She predicted that the nonregulated state of cheerleading would likely end if cheerleading becomes an official sport.

Pediatricians can do their part to help ensure cheerleaders' safety by providing guidance to their own cheerleading patients. (See box.)

Dr. McCambridge encouraged those who provide sports coverage to high schools to advocate for safety certification requirements in their schools.

Padding, Matting, and Lighting Spell Safety

Dr. McCambridge recommended that physicians discuss the following questions with families of cheerleaders:

▸ Is a separate practice area available?

▸ Is there sufficient space—floor space and ceiling height—for the type of stunts being performed?

▸ Are there enough spotters present for the stunt being performed?

▸ Are nearby objects properly padded?

▸ Is there adequate matting?

▸ Is there adequate lighting?

▸ Are the cheerleaders practicing and performing on an appropriate flooring surface?

▸ Are the cheerleaders in appropriate attire (tennis shoes, tight-fitting clothes, no dangly earrings or facial piercings)?

MIAMI — Although the overall risk of injury in cheerleading is low, the activity accounts for more than half of all catastrophic sports injuries in females, Dr. Teri McCambridge said at a meeting on pediatric sports medicine sponsored by the American Academy of Pediatrics.

In the last 25 years, cheerleading has progressed from a spirit-raising sideline activity to an exacting athletic endeavor, and with that change, there has been an increase in the number of injuries among cheerleaders.

Partner stunts, particularly basket tosses and pyramids, account for the greatest number of cheerleading injuries. In a basket toss, three or four “bases” toss a “flier” into the air. The flier reaches heights of 6–20 feet before falling into the arms of the bases. Most basket toss injuries occur indoors, when cheerleaders perform them in a gymnasium during winter sports.

Performing stunts on an improper surface during a game or practice session is one common yet preventable cause of serious injury. According to surveys completed by 425 high school cheerleaders in the Midwest, 10% of cheerleading practices are held in the cafeteria or hallway, where the concrete floors offer minimal padding. Other contributors include performing stunts on wet floors, forming pyramids without mats or spotters, trying to perform stunts in a short time frame, and cheerleading too close to the field or court, said Dr. McCambridge, a pediatrician at Johns Hopkins University, Baltimore.

The American Association of Cheerleading Coaches and Administrators (AACCA) has published safety guidelines, including pyramid restrictions of two levels in high school and 2.5 levels in college. Following these guidelines can prevent cheerleaders from attempting skills beyond their developmental abilities.

In a larger context, a primary issue with cheerleading is the lack of standardized rules and regulations. Various cheerleading associations have published guidelines, but universal guidelines do not exist. Moreover, cheerleading coaches are not required to obtain a universal safety certification; as of 2003, only 30% of coaches were certified.

Some states require coaches to be AACCA safety-certified before they can teach children stunts, however, and beginning this year, the National Collegiate Athletic Association (NCAA) will require all coaches to have AACCA safety certifications. Some insurance companies are also requiring coaches to be AACCA-certified before they can obtain liability insurance.

These issues of nonregulation likely stem from the fact that cheerleading in most cases is not considered a sport according to the NCAA definition, and it is thus not as well regulated as other sports. This exclusion makes cheerleading squads ineligible for funding that can help pay for coaches, equipment, and other expenses, but it also frees them from constraints of sports such as having a defined competitive season. The debate on whether to classify cheerleading as a sport is ongoing.

“It would help us as primary care providers to have it be a sport,” Dr. McCambridge said, “because then the NCAA would track their injuries, and we could make more educated changes in their safety requirements.” She predicted that the nonregulated state of cheerleading would likely end if cheerleading becomes an official sport.

Pediatricians can do their part to help ensure cheerleaders' safety by providing guidance to their own cheerleading patients. (See box.)

Dr. McCambridge encouraged those who provide sports coverage to high schools to advocate for safety certification requirements in their schools.

Padding, Matting, and Lighting Spell Safety

Dr. McCambridge recommended that physicians discuss the following questions with families of cheerleaders:

▸ Is a separate practice area available?

▸ Is there sufficient space—floor space and ceiling height—for the type of stunts being performed?

▸ Are there enough spotters present for the stunt being performed?

▸ Are nearby objects properly padded?

▸ Is there adequate matting?

▸ Is there adequate lighting?

▸ Are the cheerleaders practicing and performing on an appropriate flooring surface?

▸ Are the cheerleaders in appropriate attire (tennis shoes, tight-fitting clothes, no dangly earrings or facial piercings)?