American Academy of Pediatrics (AAP): 2015 National Conference and Exhibition

WASHINGTON – Understanding a child’s fever history and other symptoms is essential to accurately determining what is causing a fever and what kind of management, if any, it requires, Dr. Kathryn M. Edwards explained at the American Academy of Pediatrics annual meeting.

Dr. Edwards aimed largely to help clinicians distinguish between familial recurrent fever syndromes and the syndrome PFAPA (Periodic Fever, Aphthous Stomatitis, Pharyngitis, Cervical Adenitis). Although familial cases of PFAPA have been reported, the syndrome’s etiology isn’t fully understood.

©IPGGutenbergUKLtd/Thinkstock

She began with a review of fever definition and pathogenesis, and used a series of case studies to introduce various fever syndromes. Although the simplest definition is an above-normal body temperature, fever is best thought of not as “a single value, but rather a range depending on time, place, individual, and measurement site,” Dr. Edwards explained. An inflammatory response, fever may result from an infection or occur secondarily to other conditions. The inflammatory response begins after both monocytes and macrophages release cytokines that stimulate the brain’s thermoregulatory center, inducing prostaglandin production.

Recurrent and periodic fever overview

Unlike a fever of unknown origin, recurrent and periodic fevers occur regularly in repeated cycles or intermittently over a period of time. The most important step in identifying what’s going on with a child’s recurrent/periodic fever is taking a complete fever history, including not only exposures and travel, but also family history and ethnicity. Clinicians can provide parents with a fever diary that tracks fever date and time, the temperature, other symptoms, medication administered, and other relevant information because “knowing the fever pattern is critical,” Dr. Edwards emphasized. A good fever history also requires clinicians to conduct a comprehensive physical exam, be aware of temperature norms for a child’s age and sex, and diligently evaluate a child’s growth parameters.

Using a flowchart adapted from Long’s article in “Pediatric Clinics of North America,” Dr. Edwards pointed out that recurrent fever may result from identified infections or may be stereotypical and episodic without an infection. The source of multiple viral infections is generally environmental, such as day care or cigarette smoke exposure. Multiple bacterial infections involving different organ systems may indicate an immunodeficiency, whereas recurrent infections in the same organ system require assessment specific to that system. Among stereotypical recurrent fevers, irregular episodes likely indicate a monogenic fever syndrome, while more predictable episodes could be cyclic neutropenia or PFAPA.

“There are a couple remarkable differences between PFAPA patients and patients with repeated viral infections,” said Dr. Edwards , professor of pediatrics at Vanderbilt University, Nashville, Tenn. “One is the frequency of the fevers, how often they come,” which underscores the need for a meticulous fever history, she explained. A parent might perceive that the fevers come once a month, but it’s essential to know whether they truly come like clockwork or whether they are more sporadic. “In addition, between the episodes, the children get nothing else,” she said, “and certainly they’re not infectious. Nobody else gets sick.”

Recognizing PFAPA

Children with PFAPA show normal growth and development, and no symptoms between very regular intervals of fever (above 38.3º C) with sore throat, mouth sores, and/or glandular swelling in the absence of an infection. About two-thirds of patients report headache, sore throat and/or mouth ulcers, and more than three quarters report swelling of the lymph nodes. About half experience abdominal pain or nausea.

PFAPA typically has an early age of onset and is diagnosed after exclusion of cyclic neutropenia and other fever syndromes. Episodes last an average of 3-4 days with intervals gradually becoming less frequent as the child ages. In one study, intervals at onset lasted an average of 28 days, but gradually extended to a mean 159 days during long-term follow-up in which average syndrome duration ranged from 5 to 7 years. Studies show a family history of recurrent fever in 10%-60% of patients, and recurrent tonsillitis in one parent is twice as likely among children with PFAPA.

Primary treatments for PFAPA include corticosteroids, cimetidine, and tonsillectomy, with anakinra, colchicine, and montelukast comprising additional options. Although the fever should subside within 4-12 hours after a corticosteroid dose of 1-2 mg/kg, a quarter of children may require a second dose within the next 12-24 hours, and corticosteroids treatment may increase episode frequency in up to half of children. By contrast, cimetidine is used prophylactically – twice daily over 6 months – and has led to remission in approximately a quarter of patients, although some experience recurrence after stopping treatment. The most successful intervention for curing PFAPA is tonsillectomy: Episodes completely stopped in 70%-97% of children in European and U.S. studies. But Dr. Edwards said the surgery should not be a first-line intervention.

“The role of the tonsils in all of the fever syndromes is quite fascinating, and I also think it’s interesting the parents have similar pharyngeal or oropharyngeal symptoms when they were children,” she said, noting that some research has been investigating tonsil cells for a better understanding of these syndromes.

“I think the decision to do a tonsillectomy is very dependent upon families,” she said. “I certainly don’t recommend it first thing, but there are some patients who have had these episodes for 2 or 3 years, the family is falling apart, and [the parents] are unable to go to work. In those situations, I will say this looks like something we should do.”

Familial fever syndromes

Dr. Edwards covered several familial fever syndromes during the remainder of the presentation using case studies to introduce each one. The first, familial Mediterranean fever (FMF), also known as Armenian disease, results from a mutation in the MEFV gene and occurs among those of Sephardic and Ashkenazi Jewish, Middle Eastern Arab, Armenian, Italian, North African or Turkish ethnicities.

Episodes last 12-72 hours, and clinical features include an erysipeloid rash and inflammation of various membranes, causing abdominal, chest or joint pain (serositis of the peritoneum, pleura or synovia, respectively). Treatment with colchicine can prevent FMF’s most significant complication, amyloidosis, which can otherwise lead to renal failure. About 95% of patients experience improvement, and 75% have remission with colchicine, and anakinra is an additional treatment option.

The second familial syndrome, hyperimmunoglobulinemia D with periodic fever syndrome, or hyper IgD (HIDS), has an early age of onset, typically before 12 months and with more than half before 6 months. Resulting from mutations in the MVK gene (and hence also called mevalonate kinase deficiency), HIDS primarily afflicts those with European ancestry, and about half of patients are of Dutch ancestry. Despite the syndrome’s name, about 22% of patients have normal IgD levels, and high IgD levels may indicate other conditions, so high IgD labs are not diagnostic. Diagnosis is based on genetic testing and elevated mevalonic acid levels in urine.

Stress, vaccination, or an upper respiratory infection may trigger a HIDS episode that lasts 3-7 days with clinical features that include a widespread red rash – frequently on the lower legs – as well as oral or vaginal ulcers. More than 80% of patients report swollen lymph nodes, abdominal pain, and joint pain, particularly in the knees, ankles, wrists, and elbows. More than half of patients report diarrhea, vomiting, skin lesions, headache, cold chills, or arthritis.

The final fever syndrome Dr. Edwards covered was tumor necrosis factor receptor–associated periodic syndrome (TRAPS), also called Hibernian fever. Resulting from mutations in TNFRSF1A gene, this condition first appeared in Scottish and Irish populations but can occur among any ethnicity. Episodes can last from a few days to 1-2 weeks, and can include migratory nonspecific pain, a rash, abdominal pain, joint pain, chest pain, mouth sores, puffy eyes, and various inflammatory eye symptoms, such as uveitis, iritis, and conjunctivitis.

Although PFAPA is the most common pediatric periodic fever syndrome, a thorough fever history and family history can help clinicians identify whether a familial syndrome is involved.

WASHINGTON – Understanding a child’s fever history and other symptoms is essential to accurately determining what is causing a fever and what kind of management, if any, it requires, Dr. Kathryn M. Edwards explained at the American Academy of Pediatrics annual meeting.

Dr. Edwards aimed largely to help clinicians distinguish between familial recurrent fever syndromes and the syndrome PFAPA (Periodic Fever, Aphthous Stomatitis, Pharyngitis, Cervical Adenitis). Although familial cases of PFAPA have been reported, the syndrome’s etiology isn’t fully understood.

©IPGGutenbergUKLtd/Thinkstock

She began with a review of fever definition and pathogenesis, and used a series of case studies to introduce various fever syndromes. Although the simplest definition is an above-normal body temperature, fever is best thought of not as “a single value, but rather a range depending on time, place, individual, and measurement site,” Dr. Edwards explained. An inflammatory response, fever may result from an infection or occur secondarily to other conditions. The inflammatory response begins after both monocytes and macrophages release cytokines that stimulate the brain’s thermoregulatory center, inducing prostaglandin production.

Recurrent and periodic fever overview

Unlike a fever of unknown origin, recurrent and periodic fevers occur regularly in repeated cycles or intermittently over a period of time. The most important step in identifying what’s going on with a child’s recurrent/periodic fever is taking a complete fever history, including not only exposures and travel, but also family history and ethnicity. Clinicians can provide parents with a fever diary that tracks fever date and time, the temperature, other symptoms, medication administered, and other relevant information because “knowing the fever pattern is critical,” Dr. Edwards emphasized. A good fever history also requires clinicians to conduct a comprehensive physical exam, be aware of temperature norms for a child’s age and sex, and diligently evaluate a child’s growth parameters.

Using a flowchart adapted from Long’s article in “Pediatric Clinics of North America,” Dr. Edwards pointed out that recurrent fever may result from identified infections or may be stereotypical and episodic without an infection. The source of multiple viral infections is generally environmental, such as day care or cigarette smoke exposure. Multiple bacterial infections involving different organ systems may indicate an immunodeficiency, whereas recurrent infections in the same organ system require assessment specific to that system. Among stereotypical recurrent fevers, irregular episodes likely indicate a monogenic fever syndrome, while more predictable episodes could be cyclic neutropenia or PFAPA.

“There are a couple remarkable differences between PFAPA patients and patients with repeated viral infections,” said Dr. Edwards , professor of pediatrics at Vanderbilt University, Nashville, Tenn. “One is the frequency of the fevers, how often they come,” which underscores the need for a meticulous fever history, she explained. A parent might perceive that the fevers come once a month, but it’s essential to know whether they truly come like clockwork or whether they are more sporadic. “In addition, between the episodes, the children get nothing else,” she said, “and certainly they’re not infectious. Nobody else gets sick.”

Recognizing PFAPA

Children with PFAPA show normal growth and development, and no symptoms between very regular intervals of fever (above 38.3º C) with sore throat, mouth sores, and/or glandular swelling in the absence of an infection. About two-thirds of patients report headache, sore throat and/or mouth ulcers, and more than three quarters report swelling of the lymph nodes. About half experience abdominal pain or nausea.

PFAPA typically has an early age of onset and is diagnosed after exclusion of cyclic neutropenia and other fever syndromes. Episodes last an average of 3-4 days with intervals gradually becoming less frequent as the child ages. In one study, intervals at onset lasted an average of 28 days, but gradually extended to a mean 159 days during long-term follow-up in which average syndrome duration ranged from 5 to 7 years. Studies show a family history of recurrent fever in 10%-60% of patients, and recurrent tonsillitis in one parent is twice as likely among children with PFAPA.

Primary treatments for PFAPA include corticosteroids, cimetidine, and tonsillectomy, with anakinra, colchicine, and montelukast comprising additional options. Although the fever should subside within 4-12 hours after a corticosteroid dose of 1-2 mg/kg, a quarter of children may require a second dose within the next 12-24 hours, and corticosteroids treatment may increase episode frequency in up to half of children. By contrast, cimetidine is used prophylactically – twice daily over 6 months – and has led to remission in approximately a quarter of patients, although some experience recurrence after stopping treatment. The most successful intervention for curing PFAPA is tonsillectomy: Episodes completely stopped in 70%-97% of children in European and U.S. studies. But Dr. Edwards said the surgery should not be a first-line intervention.

“The role of the tonsils in all of the fever syndromes is quite fascinating, and I also think it’s interesting the parents have similar pharyngeal or oropharyngeal symptoms when they were children,” she said, noting that some research has been investigating tonsil cells for a better understanding of these syndromes.

“I think the decision to do a tonsillectomy is very dependent upon families,” she said. “I certainly don’t recommend it first thing, but there are some patients who have had these episodes for 2 or 3 years, the family is falling apart, and [the parents] are unable to go to work. In those situations, I will say this looks like something we should do.”

Familial fever syndromes

Dr. Edwards covered several familial fever syndromes during the remainder of the presentation using case studies to introduce each one. The first, familial Mediterranean fever (FMF), also known as Armenian disease, results from a mutation in the MEFV gene and occurs among those of Sephardic and Ashkenazi Jewish, Middle Eastern Arab, Armenian, Italian, North African or Turkish ethnicities.

Episodes last 12-72 hours, and clinical features include an erysipeloid rash and inflammation of various membranes, causing abdominal, chest or joint pain (serositis of the peritoneum, pleura or synovia, respectively). Treatment with colchicine can prevent FMF’s most significant complication, amyloidosis, which can otherwise lead to renal failure. About 95% of patients experience improvement, and 75% have remission with colchicine, and anakinra is an additional treatment option.

The second familial syndrome, hyperimmunoglobulinemia D with periodic fever syndrome, or hyper IgD (HIDS), has an early age of onset, typically before 12 months and with more than half before 6 months. Resulting from mutations in the MVK gene (and hence also called mevalonate kinase deficiency), HIDS primarily afflicts those with European ancestry, and about half of patients are of Dutch ancestry. Despite the syndrome’s name, about 22% of patients have normal IgD levels, and high IgD levels may indicate other conditions, so high IgD labs are not diagnostic. Diagnosis is based on genetic testing and elevated mevalonic acid levels in urine.

Stress, vaccination, or an upper respiratory infection may trigger a HIDS episode that lasts 3-7 days with clinical features that include a widespread red rash – frequently on the lower legs – as well as oral or vaginal ulcers. More than 80% of patients report swollen lymph nodes, abdominal pain, and joint pain, particularly in the knees, ankles, wrists, and elbows. More than half of patients report diarrhea, vomiting, skin lesions, headache, cold chills, or arthritis.

The final fever syndrome Dr. Edwards covered was tumor necrosis factor receptor–associated periodic syndrome (TRAPS), also called Hibernian fever. Resulting from mutations in TNFRSF1A gene, this condition first appeared in Scottish and Irish populations but can occur among any ethnicity. Episodes can last from a few days to 1-2 weeks, and can include migratory nonspecific pain, a rash, abdominal pain, joint pain, chest pain, mouth sores, puffy eyes, and various inflammatory eye symptoms, such as uveitis, iritis, and conjunctivitis.

Although PFAPA is the most common pediatric periodic fever syndrome, a thorough fever history and family history can help clinicians identify whether a familial syndrome is involved.

WASHINGTON – Understanding a child’s fever history and other symptoms is essential to accurately determining what is causing a fever and what kind of management, if any, it requires, Dr. Kathryn M. Edwards explained at the American Academy of Pediatrics annual meeting.

Dr. Edwards aimed largely to help clinicians distinguish between familial recurrent fever syndromes and the syndrome PFAPA (Periodic Fever, Aphthous Stomatitis, Pharyngitis, Cervical Adenitis). Although familial cases of PFAPA have been reported, the syndrome’s etiology isn’t fully understood.

©IPGGutenbergUKLtd/Thinkstock

She began with a review of fever definition and pathogenesis, and used a series of case studies to introduce various fever syndromes. Although the simplest definition is an above-normal body temperature, fever is best thought of not as “a single value, but rather a range depending on time, place, individual, and measurement site,” Dr. Edwards explained. An inflammatory response, fever may result from an infection or occur secondarily to other conditions. The inflammatory response begins after both monocytes and macrophages release cytokines that stimulate the brain’s thermoregulatory center, inducing prostaglandin production.

Recurrent and periodic fever overview

Unlike a fever of unknown origin, recurrent and periodic fevers occur regularly in repeated cycles or intermittently over a period of time. The most important step in identifying what’s going on with a child’s recurrent/periodic fever is taking a complete fever history, including not only exposures and travel, but also family history and ethnicity. Clinicians can provide parents with a fever diary that tracks fever date and time, the temperature, other symptoms, medication administered, and other relevant information because “knowing the fever pattern is critical,” Dr. Edwards emphasized. A good fever history also requires clinicians to conduct a comprehensive physical exam, be aware of temperature norms for a child’s age and sex, and diligently evaluate a child’s growth parameters.

Using a flowchart adapted from Long’s article in “Pediatric Clinics of North America,” Dr. Edwards pointed out that recurrent fever may result from identified infections or may be stereotypical and episodic without an infection. The source of multiple viral infections is generally environmental, such as day care or cigarette smoke exposure. Multiple bacterial infections involving different organ systems may indicate an immunodeficiency, whereas recurrent infections in the same organ system require assessment specific to that system. Among stereotypical recurrent fevers, irregular episodes likely indicate a monogenic fever syndrome, while more predictable episodes could be cyclic neutropenia or PFAPA.

“There are a couple remarkable differences between PFAPA patients and patients with repeated viral infections,” said Dr. Edwards , professor of pediatrics at Vanderbilt University, Nashville, Tenn. “One is the frequency of the fevers, how often they come,” which underscores the need for a meticulous fever history, she explained. A parent might perceive that the fevers come once a month, but it’s essential to know whether they truly come like clockwork or whether they are more sporadic. “In addition, between the episodes, the children get nothing else,” she said, “and certainly they’re not infectious. Nobody else gets sick.”

Recognizing PFAPA

Children with PFAPA show normal growth and development, and no symptoms between very regular intervals of fever (above 38.3º C) with sore throat, mouth sores, and/or glandular swelling in the absence of an infection. About two-thirds of patients report headache, sore throat and/or mouth ulcers, and more than three quarters report swelling of the lymph nodes. About half experience abdominal pain or nausea.

PFAPA typically has an early age of onset and is diagnosed after exclusion of cyclic neutropenia and other fever syndromes. Episodes last an average of 3-4 days with intervals gradually becoming less frequent as the child ages. In one study, intervals at onset lasted an average of 28 days, but gradually extended to a mean 159 days during long-term follow-up in which average syndrome duration ranged from 5 to 7 years. Studies show a family history of recurrent fever in 10%-60% of patients, and recurrent tonsillitis in one parent is twice as likely among children with PFAPA.

Primary treatments for PFAPA include corticosteroids, cimetidine, and tonsillectomy, with anakinra, colchicine, and montelukast comprising additional options. Although the fever should subside within 4-12 hours after a corticosteroid dose of 1-2 mg/kg, a quarter of children may require a second dose within the next 12-24 hours, and corticosteroids treatment may increase episode frequency in up to half of children. By contrast, cimetidine is used prophylactically – twice daily over 6 months – and has led to remission in approximately a quarter of patients, although some experience recurrence after stopping treatment. The most successful intervention for curing PFAPA is tonsillectomy: Episodes completely stopped in 70%-97% of children in European and U.S. studies. But Dr. Edwards said the surgery should not be a first-line intervention.

“The role of the tonsils in all of the fever syndromes is quite fascinating, and I also think it’s interesting the parents have similar pharyngeal or oropharyngeal symptoms when they were children,” she said, noting that some research has been investigating tonsil cells for a better understanding of these syndromes.

“I think the decision to do a tonsillectomy is very dependent upon families,” she said. “I certainly don’t recommend it first thing, but there are some patients who have had these episodes for 2 or 3 years, the family is falling apart, and [the parents] are unable to go to work. In those situations, I will say this looks like something we should do.”

Familial fever syndromes

Dr. Edwards covered several familial fever syndromes during the remainder of the presentation using case studies to introduce each one. The first, familial Mediterranean fever (FMF), also known as Armenian disease, results from a mutation in the MEFV gene and occurs among those of Sephardic and Ashkenazi Jewish, Middle Eastern Arab, Armenian, Italian, North African or Turkish ethnicities.

Episodes last 12-72 hours, and clinical features include an erysipeloid rash and inflammation of various membranes, causing abdominal, chest or joint pain (serositis of the peritoneum, pleura or synovia, respectively). Treatment with colchicine can prevent FMF’s most significant complication, amyloidosis, which can otherwise lead to renal failure. About 95% of patients experience improvement, and 75% have remission with colchicine, and anakinra is an additional treatment option.

The second familial syndrome, hyperimmunoglobulinemia D with periodic fever syndrome, or hyper IgD (HIDS), has an early age of onset, typically before 12 months and with more than half before 6 months. Resulting from mutations in the MVK gene (and hence also called mevalonate kinase deficiency), HIDS primarily afflicts those with European ancestry, and about half of patients are of Dutch ancestry. Despite the syndrome’s name, about 22% of patients have normal IgD levels, and high IgD levels may indicate other conditions, so high IgD labs are not diagnostic. Diagnosis is based on genetic testing and elevated mevalonic acid levels in urine.

Stress, vaccination, or an upper respiratory infection may trigger a HIDS episode that lasts 3-7 days with clinical features that include a widespread red rash – frequently on the lower legs – as well as oral or vaginal ulcers. More than 80% of patients report swollen lymph nodes, abdominal pain, and joint pain, particularly in the knees, ankles, wrists, and elbows. More than half of patients report diarrhea, vomiting, skin lesions, headache, cold chills, or arthritis.

The final fever syndrome Dr. Edwards covered was tumor necrosis factor receptor–associated periodic syndrome (TRAPS), also called Hibernian fever. Resulting from mutations in TNFRSF1A gene, this condition first appeared in Scottish and Irish populations but can occur among any ethnicity. Episodes can last from a few days to 1-2 weeks, and can include migratory nonspecific pain, a rash, abdominal pain, joint pain, chest pain, mouth sores, puffy eyes, and various inflammatory eye symptoms, such as uveitis, iritis, and conjunctivitis.

Although PFAPA is the most common pediatric periodic fever syndrome, a thorough fever history and family history can help clinicians identify whether a familial syndrome is involved.

WASHINGTON – With fluoride varnish treatments now on the Bright Futures periodicity schedule, reimbursement is attainable, and pediatricians can focus on integrating the 45- to 60-second procedure into their practices and strengthening their oral health messaging to families.

Pediatrician Melinda Clark and pediatric dentist Rocio B. Quiñonez teamed up at the annual meeting of the American Academy of Pediatrics to deliver this message and to show pediatricians through a hands-on workshop how simple and important fluoride varnishing and oral health counseling are to pediatric preventive care.

Christine Kilgore

“We have to own a part of this,” said Dr. Clark of the Albany (N.Y.) Medical Center Pediatric Group. With the dental community overloaded and dental caries the most common chronic childhood disease, “we cannot just cut out the teeth from our medical prevention paradigm.”

Dental caries is five times more common than asthma and seven times more common than hay fever. One in four children begin kindergarten with a history of early childhood caries, and children with the disease are three times as likely to miss school. The disease can progress to local infections, systemic infection, and in rare cases, death.

In 2014, the U.S. Preventive Services Task Force (USPSTF) recommended that primary care clinicians apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption. The USPSTF did not specifically recommend the frequency of application, but in a clinical report published later in 2014 on “Fluoride Use in Caries Prevention in the Primary Care Setting,” the American Academy of Pediatrics recommended fluoride varnish at least once every 6 months – and preferably every 3 months – starting at tooth emergence (Pediatrics. 2014 Sep;134[3]:626-33).

Courtesy Dr. Rocio Quinonez

And in September 2015, fluoride varnish was added to the Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents and integrated into the Bright Futures–AAP periodicity schedule.

Both the B recommendation given by the USPSTF to fluoride varnish application and inclusion in the Bright Futures periodicity schedule mean that it is required by the Affordable Care Act to be covered by insurers without out of pocket costs to the patient. Currently, 49 states are reimbursing physicians for fluoride varnish in the Medicaid population.

“It’s become the standard of care,” said Dr. Quiñonez of the division of pediatric dentistry at the University of North Carolina at Chapel Hill.

Fluoride varnish is a concentrated topical fluoride that sets on contact with saliva and helps prevent caries by enhancing remineralization and inhibiting bacterial enzymes. It has been shown to reduce decay by 30%-63%, depending on whether it is coupled with dental health counseling. The treatment has its greatest effect when applied before the onset of caries, but it also may help halt or reverse early carious lesions, which present as decalcified “white spot lesions” along the gum line.

Courtesy Dr. Rocio Quinonez

“We have months, often times many months, to prevent disease and to intervene in the earliest stages [of childhood caries] … before children end up in the hospital or operating room,” said Dr. Clark, a former member of the AAP’s Section on Oral Health Executive Committee and a lead author of the AAP’s report on fluoride use.

She advised taking a systematic approach to applying the varnish. “I often apply it by arches [upper and lower, one dab per arch], as opposed to quadrants,” she said. “As long as you’re painting all the surfaces of every tooth with a thin layer of fluoride varnish, it’s an incredibly safe and effective procedure.”

“And you’ll get good at keeping the tongue out of the way using the gauze,” she said.

Varnish is best applied in infants and toddlers in a knee-to-knee format [provider-to-parent] with the child facing the parent and holding the parent’s hands, and the provider tipping the child into his or her lap. The teeth are dried first with a 2-inch gauze square. The fluoride is painted on with a brush provided with the varnish. Dr. Clark uses a head lamp as a light source so she has full use of both hands. Some providers use a dental mirror to increase visibility, but “I don’t find this necessary for most young children,” she said.

Courtesy Dr. Rocio Quinonez

Questions about the safety of fluoride overall and fluoride varnish specifically “will come up” during discussions of oral health, Dr. Clark said. The only scientifically proven risk of fluoride is the development of fluorosis, which may occur if too much fluoride is ingested during the period of tooth and bone development, she said.

The small rise in plasma fluoride levels that can follow an application of fluoride varnish is comparable to ingesting a 1 mg fluoride tablet or brushing with fluoridated toothpaste, Dr. Clark said. Parents should be instructed not to brush the child’s teeth that evening or give any fluoride supplementation that day, if supplements are being used.

Not brushing teeth until the next morning also allows the varnish to stay on and continue depositing fluoride, she said. The child may eat, drink, and use a pacifier immediately after a varnish application. Hot, sticky, and crunchy foods should be avoided the same day.

The only contraindications to fluoride varnish are allergy to colophony/pine rosin, allergy to pine nuts, and ulcerative gingivitis/stomatitis or other open lesions. There are only three cases in the literature of side effects: one case of contact dermatitis and two cases of stomatitis. Colophony-free versions of fluoride varnish are available, Dr. Clark said.

Courtesy Dr. Rocio Quinonez

Fluoride varnish is approved by the Food and Drug Administration as a cavity liner – not as a cavity prevention agent – but more than 110 studies and 40 clinical trials have documented its safety and effectiveness for cavity prevention, Dr. Clark reported. The 0.25 ml dose of varnish, which costs between $1 and $2, is the appropriate dose for children aged 4 years and under.Fluoride varnish is part of a bigger picture of oral health care in pediatrics – one that, first and foremost, involves “routinely asking if your patients have a dental home,” Dr. Clark said. The effectiveness of fluoride varnish is enhanced by regular discussions of oral health and counseling about risk factors for early childhood caries, such as frequent snacking and continual bottle or sippy cup use with fluid other than water.

Both Dr. Clark and Dr. Quiñonez urged pediatricians to take advantage of the parallels between obesity prevention and early childhood caries prevention nutritional messages (such as the risks of frequent juice and soda). And Dr. Clark suggested talking about bacteria and not just hygiene. “It sounds better to blame the evil bacteria than it does to blame poor hygiene, and that’s fine,” she said. “We can talk about how we’re going to keep the bacteria at bay.”

Dr. Quiñonez pointed out that children who were born premature or with low birth weights tend to have a higher prevalence of enamel defects and therefore are at greater risk of developing early childhood caries.

Courtesy Dr. Rocio Quinonez

The AAP successfully advocated that fluoride varnish application be reimbursed as a separately reported service with use of the medical CPT code 99188. Use of the code to report fluoride varnish application by a physician or other qualified health professional took effect in January 2015. In some states, the dental code D1206 has been used with a V modifier specific to prophylactic fluoride administration for reimbursement through Medicaid and managed care. The modifier for use in ICD-10 is Z41.8.

“I’m in New York state, and we’ve been reimbursed $30 per fluoride varnish application (since 2009), and this includes risk assessment and counseling,” said Dr. Clark. “Some states pay in the single digits, and some pay in the high $50s.”

State by state information on payment and a host of practice tools and information on fluoride, fluoride varnish, and oral health risk assessment and counseling are available at the AAP’s Oral Health website. The site also provides links to each state’s AAP Chapter Oral Health Advocate who provides or coordinates education and training.

WASHINGTON – With fluoride varnish treatments now on the Bright Futures periodicity schedule, reimbursement is attainable, and pediatricians can focus on integrating the 45- to 60-second procedure into their practices and strengthening their oral health messaging to families.

Pediatrician Melinda Clark and pediatric dentist Rocio B. Quiñonez teamed up at the annual meeting of the American Academy of Pediatrics to deliver this message and to show pediatricians through a hands-on workshop how simple and important fluoride varnishing and oral health counseling are to pediatric preventive care.

Christine Kilgore

“We have to own a part of this,” said Dr. Clark of the Albany (N.Y.) Medical Center Pediatric Group. With the dental community overloaded and dental caries the most common chronic childhood disease, “we cannot just cut out the teeth from our medical prevention paradigm.”

Dental caries is five times more common than asthma and seven times more common than hay fever. One in four children begin kindergarten with a history of early childhood caries, and children with the disease are three times as likely to miss school. The disease can progress to local infections, systemic infection, and in rare cases, death.

In 2014, the U.S. Preventive Services Task Force (USPSTF) recommended that primary care clinicians apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption. The USPSTF did not specifically recommend the frequency of application, but in a clinical report published later in 2014 on “Fluoride Use in Caries Prevention in the Primary Care Setting,” the American Academy of Pediatrics recommended fluoride varnish at least once every 6 months – and preferably every 3 months – starting at tooth emergence (Pediatrics. 2014 Sep;134[3]:626-33).

Courtesy Dr. Rocio Quinonez

And in September 2015, fluoride varnish was added to the Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents and integrated into the Bright Futures–AAP periodicity schedule.

Both the B recommendation given by the USPSTF to fluoride varnish application and inclusion in the Bright Futures periodicity schedule mean that it is required by the Affordable Care Act to be covered by insurers without out of pocket costs to the patient. Currently, 49 states are reimbursing physicians for fluoride varnish in the Medicaid population.

“It’s become the standard of care,” said Dr. Quiñonez of the division of pediatric dentistry at the University of North Carolina at Chapel Hill.

Fluoride varnish is a concentrated topical fluoride that sets on contact with saliva and helps prevent caries by enhancing remineralization and inhibiting bacterial enzymes. It has been shown to reduce decay by 30%-63%, depending on whether it is coupled with dental health counseling. The treatment has its greatest effect when applied before the onset of caries, but it also may help halt or reverse early carious lesions, which present as decalcified “white spot lesions” along the gum line.

Courtesy Dr. Rocio Quinonez

“We have months, often times many months, to prevent disease and to intervene in the earliest stages [of childhood caries] … before children end up in the hospital or operating room,” said Dr. Clark, a former member of the AAP’s Section on Oral Health Executive Committee and a lead author of the AAP’s report on fluoride use.

She advised taking a systematic approach to applying the varnish. “I often apply it by arches [upper and lower, one dab per arch], as opposed to quadrants,” she said. “As long as you’re painting all the surfaces of every tooth with a thin layer of fluoride varnish, it’s an incredibly safe and effective procedure.”

“And you’ll get good at keeping the tongue out of the way using the gauze,” she said.

Varnish is best applied in infants and toddlers in a knee-to-knee format [provider-to-parent] with the child facing the parent and holding the parent’s hands, and the provider tipping the child into his or her lap. The teeth are dried first with a 2-inch gauze square. The fluoride is painted on with a brush provided with the varnish. Dr. Clark uses a head lamp as a light source so she has full use of both hands. Some providers use a dental mirror to increase visibility, but “I don’t find this necessary for most young children,” she said.

Courtesy Dr. Rocio Quinonez

Questions about the safety of fluoride overall and fluoride varnish specifically “will come up” during discussions of oral health, Dr. Clark said. The only scientifically proven risk of fluoride is the development of fluorosis, which may occur if too much fluoride is ingested during the period of tooth and bone development, she said.

The small rise in plasma fluoride levels that can follow an application of fluoride varnish is comparable to ingesting a 1 mg fluoride tablet or brushing with fluoridated toothpaste, Dr. Clark said. Parents should be instructed not to brush the child’s teeth that evening or give any fluoride supplementation that day, if supplements are being used.

Not brushing teeth until the next morning also allows the varnish to stay on and continue depositing fluoride, she said. The child may eat, drink, and use a pacifier immediately after a varnish application. Hot, sticky, and crunchy foods should be avoided the same day.

The only contraindications to fluoride varnish are allergy to colophony/pine rosin, allergy to pine nuts, and ulcerative gingivitis/stomatitis or other open lesions. There are only three cases in the literature of side effects: one case of contact dermatitis and two cases of stomatitis. Colophony-free versions of fluoride varnish are available, Dr. Clark said.

Courtesy Dr. Rocio Quinonez

Fluoride varnish is approved by the Food and Drug Administration as a cavity liner – not as a cavity prevention agent – but more than 110 studies and 40 clinical trials have documented its safety and effectiveness for cavity prevention, Dr. Clark reported. The 0.25 ml dose of varnish, which costs between $1 and $2, is the appropriate dose for children aged 4 years and under.Fluoride varnish is part of a bigger picture of oral health care in pediatrics – one that, first and foremost, involves “routinely asking if your patients have a dental home,” Dr. Clark said. The effectiveness of fluoride varnish is enhanced by regular discussions of oral health and counseling about risk factors for early childhood caries, such as frequent snacking and continual bottle or sippy cup use with fluid other than water.

Both Dr. Clark and Dr. Quiñonez urged pediatricians to take advantage of the parallels between obesity prevention and early childhood caries prevention nutritional messages (such as the risks of frequent juice and soda). And Dr. Clark suggested talking about bacteria and not just hygiene. “It sounds better to blame the evil bacteria than it does to blame poor hygiene, and that’s fine,” she said. “We can talk about how we’re going to keep the bacteria at bay.”

Dr. Quiñonez pointed out that children who were born premature or with low birth weights tend to have a higher prevalence of enamel defects and therefore are at greater risk of developing early childhood caries.

Courtesy Dr. Rocio Quinonez

The AAP successfully advocated that fluoride varnish application be reimbursed as a separately reported service with use of the medical CPT code 99188. Use of the code to report fluoride varnish application by a physician or other qualified health professional took effect in January 2015. In some states, the dental code D1206 has been used with a V modifier specific to prophylactic fluoride administration for reimbursement through Medicaid and managed care. The modifier for use in ICD-10 is Z41.8.

“I’m in New York state, and we’ve been reimbursed $30 per fluoride varnish application (since 2009), and this includes risk assessment and counseling,” said Dr. Clark. “Some states pay in the single digits, and some pay in the high $50s.”

State by state information on payment and a host of practice tools and information on fluoride, fluoride varnish, and oral health risk assessment and counseling are available at the AAP’s Oral Health website. The site also provides links to each state’s AAP Chapter Oral Health Advocate who provides or coordinates education and training.

WASHINGTON – With fluoride varnish treatments now on the Bright Futures periodicity schedule, reimbursement is attainable, and pediatricians can focus on integrating the 45- to 60-second procedure into their practices and strengthening their oral health messaging to families.

Pediatrician Melinda Clark and pediatric dentist Rocio B. Quiñonez teamed up at the annual meeting of the American Academy of Pediatrics to deliver this message and to show pediatricians through a hands-on workshop how simple and important fluoride varnishing and oral health counseling are to pediatric preventive care.

Christine Kilgore

“We have to own a part of this,” said Dr. Clark of the Albany (N.Y.) Medical Center Pediatric Group. With the dental community overloaded and dental caries the most common chronic childhood disease, “we cannot just cut out the teeth from our medical prevention paradigm.”

Dental caries is five times more common than asthma and seven times more common than hay fever. One in four children begin kindergarten with a history of early childhood caries, and children with the disease are three times as likely to miss school. The disease can progress to local infections, systemic infection, and in rare cases, death.

In 2014, the U.S. Preventive Services Task Force (USPSTF) recommended that primary care clinicians apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption. The USPSTF did not specifically recommend the frequency of application, but in a clinical report published later in 2014 on “Fluoride Use in Caries Prevention in the Primary Care Setting,” the American Academy of Pediatrics recommended fluoride varnish at least once every 6 months – and preferably every 3 months – starting at tooth emergence (Pediatrics. 2014 Sep;134[3]:626-33).

Courtesy Dr. Rocio Quinonez

And in September 2015, fluoride varnish was added to the Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents and integrated into the Bright Futures–AAP periodicity schedule.

Both the B recommendation given by the USPSTF to fluoride varnish application and inclusion in the Bright Futures periodicity schedule mean that it is required by the Affordable Care Act to be covered by insurers without out of pocket costs to the patient. Currently, 49 states are reimbursing physicians for fluoride varnish in the Medicaid population.

“It’s become the standard of care,” said Dr. Quiñonez of the division of pediatric dentistry at the University of North Carolina at Chapel Hill.

Fluoride varnish is a concentrated topical fluoride that sets on contact with saliva and helps prevent caries by enhancing remineralization and inhibiting bacterial enzymes. It has been shown to reduce decay by 30%-63%, depending on whether it is coupled with dental health counseling. The treatment has its greatest effect when applied before the onset of caries, but it also may help halt or reverse early carious lesions, which present as decalcified “white spot lesions” along the gum line.

Courtesy Dr. Rocio Quinonez

“We have months, often times many months, to prevent disease and to intervene in the earliest stages [of childhood caries] … before children end up in the hospital or operating room,” said Dr. Clark, a former member of the AAP’s Section on Oral Health Executive Committee and a lead author of the AAP’s report on fluoride use.

She advised taking a systematic approach to applying the varnish. “I often apply it by arches [upper and lower, one dab per arch], as opposed to quadrants,” she said. “As long as you’re painting all the surfaces of every tooth with a thin layer of fluoride varnish, it’s an incredibly safe and effective procedure.”

“And you’ll get good at keeping the tongue out of the way using the gauze,” she said.

Varnish is best applied in infants and toddlers in a knee-to-knee format [provider-to-parent] with the child facing the parent and holding the parent’s hands, and the provider tipping the child into his or her lap. The teeth are dried first with a 2-inch gauze square. The fluoride is painted on with a brush provided with the varnish. Dr. Clark uses a head lamp as a light source so she has full use of both hands. Some providers use a dental mirror to increase visibility, but “I don’t find this necessary for most young children,” she said.

Courtesy Dr. Rocio Quinonez

Questions about the safety of fluoride overall and fluoride varnish specifically “will come up” during discussions of oral health, Dr. Clark said. The only scientifically proven risk of fluoride is the development of fluorosis, which may occur if too much fluoride is ingested during the period of tooth and bone development, she said.

The small rise in plasma fluoride levels that can follow an application of fluoride varnish is comparable to ingesting a 1 mg fluoride tablet or brushing with fluoridated toothpaste, Dr. Clark said. Parents should be instructed not to brush the child’s teeth that evening or give any fluoride supplementation that day, if supplements are being used.

Not brushing teeth until the next morning also allows the varnish to stay on and continue depositing fluoride, she said. The child may eat, drink, and use a pacifier immediately after a varnish application. Hot, sticky, and crunchy foods should be avoided the same day.

The only contraindications to fluoride varnish are allergy to colophony/pine rosin, allergy to pine nuts, and ulcerative gingivitis/stomatitis or other open lesions. There are only three cases in the literature of side effects: one case of contact dermatitis and two cases of stomatitis. Colophony-free versions of fluoride varnish are available, Dr. Clark said.

Courtesy Dr. Rocio Quinonez

Fluoride varnish is approved by the Food and Drug Administration as a cavity liner – not as a cavity prevention agent – but more than 110 studies and 40 clinical trials have documented its safety and effectiveness for cavity prevention, Dr. Clark reported. The 0.25 ml dose of varnish, which costs between $1 and $2, is the appropriate dose for children aged 4 years and under.Fluoride varnish is part of a bigger picture of oral health care in pediatrics – one that, first and foremost, involves “routinely asking if your patients have a dental home,” Dr. Clark said. The effectiveness of fluoride varnish is enhanced by regular discussions of oral health and counseling about risk factors for early childhood caries, such as frequent snacking and continual bottle or sippy cup use with fluid other than water.

Both Dr. Clark and Dr. Quiñonez urged pediatricians to take advantage of the parallels between obesity prevention and early childhood caries prevention nutritional messages (such as the risks of frequent juice and soda). And Dr. Clark suggested talking about bacteria and not just hygiene. “It sounds better to blame the evil bacteria than it does to blame poor hygiene, and that’s fine,” she said. “We can talk about how we’re going to keep the bacteria at bay.”

Dr. Quiñonez pointed out that children who were born premature or with low birth weights tend to have a higher prevalence of enamel defects and therefore are at greater risk of developing early childhood caries.

Courtesy Dr. Rocio Quinonez

The AAP successfully advocated that fluoride varnish application be reimbursed as a separately reported service with use of the medical CPT code 99188. Use of the code to report fluoride varnish application by a physician or other qualified health professional took effect in January 2015. In some states, the dental code D1206 has been used with a V modifier specific to prophylactic fluoride administration for reimbursement through Medicaid and managed care. The modifier for use in ICD-10 is Z41.8.

“I’m in New York state, and we’ve been reimbursed $30 per fluoride varnish application (since 2009), and this includes risk assessment and counseling,” said Dr. Clark. “Some states pay in the single digits, and some pay in the high $50s.”

State by state information on payment and a host of practice tools and information on fluoride, fluoride varnish, and oral health risk assessment and counseling are available at the AAP’s Oral Health website. The site also provides links to each state’s AAP Chapter Oral Health Advocate who provides or coordinates education and training.

WASHINGTON – Pediatric practices can combat the toxic stress created by intimate partner violence – and often prevent child maltreatment – by providing “multiple layers of opportunity” for disclosure and access to resources, Dr. Kimberly Randell said at the annual meeting of the American Academy of Pediatrics.

Each year, approximately 15.5 million children – disproportionately younger children – are exposed to intimate partner violence (IPV) (J Fam Psychol. 2006;20[1]:137-42). Their mothers, IPV victims, will seek care for their children when they don’t seek care for themselves, and they will address IPV for their children, she said.

“These are women who are coming in for the 2-, 4-, 6-month visits, but haven’t seen their ob for the postpartum visit ,and they may not see their primary care physician for several more years,” said Dr. Randell, who coordinates the IPV program at Children’s Mercy Hospital in Kansas City, Mo. “They’ll address IPV in the context of how it affects their kids.”

Between 1 in 3 women and 1 in 4 men will experience intimate partner violence (IPV) at some point in their lifetime, according to The National Intimate Partner and Sexual Violence Survey 2010 Summary Report by the Centers for Disease Control and Prevention. Families experiencing IPV “look no different from families who aren’t,” making it worthwhile to universally screen for the problem as part of anticipatory guidance. There is no hard evidence favoring written or verbal assessment – “it all depends on what works best for your practice,” Dr. Randell said.

However, she implored pediatricians to line up advocacy resources, educate staff, and develop processes for intervention. “We know that if you just hand someone a pamphlet or a help line number and say ‘call when you’re ready,’ the odds are they’re not going to call,” Dr. Randell said.

Instead, tell the mother you would like to connect her with a community partner who specializes in IVP and can help her figure out a plan for her and her child’s safety. Ideally, a nurse or staff member in the pediatric office who is educated about IVP could be the initial link – someone “to whom you can make a warm hand-off.”

In this case, she explained, the pediatrician can “say something like, ‘I’d like you to talk with Jennifer. She knows a lot about situations like these and can offer some resources. We can even make the call from the office today.’ ”

Phone calls made from the office, when agreed to, are “very safe calls,” Dr. Randell emphasized.

Ideally, pediatric offices can partner with a local IPV agency for education and referrals. Other possibilities are the social work department at a local children’s hospital or the National Domestic Violence hot line (1-800-799-7233, 1-800-787-3224 TTY). Dr. Randell advised using the term “help line” instead of “hotline” because, in her experience, families associate a “hotline” with children “being taken away.”

Physicians worry about damaging trust by asking about IPV, but numerous studies show most mothers agree that pediatric health care providers should ask.

Introducing questions about IPV with a “framing statement” can minimize any perception of judgment. An example: “Because violence at home is common and affects children’s health and safety, I now ask all families in my practice about exposure to violence.”

The framing statement can then be followed with an indirect question such as “Do you feel safe at home and in your relationship?” or a more direct question, such as:

• “Has your child ever seen a violent or frightening event at home or in your neighborhood?”

• “Have you ever been hurt or threatened by your partner?”

• “Do you ever feel afraid of or controlled by or isolated by your partner?”

IPV is an adverse childhood experience that not only creates toxic stress, but puts children at significantly higher risk – up to 15 times the risk – for all forms of childhood maltreatment. Men also experience IPV, but women are most frequently the nonoffenders, she noted.

Pediatricians should know their states’ child abuse and IVP reporting laws, and inform the nonoffending parent of any limits on confidentiality. “If your state has mandatory reporting for exposure to IVP, you need to let the parent know,” she said. “They need to be able to take this into consideration when they’re deciding if it’s safe or the right time to disclose.”

Dr. Randell advised physicians to try to involve the parent when reporting IPV, either per mandatory reporting laws or per results of a child safety assessment. Explain that you’d like them to make the report with you,” she said. “This can be an important step in maintaining a trusting relationship and empowering her.”

Care must be taken in documenting IPV disclosure because the abusive parent often has access to the child’s chart and/or receives insurance statements. Dr. Randell offered several tips:

Use limited, coded documentation in the chart.

• Do not use IPV-related billing codes or mention the terms “domestic violence” or “IPV.”

• Do not use the word shelter or include notes about safety plans.

• Do not screen in the presence of verbal children, or children aged 3 years and older.

Children may inadvertently tell the abuser that mom has been talking to someone, she explained. “And it’s also probably bad for kids to hear mom denying [IPV] because it reinforces that this is a behavior that we keep secret and don’t talk about.”

Posters, pamphlets, and other environmental cues are an important layer for helping families who are experiencing IPV, largely because these items provide women with the opportunity to access resources without having to disclose IPV.

In focus groups at Children’s Mercy, mothers who had experienced or were experiencing IPV said they wanted information “not only on what IPV looks like … but about how it impacts kids, about resources, and about safety planning,” Dr. Randell said. “And they wanted things that are hopeful ... They don’t want to be labeled [as victims].”

There are several validated screening instruments for IPV (such as the Partner Violence Screen and the Woman Abuse Screening Tool), but the tools have significantly variable sensitivities and specificities and have not been studied in pediatric settings. General psychosocial screening tools used in pediatrics, such as the Pediatric Symptom Checklist and the Strengths and Difficulties Questionnaire, may provide clues of possible trauma, including IPV, she noted.

Among the resources recommended by Dr. Randell:

• The Harvard Center for the Developing Child (www.developingchild.harvard.edu).

• Futures Without Violence (www.futureswithoutviolence.org).

• AAP’s policy statement on IPV: pediatrics.aappublications.org/content/125/5/1094).

WASHINGTON – Pediatric practices can combat the toxic stress created by intimate partner violence – and often prevent child maltreatment – by providing “multiple layers of opportunity” for disclosure and access to resources, Dr. Kimberly Randell said at the annual meeting of the American Academy of Pediatrics.

Each year, approximately 15.5 million children – disproportionately younger children – are exposed to intimate partner violence (IPV) (J Fam Psychol. 2006;20[1]:137-42). Their mothers, IPV victims, will seek care for their children when they don’t seek care for themselves, and they will address IPV for their children, she said.

“These are women who are coming in for the 2-, 4-, 6-month visits, but haven’t seen their ob for the postpartum visit ,and they may not see their primary care physician for several more years,” said Dr. Randell, who coordinates the IPV program at Children’s Mercy Hospital in Kansas City, Mo. “They’ll address IPV in the context of how it affects their kids.”

Between 1 in 3 women and 1 in 4 men will experience intimate partner violence (IPV) at some point in their lifetime, according to The National Intimate Partner and Sexual Violence Survey 2010 Summary Report by the Centers for Disease Control and Prevention. Families experiencing IPV “look no different from families who aren’t,” making it worthwhile to universally screen for the problem as part of anticipatory guidance. There is no hard evidence favoring written or verbal assessment – “it all depends on what works best for your practice,” Dr. Randell said.

However, she implored pediatricians to line up advocacy resources, educate staff, and develop processes for intervention. “We know that if you just hand someone a pamphlet or a help line number and say ‘call when you’re ready,’ the odds are they’re not going to call,” Dr. Randell said.

Instead, tell the mother you would like to connect her with a community partner who specializes in IVP and can help her figure out a plan for her and her child’s safety. Ideally, a nurse or staff member in the pediatric office who is educated about IVP could be the initial link – someone “to whom you can make a warm hand-off.”

In this case, she explained, the pediatrician can “say something like, ‘I’d like you to talk with Jennifer. She knows a lot about situations like these and can offer some resources. We can even make the call from the office today.’ ”

Phone calls made from the office, when agreed to, are “very safe calls,” Dr. Randell emphasized.

Ideally, pediatric offices can partner with a local IPV agency for education and referrals. Other possibilities are the social work department at a local children’s hospital or the National Domestic Violence hot line (1-800-799-7233, 1-800-787-3224 TTY). Dr. Randell advised using the term “help line” instead of “hotline” because, in her experience, families associate a “hotline” with children “being taken away.”

Physicians worry about damaging trust by asking about IPV, but numerous studies show most mothers agree that pediatric health care providers should ask.

Introducing questions about IPV with a “framing statement” can minimize any perception of judgment. An example: “Because violence at home is common and affects children’s health and safety, I now ask all families in my practice about exposure to violence.”

The framing statement can then be followed with an indirect question such as “Do you feel safe at home and in your relationship?” or a more direct question, such as:

• “Has your child ever seen a violent or frightening event at home or in your neighborhood?”

• “Have you ever been hurt or threatened by your partner?”

• “Do you ever feel afraid of or controlled by or isolated by your partner?”

IPV is an adverse childhood experience that not only creates toxic stress, but puts children at significantly higher risk – up to 15 times the risk – for all forms of childhood maltreatment. Men also experience IPV, but women are most frequently the nonoffenders, she noted.

Pediatricians should know their states’ child abuse and IVP reporting laws, and inform the nonoffending parent of any limits on confidentiality. “If your state has mandatory reporting for exposure to IVP, you need to let the parent know,” she said. “They need to be able to take this into consideration when they’re deciding if it’s safe or the right time to disclose.”

Dr. Randell advised physicians to try to involve the parent when reporting IPV, either per mandatory reporting laws or per results of a child safety assessment. Explain that you’d like them to make the report with you,” she said. “This can be an important step in maintaining a trusting relationship and empowering her.”

Care must be taken in documenting IPV disclosure because the abusive parent often has access to the child’s chart and/or receives insurance statements. Dr. Randell offered several tips:

Use limited, coded documentation in the chart.

• Do not use IPV-related billing codes or mention the terms “domestic violence” or “IPV.”

• Do not use the word shelter or include notes about safety plans.

• Do not screen in the presence of verbal children, or children aged 3 years and older.

Children may inadvertently tell the abuser that mom has been talking to someone, she explained. “And it’s also probably bad for kids to hear mom denying [IPV] because it reinforces that this is a behavior that we keep secret and don’t talk about.”

Posters, pamphlets, and other environmental cues are an important layer for helping families who are experiencing IPV, largely because these items provide women with the opportunity to access resources without having to disclose IPV.

In focus groups at Children’s Mercy, mothers who had experienced or were experiencing IPV said they wanted information “not only on what IPV looks like … but about how it impacts kids, about resources, and about safety planning,” Dr. Randell said. “And they wanted things that are hopeful ... They don’t want to be labeled [as victims].”

There are several validated screening instruments for IPV (such as the Partner Violence Screen and the Woman Abuse Screening Tool), but the tools have significantly variable sensitivities and specificities and have not been studied in pediatric settings. General psychosocial screening tools used in pediatrics, such as the Pediatric Symptom Checklist and the Strengths and Difficulties Questionnaire, may provide clues of possible trauma, including IPV, she noted.

Among the resources recommended by Dr. Randell:

• The Harvard Center for the Developing Child (www.developingchild.harvard.edu).

• Futures Without Violence (www.futureswithoutviolence.org).

• AAP’s policy statement on IPV: pediatrics.aappublications.org/content/125/5/1094).

WASHINGTON – Pediatric practices can combat the toxic stress created by intimate partner violence – and often prevent child maltreatment – by providing “multiple layers of opportunity” for disclosure and access to resources, Dr. Kimberly Randell said at the annual meeting of the American Academy of Pediatrics.

Each year, approximately 15.5 million children – disproportionately younger children – are exposed to intimate partner violence (IPV) (J Fam Psychol. 2006;20[1]:137-42). Their mothers, IPV victims, will seek care for their children when they don’t seek care for themselves, and they will address IPV for their children, she said.

“These are women who are coming in for the 2-, 4-, 6-month visits, but haven’t seen their ob for the postpartum visit ,and they may not see their primary care physician for several more years,” said Dr. Randell, who coordinates the IPV program at Children’s Mercy Hospital in Kansas City, Mo. “They’ll address IPV in the context of how it affects their kids.”

Between 1 in 3 women and 1 in 4 men will experience intimate partner violence (IPV) at some point in their lifetime, according to The National Intimate Partner and Sexual Violence Survey 2010 Summary Report by the Centers for Disease Control and Prevention. Families experiencing IPV “look no different from families who aren’t,” making it worthwhile to universally screen for the problem as part of anticipatory guidance. There is no hard evidence favoring written or verbal assessment – “it all depends on what works best for your practice,” Dr. Randell said.

However, she implored pediatricians to line up advocacy resources, educate staff, and develop processes for intervention. “We know that if you just hand someone a pamphlet or a help line number and say ‘call when you’re ready,’ the odds are they’re not going to call,” Dr. Randell said.

Instead, tell the mother you would like to connect her with a community partner who specializes in IVP and can help her figure out a plan for her and her child’s safety. Ideally, a nurse or staff member in the pediatric office who is educated about IVP could be the initial link – someone “to whom you can make a warm hand-off.”

In this case, she explained, the pediatrician can “say something like, ‘I’d like you to talk with Jennifer. She knows a lot about situations like these and can offer some resources. We can even make the call from the office today.’ ”

Phone calls made from the office, when agreed to, are “very safe calls,” Dr. Randell emphasized.

Ideally, pediatric offices can partner with a local IPV agency for education and referrals. Other possibilities are the social work department at a local children’s hospital or the National Domestic Violence hot line (1-800-799-7233, 1-800-787-3224 TTY). Dr. Randell advised using the term “help line” instead of “hotline” because, in her experience, families associate a “hotline” with children “being taken away.”

Physicians worry about damaging trust by asking about IPV, but numerous studies show most mothers agree that pediatric health care providers should ask.

Introducing questions about IPV with a “framing statement” can minimize any perception of judgment. An example: “Because violence at home is common and affects children’s health and safety, I now ask all families in my practice about exposure to violence.”

The framing statement can then be followed with an indirect question such as “Do you feel safe at home and in your relationship?” or a more direct question, such as:

• “Has your child ever seen a violent or frightening event at home or in your neighborhood?”

• “Have you ever been hurt or threatened by your partner?”

• “Do you ever feel afraid of or controlled by or isolated by your partner?”

IPV is an adverse childhood experience that not only creates toxic stress, but puts children at significantly higher risk – up to 15 times the risk – for all forms of childhood maltreatment. Men also experience IPV, but women are most frequently the nonoffenders, she noted.

Pediatricians should know their states’ child abuse and IVP reporting laws, and inform the nonoffending parent of any limits on confidentiality. “If your state has mandatory reporting for exposure to IVP, you need to let the parent know,” she said. “They need to be able to take this into consideration when they’re deciding if it’s safe or the right time to disclose.”

Dr. Randell advised physicians to try to involve the parent when reporting IPV, either per mandatory reporting laws or per results of a child safety assessment. Explain that you’d like them to make the report with you,” she said. “This can be an important step in maintaining a trusting relationship and empowering her.”

Care must be taken in documenting IPV disclosure because the abusive parent often has access to the child’s chart and/or receives insurance statements. Dr. Randell offered several tips:

Use limited, coded documentation in the chart.

• Do not use IPV-related billing codes or mention the terms “domestic violence” or “IPV.”

• Do not use the word shelter or include notes about safety plans.

• Do not screen in the presence of verbal children, or children aged 3 years and older.

Children may inadvertently tell the abuser that mom has been talking to someone, she explained. “And it’s also probably bad for kids to hear mom denying [IPV] because it reinforces that this is a behavior that we keep secret and don’t talk about.”

Posters, pamphlets, and other environmental cues are an important layer for helping families who are experiencing IPV, largely because these items provide women with the opportunity to access resources without having to disclose IPV.

In focus groups at Children’s Mercy, mothers who had experienced or were experiencing IPV said they wanted information “not only on what IPV looks like … but about how it impacts kids, about resources, and about safety planning,” Dr. Randell said. “And they wanted things that are hopeful ... They don’t want to be labeled [as victims].”

There are several validated screening instruments for IPV (such as the Partner Violence Screen and the Woman Abuse Screening Tool), but the tools have significantly variable sensitivities and specificities and have not been studied in pediatric settings. General psychosocial screening tools used in pediatrics, such as the Pediatric Symptom Checklist and the Strengths and Difficulties Questionnaire, may provide clues of possible trauma, including IPV, she noted.

Among the resources recommended by Dr. Randell:

• The Harvard Center for the Developing Child (www.developingchild.harvard.edu).

• Futures Without Violence (www.futureswithoutviolence.org).

• AAP’s policy statement on IPV: pediatrics.aappublications.org/content/125/5/1094).

One of the biggest barriers to mental health services for victims of bullying is the fact that too few medical providers are screening adolescents for bullying, according to a recent study.

“Efforts are needed to encourage medical providers to screen for bullying and to refer to mental health services when necessary,” said Dr. Amira El Sherif of KidzCare Pediatrics in Fayetteville, N.C. The study by Dr. El Sherif and her colleagues was presented at the annual meeting of the American Academy of Pediatrics.

©monkeybusinessimages/Thinkstock.com

“There is also a continuous need for school training programs to ensure staff respond appropriately to bullying incidents, and that investigation procedures are followed,” Dr. El Sherif said in an interview, echoing her research team’s conclusions. “Finally, it is critical to streamline a process of communication between medical providers, school officials, and parents to allow for a team approach to bullying,” she said.

Almost 30% of U.S. adolescents are involved in bullying, which is linked to various mental health conditions, such as attention-deficit/hyperactivity disorder, anxiety, self-harming behaviors, suicidal thoughts, and suicide attempts, the researchers noted. Yet only one in five children who need mental health evaluations actually receive services.

To learn what factors are contributing to poor access to services, Dr. El Sherif and her associates conducted focus groups with bullying victims and their parents as well as interviews with teachers and community mental health providers. Based on the findings from these interviews and focus groups, the team developed a survey they administered to 440 middle school and high school students in Cumberland County, N.C. Among these students, 29% said they had been victims of bullying in the past.

All the students rated answers to questions on a Likert scale which assigned 5 points to the greatest potential barrier to receiving mental health services. Of the 28 barriers reported, students who had previously been bullied reported 11 more often.

“Our study showed that the biggest barriers to mental health care were the lack of screening and counseling about bullying by medical providers,” Dr. El Sherif said in the interview. “There were also school system challenges, including inaction by school personnel and poor enforcement of investigation procedures. Inadequate school follow-up and communication with parents were other major obstacles.”

Among barriers with the highest scores from adolescents who had been bullied were not having the school investigate the bullying incident, and the teen’s doctor not talking to the school or counseling the student.

Because the study was limited to one North Carolina county, it is not clear how generalizable the findings are, Dr. El Sherif said, indicating the need for larger, more nationally representative studies.

“We noted that girls were more likely to be bullied than boys,” Dr. El Sherif said. “Larger studies may be necessary to ascertain differences between racial/ethnic groups.”

In this study, 55% of respondents were male, but 44% of those who reported being bullied were male. Although girls made up 45% of the sample, they represented 56% of those who said they had been bullied. Among all the respondents, 18% were white, 65% were black, 5% were Latino, 1% were Asian, and 11% were of another race/ethnic group.

The implications of the study, however, still apply to children across the United States, Dr. El Sherif suggested.

“In general, all children should be screened for mental health concerns during their annual physicals, particularly children with risk factors for mental health sequelae such as bullying,” she said.

Parents also have an important role to play in helping their children if they have been bullied, Dr. El Sherif said.

“Parents are a child’s primary advocate both at home and out in the world,” she said. “They should provide support and advice to their child at home on how to handle bullying, report the incident to the school, and seek help from their pediatrician if they feel that bullying is affecting their child’s everyday life.”

No disclosures or external funding were reported.

One of the biggest barriers to mental health services for victims of bullying is the fact that too few medical providers are screening adolescents for bullying, according to a recent study.

“Efforts are needed to encourage medical providers to screen for bullying and to refer to mental health services when necessary,” said Dr. Amira El Sherif of KidzCare Pediatrics in Fayetteville, N.C. The study by Dr. El Sherif and her colleagues was presented at the annual meeting of the American Academy of Pediatrics.

©monkeybusinessimages/Thinkstock.com

“There is also a continuous need for school training programs to ensure staff respond appropriately to bullying incidents, and that investigation procedures are followed,” Dr. El Sherif said in an interview, echoing her research team’s conclusions. “Finally, it is critical to streamline a process of communication between medical providers, school officials, and parents to allow for a team approach to bullying,” she said.

Almost 30% of U.S. adolescents are involved in bullying, which is linked to various mental health conditions, such as attention-deficit/hyperactivity disorder, anxiety, self-harming behaviors, suicidal thoughts, and suicide attempts, the researchers noted. Yet only one in five children who need mental health evaluations actually receive services.

To learn what factors are contributing to poor access to services, Dr. El Sherif and her associates conducted focus groups with bullying victims and their parents as well as interviews with teachers and community mental health providers. Based on the findings from these interviews and focus groups, the team developed a survey they administered to 440 middle school and high school students in Cumberland County, N.C. Among these students, 29% said they had been victims of bullying in the past.

All the students rated answers to questions on a Likert scale which assigned 5 points to the greatest potential barrier to receiving mental health services. Of the 28 barriers reported, students who had previously been bullied reported 11 more often.

“Our study showed that the biggest barriers to mental health care were the lack of screening and counseling about bullying by medical providers,” Dr. El Sherif said in the interview. “There were also school system challenges, including inaction by school personnel and poor enforcement of investigation procedures. Inadequate school follow-up and communication with parents were other major obstacles.”

Among barriers with the highest scores from adolescents who had been bullied were not having the school investigate the bullying incident, and the teen’s doctor not talking to the school or counseling the student.

Because the study was limited to one North Carolina county, it is not clear how generalizable the findings are, Dr. El Sherif said, indicating the need for larger, more nationally representative studies.

“We noted that girls were more likely to be bullied than boys,” Dr. El Sherif said. “Larger studies may be necessary to ascertain differences between racial/ethnic groups.”

In this study, 55% of respondents were male, but 44% of those who reported being bullied were male. Although girls made up 45% of the sample, they represented 56% of those who said they had been bullied. Among all the respondents, 18% were white, 65% were black, 5% were Latino, 1% were Asian, and 11% were of another race/ethnic group.

The implications of the study, however, still apply to children across the United States, Dr. El Sherif suggested.

“In general, all children should be screened for mental health concerns during their annual physicals, particularly children with risk factors for mental health sequelae such as bullying,” she said.

Parents also have an important role to play in helping their children if they have been bullied, Dr. El Sherif said.

“Parents are a child’s primary advocate both at home and out in the world,” she said. “They should provide support and advice to their child at home on how to handle bullying, report the incident to the school, and seek help from their pediatrician if they feel that bullying is affecting their child’s everyday life.”

No disclosures or external funding were reported.

One of the biggest barriers to mental health services for victims of bullying is the fact that too few medical providers are screening adolescents for bullying, according to a recent study.

“Efforts are needed to encourage medical providers to screen for bullying and to refer to mental health services when necessary,” said Dr. Amira El Sherif of KidzCare Pediatrics in Fayetteville, N.C. The study by Dr. El Sherif and her colleagues was presented at the annual meeting of the American Academy of Pediatrics.

©monkeybusinessimages/Thinkstock.com

“There is also a continuous need for school training programs to ensure staff respond appropriately to bullying incidents, and that investigation procedures are followed,” Dr. El Sherif said in an interview, echoing her research team’s conclusions. “Finally, it is critical to streamline a process of communication between medical providers, school officials, and parents to allow for a team approach to bullying,” she said.

Almost 30% of U.S. adolescents are involved in bullying, which is linked to various mental health conditions, such as attention-deficit/hyperactivity disorder, anxiety, self-harming behaviors, suicidal thoughts, and suicide attempts, the researchers noted. Yet only one in five children who need mental health evaluations actually receive services.

To learn what factors are contributing to poor access to services, Dr. El Sherif and her associates conducted focus groups with bullying victims and their parents as well as interviews with teachers and community mental health providers. Based on the findings from these interviews and focus groups, the team developed a survey they administered to 440 middle school and high school students in Cumberland County, N.C. Among these students, 29% said they had been victims of bullying in the past.

All the students rated answers to questions on a Likert scale which assigned 5 points to the greatest potential barrier to receiving mental health services. Of the 28 barriers reported, students who had previously been bullied reported 11 more often.

“Our study showed that the biggest barriers to mental health care were the lack of screening and counseling about bullying by medical providers,” Dr. El Sherif said in the interview. “There were also school system challenges, including inaction by school personnel and poor enforcement of investigation procedures. Inadequate school follow-up and communication with parents were other major obstacles.”

Among barriers with the highest scores from adolescents who had been bullied were not having the school investigate the bullying incident, and the teen’s doctor not talking to the school or counseling the student.

Because the study was limited to one North Carolina county, it is not clear how generalizable the findings are, Dr. El Sherif said, indicating the need for larger, more nationally representative studies.

“We noted that girls were more likely to be bullied than boys,” Dr. El Sherif said. “Larger studies may be necessary to ascertain differences between racial/ethnic groups.”

In this study, 55% of respondents were male, but 44% of those who reported being bullied were male. Although girls made up 45% of the sample, they represented 56% of those who said they had been bullied. Among all the respondents, 18% were white, 65% were black, 5% were Latino, 1% were Asian, and 11% were of another race/ethnic group.

The implications of the study, however, still apply to children across the United States, Dr. El Sherif suggested.

“In general, all children should be screened for mental health concerns during their annual physicals, particularly children with risk factors for mental health sequelae such as bullying,” she said.

Parents also have an important role to play in helping their children if they have been bullied, Dr. El Sherif said.

“Parents are a child’s primary advocate both at home and out in the world,” she said. “They should provide support and advice to their child at home on how to handle bullying, report the incident to the school, and seek help from their pediatrician if they feel that bullying is affecting their child’s everyday life.”

No disclosures or external funding were reported.

Marijuana is dangerous, and you need to know how dangerous to adequately counsel adolescent patients and their families.

The growing number of states legalizing marijuana, whether exclusively for medical use or for recreational use, is changing the landscape for physicians, addiction specialists, and others working in public health, explained Dr. Miriam Schizer of the adolescent substance abuse program at Boston Children’s Hospital.

Currently, 23 states plus Washington have legalized medical marijuana, and 4 states plus Washington have legalized recreational use, Dr. Schizer said at the annual meeting of the American Academy of Pediatrics. Cannabis products are expanding rapidly, with many becoming more potent, but misconceptions about marijuana use also are potent and growing.

©iStock/ThinkStockPhotos.com

The proportion of high school seniors who believe marijuana carries a “great risk of harm” is nearly at an all-time low, based on findings from the Monitoring the Future survey. With annual samples of approximately 50,000 8th, 10th and 12th grade students each year, the survey provides a glimpse into long-term trends in adolescents’ attitudes and behaviors regarding substance use. Just over a third of high school seniors (36%) perceived marijuana to have a great risk of harm in 2014, one of the lowest recorded numbers since the survey began in 1975. And 14% of seniors surveyed reported having used marijuana in the past month.

Understanding the mechanisms of THC

The primary psychoactive ingredient in marijuana is delta-9 tetrahydrocannabinol, or THC, one of more than 100 cannabinoids in marijuana. This fat-soluble molecule crosses both the blood-brain barrier and the placenta and accumulates in adipose tissue, where its half-life ranges from several days to a week. Its concentration in cannabis products also has increased from an average of less than 4% in 1994 to an average of 9% in cannabis products in 2008.

The way THC makes its way into adolescents’ systems varies: Smoking buds and leaves is the most common, but people also eat edible products, inhale cannabis through hookahs or e-cigarette–like “vaping” systems, or use hash oil “dabbing” for an exceptionally potent dose.

While the positive effects of cannabis use are what keep users coming back, the negative effects are just as common and can carry over until the day after, like a hangover. Those include paranoia, anxiety, irritability, impaired short-term memory, poor attention or judgment, poor coordination, distorted spatial perception, and an altered sense of the passage of time. The positive effects that users report include reduced anxiety, increased sociability, the perception that time slows down, an increased appetite, decreased pain, and overall euphoria.

Physiologic effects – peaking 30 minutes after inhalation or 2-4 hours after ingestion – can include tachycardia up to 20-50 beats per minute above baseline, increased blood pressure, bronchial relaxation, red eyes, and dry mouth and throat. These effects increase with the concentration of THC, also increasing the likelihood of paranoia, panic, hallucinations, vomiting, erratic mood swings, and aggressive behavior.

Following the discovery of cannabinoid receptors in the brain in 1988, scientists learned that the brain contains its own cannabinoid known as anandamide, giving rise to an endocannabinoid system in the brain. This system shapes brain development, supports myelin growth on neurons, and controls neuron activity. Both THC and anandamide play a role in regulating neurotransmitters such as dopamine, glutamate, endorphins, and serotonin, but THC has much stronger, longer-lasting effects and consequently interferes with cell function and growth.

Misconceptions about marijuana use

Dr. Schizer addressed the most common myths about marijuana use, pointing out that it is harmful to human health, it is addictive, and it does impair driving. Short-term harms include impaired short-term memory and motor coordination, altered judgment, and, in higher doses, paranoia and psychosis.

“There is a link to worsening depression and anxiety over time,” Dr. Schizer said. “Something is emerging very clearly: Among individuals with a genetic disposition to psychotic disorder, there’s an increased risk of developing the psychotic disorder.”

Long-term use can alter brain development, particularly among those using it in early adolescence, and lead to higher dropout rates, a lower IQ, and a poorer sense of life satisfaction. In one study of 1,037 individuals tracked from age 13 to 38 years, the average IQ of those who never used marijuana ranged from 99.8 to 100.6, compared with 99.7 to 93.9 among those dependent on marijuana for at least 3 years (Proc Natl Acad Sci USA. 2012 Oct 2;109[40]:E2657-64).

Marijuana use also has adverse effects on the lungs, on male and female sexual function, and on the cardiovascular system. In pregnant women using marijuana, the fetus is exposed to THC through the placenta and umbilical cord, receives less oxygen, and has a higher risk of birth defects.

Approximately 9% of users develop an addiction to marijuana, but that nearly doubles to 17% among users who start in adolescence, according to the National Institute on Drug Abuse.

“The earlier they are when they start, the more likely they are to develop an addiction,” Dr. Schizer said, pointing out that 88% of all substance abuse treatment admissions among adolescents aged 12-17 years involved marijuana, according to 2012 Substance Abuse and Mental Health Services Administration data. By age 21 years, approximately 4% of users are addicted, but about a quarter to half of daily users develop an addiction. Further evidence of marijuana’s addictiveness are “bona fide withdrawal symptoms,” which typically peak about 10 days after last use, and can include restlessness, anxiety, increased irritability or aggression, difficulty falling and staying asleep, nightmares or strange dreams, decreased appetite, and weight loss.

Driving impairment under the influence of marijuana results from poorer attention, worse working memory, lack of coordination, poorer reaction time, and lack of visual perception caused by THC. In a graphic Dr. Schizer presented comparing Colorado to 34 states without medical marijuana, the proportion of drivers testing positive for marijuana in fatal crashes began sharply increasing in 2009, the year widespread medical marijuana was implemented in Colorado.

“In particular, we are thinking about relatively inexperienced drivers, so the effects are even more important,” Dr. Schizer said.

Medical marijuana

What began as an Institute of Medicine recommendation for “compassionate use” to relieve suffering in terminally ill patients has become a movement to medicalize marijuana despite limited evidence of its therapeutic benefits, Dr. Schizer explained. Since California legalized medical marijuana in 1996, many other states have followed suit. Yet the only condition for which modest evidence supports its use is treating adults’ nausea and vomiting resulting from chemotherapy. For chronic pain, anorexia associated with HIV/AIDS, and neurologic problems such as multiple sclerosis, the evidence is not sufficient to show therapeutic efficacy, and no studies have looked at medical marijuana use in children.

“Marijuana is not a medication,” Dr. Schizer said. “There is therapeutic potential in these cannabinoids, but that’s not the same as directing patients to using medical marijuana. We know that penicillin was originally derived from mold, but you would give patients penicillin, not a slice of moldy bread” to treat a bacterial infection.

Actual medical cannabinoids approved for treatments include Marinol and Sativex. The Food and Drug Administration has approved Marinol, a slow-acting oral formulation, to treat weight loss in patients with anorexia or AIDS and to treat nausea and vomiting from chemotherapy. Ongoing phase III clinical studies are testing Sativex for the treatment of advanced cancer pain. To suggest that a patient use commercially available marijuana therapeutically would be akin to sending patients to an opium den instead of prescribing a precise opioid for pain, Dr. Schizer suggested. “I think it’s unconscionable for doctors to prescribe something that is smoked.”

Data from Colorado and Oregon suggest few individuals with medical marijuana cards may be using it for serious illnesses, Dr. Schizer pointed out. Less than 2% of medical marijuana cardholders report cancer, HIV/AIDS, glaucoma,i or multiple sclerosis as their reasons for using marijuana. The typical profile of a cardholder is a 32-year-old white man with a history of alcohol and cocaine abuse and no history of life-threatening illnesses, she said. According to the Colorado Department of Public Health and Environment, 12% of medical marijuana users report using it for severe nausea, 17% for muscle spasms, and 94% for “severe pain.”

Meanwhile, Colorado’s legalization of recreational marijuana imparts several lessons, Dr. Schizer said. The highest rate of teen marijuana use in the United States occurs in Denver, and 11% of teens report using marijuana in the past month, compared with a national average of 8%. Drug-related school suspensions have increased, and the rate of car crashes in which the driver tested positive for marijuana tripled between January 2014, when stores opened, and April 2014.

Dr. Schizer reported no relevant financial disclosures.

Marijuana is dangerous, and you need to know how dangerous to adequately counsel adolescent patients and their families.

The growing number of states legalizing marijuana, whether exclusively for medical use or for recreational use, is changing the landscape for physicians, addiction specialists, and others working in public health, explained Dr. Miriam Schizer of the adolescent substance abuse program at Boston Children’s Hospital.

Currently, 23 states plus Washington have legalized medical marijuana, and 4 states plus Washington have legalized recreational use, Dr. Schizer said at the annual meeting of the American Academy of Pediatrics. Cannabis products are expanding rapidly, with many becoming more potent, but misconceptions about marijuana use also are potent and growing.

©iStock/ThinkStockPhotos.com

The proportion of high school seniors who believe marijuana carries a “great risk of harm” is nearly at an all-time low, based on findings from the Monitoring the Future survey. With annual samples of approximately 50,000 8th, 10th and 12th grade students each year, the survey provides a glimpse into long-term trends in adolescents’ attitudes and behaviors regarding substance use. Just over a third of high school seniors (36%) perceived marijuana to have a great risk of harm in 2014, one of the lowest recorded numbers since the survey began in 1975. And 14% of seniors surveyed reported having used marijuana in the past month.

Understanding the mechanisms of THC

The primary psychoactive ingredient in marijuana is delta-9 tetrahydrocannabinol, or THC, one of more than 100 cannabinoids in marijuana. This fat-soluble molecule crosses both the blood-brain barrier and the placenta and accumulates in adipose tissue, where its half-life ranges from several days to a week. Its concentration in cannabis products also has increased from an average of less than 4% in 1994 to an average of 9% in cannabis products in 2008.

The way THC makes its way into adolescents’ systems varies: Smoking buds and leaves is the most common, but people also eat edible products, inhale cannabis through hookahs or e-cigarette–like “vaping” systems, or use hash oil “dabbing” for an exceptionally potent dose.

While the positive effects of cannabis use are what keep users coming back, the negative effects are just as common and can carry over until the day after, like a hangover. Those include paranoia, anxiety, irritability, impaired short-term memory, poor attention or judgment, poor coordination, distorted spatial perception, and an altered sense of the passage of time. The positive effects that users report include reduced anxiety, increased sociability, the perception that time slows down, an increased appetite, decreased pain, and overall euphoria.

Physiologic effects – peaking 30 minutes after inhalation or 2-4 hours after ingestion – can include tachycardia up to 20-50 beats per minute above baseline, increased blood pressure, bronchial relaxation, red eyes, and dry mouth and throat. These effects increase with the concentration of THC, also increasing the likelihood of paranoia, panic, hallucinations, vomiting, erratic mood swings, and aggressive behavior.

Following the discovery of cannabinoid receptors in the brain in 1988, scientists learned that the brain contains its own cannabinoid known as anandamide, giving rise to an endocannabinoid system in the brain. This system shapes brain development, supports myelin growth on neurons, and controls neuron activity. Both THC and anandamide play a role in regulating neurotransmitters such as dopamine, glutamate, endorphins, and serotonin, but THC has much stronger, longer-lasting effects and consequently interferes with cell function and growth.

Misconceptions about marijuana use

Dr. Schizer addressed the most common myths about marijuana use, pointing out that it is harmful to human health, it is addictive, and it does impair driving. Short-term harms include impaired short-term memory and motor coordination, altered judgment, and, in higher doses, paranoia and psychosis.

“There is a link to worsening depression and anxiety over time,” Dr. Schizer said. “Something is emerging very clearly: Among individuals with a genetic disposition to psychotic disorder, there’s an increased risk of developing the psychotic disorder.”

Long-term use can alter brain development, particularly among those using it in early adolescence, and lead to higher dropout rates, a lower IQ, and a poorer sense of life satisfaction. In one study of 1,037 individuals tracked from age 13 to 38 years, the average IQ of those who never used marijuana ranged from 99.8 to 100.6, compared with 99.7 to 93.9 among those dependent on marijuana for at least 3 years (Proc Natl Acad Sci USA. 2012 Oct 2;109[40]:E2657-64).

Marijuana use also has adverse effects on the lungs, on male and female sexual function, and on the cardiovascular system. In pregnant women using marijuana, the fetus is exposed to THC through the placenta and umbilical cord, receives less oxygen, and has a higher risk of birth defects.

Approximately 9% of users develop an addiction to marijuana, but that nearly doubles to 17% among users who start in adolescence, according to the National Institute on Drug Abuse.

“The earlier they are when they start, the more likely they are to develop an addiction,” Dr. Schizer said, pointing out that 88% of all substance abuse treatment admissions among adolescents aged 12-17 years involved marijuana, according to 2012 Substance Abuse and Mental Health Services Administration data. By age 21 years, approximately 4% of users are addicted, but about a quarter to half of daily users develop an addiction. Further evidence of marijuana’s addictiveness are “bona fide withdrawal symptoms,” which typically peak about 10 days after last use, and can include restlessness, anxiety, increased irritability or aggression, difficulty falling and staying asleep, nightmares or strange dreams, decreased appetite, and weight loss.

Driving impairment under the influence of marijuana results from poorer attention, worse working memory, lack of coordination, poorer reaction time, and lack of visual perception caused by THC. In a graphic Dr. Schizer presented comparing Colorado to 34 states without medical marijuana, the proportion of drivers testing positive for marijuana in fatal crashes began sharply increasing in 2009, the year widespread medical marijuana was implemented in Colorado.

“In particular, we are thinking about relatively inexperienced drivers, so the effects are even more important,” Dr. Schizer said.

Medical marijuana

What began as an Institute of Medicine recommendation for “compassionate use” to relieve suffering in terminally ill patients has become a movement to medicalize marijuana despite limited evidence of its therapeutic benefits, Dr. Schizer explained. Since California legalized medical marijuana in 1996, many other states have followed suit. Yet the only condition for which modest evidence supports its use is treating adults’ nausea and vomiting resulting from chemotherapy. For chronic pain, anorexia associated with HIV/AIDS, and neurologic problems such as multiple sclerosis, the evidence is not sufficient to show therapeutic efficacy, and no studies have looked at medical marijuana use in children.

“Marijuana is not a medication,” Dr. Schizer said. “There is therapeutic potential in these cannabinoids, but that’s not the same as directing patients to using medical marijuana. We know that penicillin was originally derived from mold, but you would give patients penicillin, not a slice of moldy bread” to treat a bacterial infection.

Actual medical cannabinoids approved for treatments include Marinol and Sativex. The Food and Drug Administration has approved Marinol, a slow-acting oral formulation, to treat weight loss in patients with anorexia or AIDS and to treat nausea and vomiting from chemotherapy. Ongoing phase III clinical studies are testing Sativex for the treatment of advanced cancer pain. To suggest that a patient use commercially available marijuana therapeutically would be akin to sending patients to an opium den instead of prescribing a precise opioid for pain, Dr. Schizer suggested. “I think it’s unconscionable for doctors to prescribe something that is smoked.”

Data from Colorado and Oregon suggest few individuals with medical marijuana cards may be using it for serious illnesses, Dr. Schizer pointed out. Less than 2% of medical marijuana cardholders report cancer, HIV/AIDS, glaucoma,i or multiple sclerosis as their reasons for using marijuana. The typical profile of a cardholder is a 32-year-old white man with a history of alcohol and cocaine abuse and no history of life-threatening illnesses, she said. According to the Colorado Department of Public Health and Environment, 12% of medical marijuana users report using it for severe nausea, 17% for muscle spasms, and 94% for “severe pain.”

Meanwhile, Colorado’s legalization of recreational marijuana imparts several lessons, Dr. Schizer said. The highest rate of teen marijuana use in the United States occurs in Denver, and 11% of teens report using marijuana in the past month, compared with a national average of 8%. Drug-related school suspensions have increased, and the rate of car crashes in which the driver tested positive for marijuana tripled between January 2014, when stores opened, and April 2014.

Dr. Schizer reported no relevant financial disclosures.

Marijuana is dangerous, and you need to know how dangerous to adequately counsel adolescent patients and their families.

The growing number of states legalizing marijuana, whether exclusively for medical use or for recreational use, is changing the landscape for physicians, addiction specialists, and others working in public health, explained Dr. Miriam Schizer of the adolescent substance abuse program at Boston Children’s Hospital.

Currently, 23 states plus Washington have legalized medical marijuana, and 4 states plus Washington have legalized recreational use, Dr. Schizer said at the annual meeting of the American Academy of Pediatrics. Cannabis products are expanding rapidly, with many becoming more potent, but misconceptions about marijuana use also are potent and growing.

©iStock/ThinkStockPhotos.com

The proportion of high school seniors who believe marijuana carries a “great risk of harm” is nearly at an all-time low, based on findings from the Monitoring the Future survey. With annual samples of approximately 50,000 8th, 10th and 12th grade students each year, the survey provides a glimpse into long-term trends in adolescents’ attitudes and behaviors regarding substance use. Just over a third of high school seniors (36%) perceived marijuana to have a great risk of harm in 2014, one of the lowest recorded numbers since the survey began in 1975. And 14% of seniors surveyed reported having used marijuana in the past month.

Understanding the mechanisms of THC

The primary psychoactive ingredient in marijuana is delta-9 tetrahydrocannabinol, or THC, one of more than 100 cannabinoids in marijuana. This fat-soluble molecule crosses both the blood-brain barrier and the placenta and accumulates in adipose tissue, where its half-life ranges from several days to a week. Its concentration in cannabis products also has increased from an average of less than 4% in 1994 to an average of 9% in cannabis products in 2008.

The way THC makes its way into adolescents’ systems varies: Smoking buds and leaves is the most common, but people also eat edible products, inhale cannabis through hookahs or e-cigarette–like “vaping” systems, or use hash oil “dabbing” for an exceptionally potent dose.

While the positive effects of cannabis use are what keep users coming back, the negative effects are just as common and can carry over until the day after, like a hangover. Those include paranoia, anxiety, irritability, impaired short-term memory, poor attention or judgment, poor coordination, distorted spatial perception, and an altered sense of the passage of time. The positive effects that users report include reduced anxiety, increased sociability, the perception that time slows down, an increased appetite, decreased pain, and overall euphoria.

Physiologic effects – peaking 30 minutes after inhalation or 2-4 hours after ingestion – can include tachycardia up to 20-50 beats per minute above baseline, increased blood pressure, bronchial relaxation, red eyes, and dry mouth and throat. These effects increase with the concentration of THC, also increasing the likelihood of paranoia, panic, hallucinations, vomiting, erratic mood swings, and aggressive behavior.

Following the discovery of cannabinoid receptors in the brain in 1988, scientists learned that the brain contains its own cannabinoid known as anandamide, giving rise to an endocannabinoid system in the brain. This system shapes brain development, supports myelin growth on neurons, and controls neuron activity. Both THC and anandamide play a role in regulating neurotransmitters such as dopamine, glutamate, endorphins, and serotonin, but THC has much stronger, longer-lasting effects and consequently interferes with cell function and growth.

Misconceptions about marijuana use

Dr. Schizer addressed the most common myths about marijuana use, pointing out that it is harmful to human health, it is addictive, and it does impair driving. Short-term harms include impaired short-term memory and motor coordination, altered judgment, and, in higher doses, paranoia and psychosis.

“There is a link to worsening depression and anxiety over time,” Dr. Schizer said. “Something is emerging very clearly: Among individuals with a genetic disposition to psychotic disorder, there’s an increased risk of developing the psychotic disorder.”

Long-term use can alter brain development, particularly among those using it in early adolescence, and lead to higher dropout rates, a lower IQ, and a poorer sense of life satisfaction. In one study of 1,037 individuals tracked from age 13 to 38 years, the average IQ of those who never used marijuana ranged from 99.8 to 100.6, compared with 99.7 to 93.9 among those dependent on marijuana for at least 3 years (Proc Natl Acad Sci USA. 2012 Oct 2;109[40]:E2657-64).

Marijuana use also has adverse effects on the lungs, on male and female sexual function, and on the cardiovascular system. In pregnant women using marijuana, the fetus is exposed to THC through the placenta and umbilical cord, receives less oxygen, and has a higher risk of birth defects.

Approximately 9% of users develop an addiction to marijuana, but that nearly doubles to 17% among users who start in adolescence, according to the National Institute on Drug Abuse.

“The earlier they are when they start, the more likely they are to develop an addiction,” Dr. Schizer said, pointing out that 88% of all substance abuse treatment admissions among adolescents aged 12-17 years involved marijuana, according to 2012 Substance Abuse and Mental Health Services Administration data. By age 21 years, approximately 4% of users are addicted, but about a quarter to half of daily users develop an addiction. Further evidence of marijuana’s addictiveness are “bona fide withdrawal symptoms,” which typically peak about 10 days after last use, and can include restlessness, anxiety, increased irritability or aggression, difficulty falling and staying asleep, nightmares or strange dreams, decreased appetite, and weight loss.

Driving impairment under the influence of marijuana results from poorer attention, worse working memory, lack of coordination, poorer reaction time, and lack of visual perception caused by THC. In a graphic Dr. Schizer presented comparing Colorado to 34 states without medical marijuana, the proportion of drivers testing positive for marijuana in fatal crashes began sharply increasing in 2009, the year widespread medical marijuana was implemented in Colorado.

“In particular, we are thinking about relatively inexperienced drivers, so the effects are even more important,” Dr. Schizer said.

Medical marijuana

What began as an Institute of Medicine recommendation for “compassionate use” to relieve suffering in terminally ill patients has become a movement to medicalize marijuana despite limited evidence of its therapeutic benefits, Dr. Schizer explained. Since California legalized medical marijuana in 1996, many other states have followed suit. Yet the only condition for which modest evidence supports its use is treating adults’ nausea and vomiting resulting from chemotherapy. For chronic pain, anorexia associated with HIV/AIDS, and neurologic problems such as multiple sclerosis, the evidence is not sufficient to show therapeutic efficacy, and no studies have looked at medical marijuana use in children.

“Marijuana is not a medication,” Dr. Schizer said. “There is therapeutic potential in these cannabinoids, but that’s not the same as directing patients to using medical marijuana. We know that penicillin was originally derived from mold, but you would give patients penicillin, not a slice of moldy bread” to treat a bacterial infection.

Actual medical cannabinoids approved for treatments include Marinol and Sativex. The Food and Drug Administration has approved Marinol, a slow-acting oral formulation, to treat weight loss in patients with anorexia or AIDS and to treat nausea and vomiting from chemotherapy. Ongoing phase III clinical studies are testing Sativex for the treatment of advanced cancer pain. To suggest that a patient use commercially available marijuana therapeutically would be akin to sending patients to an opium den instead of prescribing a precise opioid for pain, Dr. Schizer suggested. “I think it’s unconscionable for doctors to prescribe something that is smoked.”

Data from Colorado and Oregon suggest few individuals with medical marijuana cards may be using it for serious illnesses, Dr. Schizer pointed out. Less than 2% of medical marijuana cardholders report cancer, HIV/AIDS, glaucoma,i or multiple sclerosis as their reasons for using marijuana. The typical profile of a cardholder is a 32-year-old white man with a history of alcohol and cocaine abuse and no history of life-threatening illnesses, she said. According to the Colorado Department of Public Health and Environment, 12% of medical marijuana users report using it for severe nausea, 17% for muscle spasms, and 94% for “severe pain.”

Meanwhile, Colorado’s legalization of recreational marijuana imparts several lessons, Dr. Schizer said. The highest rate of teen marijuana use in the United States occurs in Denver, and 11% of teens report using marijuana in the past month, compared with a national average of 8%. Drug-related school suspensions have increased, and the rate of car crashes in which the driver tested positive for marijuana tripled between January 2014, when stores opened, and April 2014.

Dr. Schizer reported no relevant financial disclosures.

WASHINGTON – Limiting the amount of full contact tackling that occurs in high school football practice reduced the rate of sports-related concussions that the athletes experienced, a prospective study showed.

“Something as simple as saying they can’t tackle all the time, limiting the amount of minutes each month, reduced the incidence,” Timothy A. McGuine, Ph.D., of the University of Wisconsin, Madison, said at the American Academy of Pediatrics annual meeting.

©Majoros Laszlo/thinkstockphotos.com

“The majority of sports-related concussions sustained in high school football practice occurred during full contact activities,” he said. “The rate of sports-related concussions sustained in high school football practice was more than twice as high in the two seasons prior to a rule change limiting the amount and duration of full contact activities.”

In their study, Dr. McGuine and his associates tested the effects of a tackle-limiting rule implemented in 2014 in a state interscholastic athletic association for all players in grades 9-12. The rule prohibited full contact play during the first practice week, with full contact defined as “drills or game situations that occur at game speed when full tackles are made at a competitive pace and players are taken to the ground.” The players engaged in full contact play for up to 75 minutes total during the second week of practice and then a maximum of 60 min/wk for all subsequent weeks in the practice season. The rule did not apply to games.

For data on the 2 years before the rule change, 2,081 athletes with a mean age of 16 years reported their concussion history in the 2012 season, involving 36 schools, and the 2013 season, involving 18 schools. In 2014, licensed athletic trainers recorded the incidence and severity of each sports-related concussion for the 945 players at 26 schools. Across all three seasons, almost half the concussions (46%) occurred during tackling. Although the overall rate of concussions dropped from 1.57/1,000 athletic exposures in the combined 2012 and 2013 seasons to 1.28/1,000 athletic exposures in the 2014 season, the difference was not significant (P = .155). During the 2012 and 2013 seasons combined, 206 players (9%) sustained 211 concussions, compared with 67 players (7%) with 70 concussions in 2014.

However, the difference in concussions occurring during practice did differ significantly before and after the rule change. The rate of concussions during practice in 2014 was 0.33 concussions per 1,000 athletic exposures, compared with 0.76 concussions per 1,000 exposures in the 2012 and 2013 seasons (P = .003). Twelve of 15 concussions in 2014 practices occurred during full contact practices, a rate of 0.571,000 exposures, and 82 of 86 concussions in the 2012 and 2013 seasons occurred during full contact practices, a rate of 0.87/1,000 exposures (P = .216).

No difference in concussion rate occurred during the games following the rule change: The 2014 rate of concussions during games was 5.74/1,000 exposures, compared with 5.81 in the combined 2012 and 2013 seasons (P = .999). The severity of concussions sustained before and after the rule change also did not differ, and athletes’ years of football-playing experience had no effect on the concussion incidence in 2014.

Despite the relationship between full contact play and concussions, Dr. McGuine said banning tackling from football is not a policy he would support.

“I think the benefits of the sport far outweigh the risks,” Dr. McGuine said. “Concussions particularly have transcended a sports issue and become a public health issue and have become political, and I’m very much against legislators, policy makers, associations making blanket rules without the evidence to back those,” he said. “There are lingering long-term effects from all orthopedic injuries, but we’re focusing on concussions.”

Equipment modification is unlikely to make much difference in concussion rates either, said Dr. McGuine, whose previous study on football helmets found that the brand and model did not influence concussion risk. “Concussions are multifactorial,” he said. “We can’t just limit the amount of force transmitted to the brain and say we’re going to stop these injuries from occurring.”

One important strategy to reducing concussions is increasing parents’ and athletes’ awareness about multiple injuries and ways to reduce the risk, Dr. McGuine said.

“Concussions are like any other injury – ankle sprains, knee injuries and surgeries, shoulder dislocations,” he said. “If you have one, you’re more susceptible to having another one as opposed to somebody who never had that injury, so the problems are repeat injuries and lingering injuries.” Any of these injuries can have a lasting impact on a young athlete’s quality of life, Dr. McGuine added.

Another way to decrease the incidence of concussions is to enforce rules against leading, or lowering, athletes’ heads during tackling.

“A big issue now is penalizing players for leading with their head and face, but I think we need to be consistent there too,” Dr. McGuine said. “We can’t penalize defensive players for lowering their helmet if we’re not going to penalize running backs and wide receivers.”

The research was internally funded. Dr. McGuine reported no relevant financial disclosures.

WASHINGTON – Limiting the amount of full contact tackling that occurs in high school football practice reduced the rate of sports-related concussions that the athletes experienced, a prospective study showed.

“Something as simple as saying they can’t tackle all the time, limiting the amount of minutes each month, reduced the incidence,” Timothy A. McGuine, Ph.D., of the University of Wisconsin, Madison, said at the American Academy of Pediatrics annual meeting.

©Majoros Laszlo/thinkstockphotos.com

“The majority of sports-related concussions sustained in high school football practice occurred during full contact activities,” he said. “The rate of sports-related concussions sustained in high school football practice was more than twice as high in the two seasons prior to a rule change limiting the amount and duration of full contact activities.”

In their study, Dr. McGuine and his associates tested the effects of a tackle-limiting rule implemented in 2014 in a state interscholastic athletic association for all players in grades 9-12. The rule prohibited full contact play during the first practice week, with full contact defined as “drills or game situations that occur at game speed when full tackles are made at a competitive pace and players are taken to the ground.” The players engaged in full contact play for up to 75 minutes total during the second week of practice and then a maximum of 60 min/wk for all subsequent weeks in the practice season. The rule did not apply to games.

For data on the 2 years before the rule change, 2,081 athletes with a mean age of 16 years reported their concussion history in the 2012 season, involving 36 schools, and the 2013 season, involving 18 schools. In 2014, licensed athletic trainers recorded the incidence and severity of each sports-related concussion for the 945 players at 26 schools. Across all three seasons, almost half the concussions (46%) occurred during tackling. Although the overall rate of concussions dropped from 1.57/1,000 athletic exposures in the combined 2012 and 2013 seasons to 1.28/1,000 athletic exposures in the 2014 season, the difference was not significant (P = .155). During the 2012 and 2013 seasons combined, 206 players (9%) sustained 211 concussions, compared with 67 players (7%) with 70 concussions in 2014.

However, the difference in concussions occurring during practice did differ significantly before and after the rule change. The rate of concussions during practice in 2014 was 0.33 concussions per 1,000 athletic exposures, compared with 0.76 concussions per 1,000 exposures in the 2012 and 2013 seasons (P = .003). Twelve of 15 concussions in 2014 practices occurred during full contact practices, a rate of 0.571,000 exposures, and 82 of 86 concussions in the 2012 and 2013 seasons occurred during full contact practices, a rate of 0.87/1,000 exposures (P = .216).

No difference in concussion rate occurred during the games following the rule change: The 2014 rate of concussions during games was 5.74/1,000 exposures, compared with 5.81 in the combined 2012 and 2013 seasons (P = .999). The severity of concussions sustained before and after the rule change also did not differ, and athletes’ years of football-playing experience had no effect on the concussion incidence in 2014.

Despite the relationship between full contact play and concussions, Dr. McGuine said banning tackling from football is not a policy he would support.

“I think the benefits of the sport far outweigh the risks,” Dr. McGuine said. “Concussions particularly have transcended a sports issue and become a public health issue and have become political, and I’m very much against legislators, policy makers, associations making blanket rules without the evidence to back those,” he said. “There are lingering long-term effects from all orthopedic injuries, but we’re focusing on concussions.”

Equipment modification is unlikely to make much difference in concussion rates either, said Dr. McGuine, whose previous study on football helmets found that the brand and model did not influence concussion risk. “Concussions are multifactorial,” he said. “We can’t just limit the amount of force transmitted to the brain and say we’re going to stop these injuries from occurring.”

One important strategy to reducing concussions is increasing parents’ and athletes’ awareness about multiple injuries and ways to reduce the risk, Dr. McGuine said.

“Concussions are like any other injury – ankle sprains, knee injuries and surgeries, shoulder dislocations,” he said. “If you have one, you’re more susceptible to having another one as opposed to somebody who never had that injury, so the problems are repeat injuries and lingering injuries.” Any of these injuries can have a lasting impact on a young athlete’s quality of life, Dr. McGuine added.

Another way to decrease the incidence of concussions is to enforce rules against leading, or lowering, athletes’ heads during tackling.

“A big issue now is penalizing players for leading with their head and face, but I think we need to be consistent there too,” Dr. McGuine said. “We can’t penalize defensive players for lowering their helmet if we’re not going to penalize running backs and wide receivers.”

The research was internally funded. Dr. McGuine reported no relevant financial disclosures.

WASHINGTON – Limiting the amount of full contact tackling that occurs in high school football practice reduced the rate of sports-related concussions that the athletes experienced, a prospective study showed.

“Something as simple as saying they can’t tackle all the time, limiting the amount of minutes each month, reduced the incidence,” Timothy A. McGuine, Ph.D., of the University of Wisconsin, Madison, said at the American Academy of Pediatrics annual meeting.

©Majoros Laszlo/thinkstockphotos.com

“The majority of sports-related concussions sustained in high school football practice occurred during full contact activities,” he said. “The rate of sports-related concussions sustained in high school football practice was more than twice as high in the two seasons prior to a rule change limiting the amount and duration of full contact activities.”

In their study, Dr. McGuine and his associates tested the effects of a tackle-limiting rule implemented in 2014 in a state interscholastic athletic association for all players in grades 9-12. The rule prohibited full contact play during the first practice week, with full contact defined as “drills or game situations that occur at game speed when full tackles are made at a competitive pace and players are taken to the ground.” The players engaged in full contact play for up to 75 minutes total during the second week of practice and then a maximum of 60 min/wk for all subsequent weeks in the practice season. The rule did not apply to games.

For data on the 2 years before the rule change, 2,081 athletes with a mean age of 16 years reported their concussion history in the 2012 season, involving 36 schools, and the 2013 season, involving 18 schools. In 2014, licensed athletic trainers recorded the incidence and severity of each sports-related concussion for the 945 players at 26 schools. Across all three seasons, almost half the concussions (46%) occurred during tackling. Although the overall rate of concussions dropped from 1.57/1,000 athletic exposures in the combined 2012 and 2013 seasons to 1.28/1,000 athletic exposures in the 2014 season, the difference was not significant (P = .155). During the 2012 and 2013 seasons combined, 206 players (9%) sustained 211 concussions, compared with 67 players (7%) with 70 concussions in 2014.

However, the difference in concussions occurring during practice did differ significantly before and after the rule change. The rate of concussions during practice in 2014 was 0.33 concussions per 1,000 athletic exposures, compared with 0.76 concussions per 1,000 exposures in the 2012 and 2013 seasons (P = .003). Twelve of 15 concussions in 2014 practices occurred during full contact practices, a rate of 0.571,000 exposures, and 82 of 86 concussions in the 2012 and 2013 seasons occurred during full contact practices, a rate of 0.87/1,000 exposures (P = .216).

No difference in concussion rate occurred during the games following the rule change: The 2014 rate of concussions during games was 5.74/1,000 exposures, compared with 5.81 in the combined 2012 and 2013 seasons (P = .999). The severity of concussions sustained before and after the rule change also did not differ, and athletes’ years of football-playing experience had no effect on the concussion incidence in 2014.

Despite the relationship between full contact play and concussions, Dr. McGuine said banning tackling from football is not a policy he would support.

“I think the benefits of the sport far outweigh the risks,” Dr. McGuine said. “Concussions particularly have transcended a sports issue and become a public health issue and have become political, and I’m very much against legislators, policy makers, associations making blanket rules without the evidence to back those,” he said. “There are lingering long-term effects from all orthopedic injuries, but we’re focusing on concussions.”

Equipment modification is unlikely to make much difference in concussion rates either, said Dr. McGuine, whose previous study on football helmets found that the brand and model did not influence concussion risk. “Concussions are multifactorial,” he said. “We can’t just limit the amount of force transmitted to the brain and say we’re going to stop these injuries from occurring.”

One important strategy to reducing concussions is increasing parents’ and athletes’ awareness about multiple injuries and ways to reduce the risk, Dr. McGuine said.

“Concussions are like any other injury – ankle sprains, knee injuries and surgeries, shoulder dislocations,” he said. “If you have one, you’re more susceptible to having another one as opposed to somebody who never had that injury, so the problems are repeat injuries and lingering injuries.” Any of these injuries can have a lasting impact on a young athlete’s quality of life, Dr. McGuine added.

Another way to decrease the incidence of concussions is to enforce rules against leading, or lowering, athletes’ heads during tackling.

“A big issue now is penalizing players for leading with their head and face, but I think we need to be consistent there too,” Dr. McGuine said. “We can’t penalize defensive players for lowering their helmet if we’re not going to penalize running backs and wide receivers.”

The research was internally funded. Dr. McGuine reported no relevant financial disclosures.

WASHINGTON – Most parents know whether they want to vaccinate their child before the child is even conceived, a study showed.

“Is giving [vaccine] information out at … well-child visits in the pediatrician’s office too late? I think we’re still too early [in our research] to say if that’s the case,” said James N. Yarnall, a fourth-year medical student at the University of North Carolina at Chapel Hill.

The study grew out of talking to parents about their hesitancy toward the hepatitis B vaccine, recommended just after birth, said Mr. Yarnall, whose mentor, pediatrician Jacob Lohr of University of North Carolina Health Care, began asking parents why they were turning down the vaccine.

© javi_indy/ Thinkstock.com

“For a lot of them, they said, ‘We’ve known for a long time,’ ” Mr. Yarnall said.

The two gave surveys to 171 parents (56% of the 304 they asked) who had given birth to a child between February and April 2015 at the University of North Carolina Women’s Hospital in Chapel Hill. The parents answered the question, “When did you develop your preferences for all/certain vaccines for your new baby?”

Among all the parents, 72% said they had developed their vaccination preferences for their newborn before the child had been conceived. The parents reported that friends and family, medical staff, and government agencies such as the Centers for Disease Control and Prevention, played a role in their decisions about vaccines.

Two thirds (66%) of first-time parents reported developing immunization preferences before conception, while 77% of parents with previous children said they had, although the difference was not significant (P = .12). Fathers trended toward being slightly more likely than mothers to have decided their vaccine preferences preconception, but that finding was not significant and weakened further after demographic differences were accounted for.

Parents who had discussed vaccines with one another and who had higher levels of education also were more likely to have decided before conception whether they would vaccinate their newborn. Those who made their vaccine decisions before conception were significantly more likely to plan to vaccinate their children than to decline some or all vaccines (P = .01). Again, this finding was no longer significant following adjustment for demographic covariates.

Although these findings suggest that discussions about vaccines in the pediatrician’s office are coming long past the time when most parents have made up their minds, it’s less clear where to go from here, Mr. Yarnall said.

He and Dr. Lohr are working on a larger study with multiple sites through the Better Outcomes Through Research in Newborns (BORN) network to confirm these findings and determine what the next steps might be.

“We want to make sure the results from this pilot study are reproducible with more national sites,” Mr. Yarnall said. “Once we get those results, we can take it from there.”

WASHINGTON – Most parents know whether they want to vaccinate their child before the child is even conceived, a study showed.

“Is giving [vaccine] information out at … well-child visits in the pediatrician’s office too late? I think we’re still too early [in our research] to say if that’s the case,” said James N. Yarnall, a fourth-year medical student at the University of North Carolina at Chapel Hill.

The study grew out of talking to parents about their hesitancy toward the hepatitis B vaccine, recommended just after birth, said Mr. Yarnall, whose mentor, pediatrician Jacob Lohr of University of North Carolina Health Care, began asking parents why they were turning down the vaccine.

© javi_indy/ Thinkstock.com

“For a lot of them, they said, ‘We’ve known for a long time,’ ” Mr. Yarnall said.

The two gave surveys to 171 parents (56% of the 304 they asked) who had given birth to a child between February and April 2015 at the University of North Carolina Women’s Hospital in Chapel Hill. The parents answered the question, “When did you develop your preferences for all/certain vaccines for your new baby?”

Among all the parents, 72% said they had developed their vaccination preferences for their newborn before the child had been conceived. The parents reported that friends and family, medical staff, and government agencies such as the Centers for Disease Control and Prevention, played a role in their decisions about vaccines.

Two thirds (66%) of first-time parents reported developing immunization preferences before conception, while 77% of parents with previous children said they had, although the difference was not significant (P = .12). Fathers trended toward being slightly more likely than mothers to have decided their vaccine preferences preconception, but that finding was not significant and weakened further after demographic differences were accounted for.

Parents who had discussed vaccines with one another and who had higher levels of education also were more likely to have decided before conception whether they would vaccinate their newborn. Those who made their vaccine decisions before conception were significantly more likely to plan to vaccinate their children than to decline some or all vaccines (P = .01). Again, this finding was no longer significant following adjustment for demographic covariates.

Although these findings suggest that discussions about vaccines in the pediatrician’s office are coming long past the time when most parents have made up their minds, it’s less clear where to go from here, Mr. Yarnall said.

He and Dr. Lohr are working on a larger study with multiple sites through the Better Outcomes Through Research in Newborns (BORN) network to confirm these findings and determine what the next steps might be.

“We want to make sure the results from this pilot study are reproducible with more national sites,” Mr. Yarnall said. “Once we get those results, we can take it from there.”

WASHINGTON – Most parents know whether they want to vaccinate their child before the child is even conceived, a study showed.

“Is giving [vaccine] information out at … well-child visits in the pediatrician’s office too late? I think we’re still too early [in our research] to say if that’s the case,” said James N. Yarnall, a fourth-year medical student at the University of North Carolina at Chapel Hill.

The study grew out of talking to parents about their hesitancy toward the hepatitis B vaccine, recommended just after birth, said Mr. Yarnall, whose mentor, pediatrician Jacob Lohr of University of North Carolina Health Care, began asking parents why they were turning down the vaccine.

© javi_indy/ Thinkstock.com

“For a lot of them, they said, ‘We’ve known for a long time,’ ” Mr. Yarnall said.

The two gave surveys to 171 parents (56% of the 304 they asked) who had given birth to a child between February and April 2015 at the University of North Carolina Women’s Hospital in Chapel Hill. The parents answered the question, “When did you develop your preferences for all/certain vaccines for your new baby?”

Among all the parents, 72% said they had developed their vaccination preferences for their newborn before the child had been conceived. The parents reported that friends and family, medical staff, and government agencies such as the Centers for Disease Control and Prevention, played a role in their decisions about vaccines.

Two thirds (66%) of first-time parents reported developing immunization preferences before conception, while 77% of parents with previous children said they had, although the difference was not significant (P = .12). Fathers trended toward being slightly more likely than mothers to have decided their vaccine preferences preconception, but that finding was not significant and weakened further after demographic differences were accounted for.

Parents who had discussed vaccines with one another and who had higher levels of education also were more likely to have decided before conception whether they would vaccinate their newborn. Those who made their vaccine decisions before conception were significantly more likely to plan to vaccinate their children than to decline some or all vaccines (P = .01). Again, this finding was no longer significant following adjustment for demographic covariates.

Although these findings suggest that discussions about vaccines in the pediatrician’s office are coming long past the time when most parents have made up their minds, it’s less clear where to go from here, Mr. Yarnall said.

He and Dr. Lohr are working on a larger study with multiple sites through the Better Outcomes Through Research in Newborns (BORN) network to confirm these findings and determine what the next steps might be.

“We want to make sure the results from this pilot study are reproducible with more national sites,” Mr. Yarnall said. “Once we get those results, we can take it from there.”

WASHINGTON – Most parents know whether they want to vaccinate their child before the child is even conceived, a study showed.

“Is giving [vaccine] information out at … well-child visits in the pediatrician’s office too late? I think we’re still too early [in our research] to say if that’s the case,” said James N. Yarnall, a fourth-year medical student at the University of North Carolina at Chapel Hill.

The study grew out of talking to parents about their hesitancy toward the hepatitis B vaccine, recommended just after birth, said Mr. Yarnall, whose mentor, pediatrician Jacob Lohr of University of North Carolina Health Care, began asking parents why they were turning down the vaccine.

© javi_indy/ Thinkstock.com

“For a lot of them, they said, ‘We’ve known for a long time,’ ” Mr. Yarnall said.

The two gave surveys to 171 parents (56% of the 304 they asked) who had given birth to a child between February and April 2015 at the University of North Carolina Women’s Hospital in Chapel Hill. The parents answered the question, “When did you develop your preferences for all/certain vaccines for your new baby?”

Among all the parents, 72% said they had developed their vaccination preferences for their newborn before the child had been conceived. The parents reported that friends and family, medical staff, and government agencies such as the Centers for Disease Control and Prevention, played a role in their decisions about vaccines.

Two thirds (66%) of first-time parents reported developing immunization preferences before conception, while 77% of parents with previous children said they had, although the difference was not significant (P = .12). Fathers trended toward being slightly more likely than mothers to have decided their vaccine preferences preconception, but that finding was not significant and weakened further after demographic differences were accounted for.

Parents who had discussed vaccines with one another and who had higher levels of education also were more likely to have decided before conception whether they would vaccinate their newborn. Those who made their vaccine decisions before conception were significantly more likely to plan to vaccinate their children than to decline some or all vaccines (P = .01). Again, this finding was no longer significant following adjustment for demographic covariates.

Although these findings suggest that discussions about vaccines in the pediatrician’s office are coming long past the time when most parents have made up their minds, it’s less clear where to go from here, Mr. Yarnall said.

He and Dr. Lohr are working on a larger study with multiple sites through the Better Outcomes Through Research in Newborns (BORN) network to confirm these findings and determine what the next steps might be.

“We want to make sure the results from this pilot study are reproducible with more national sites,” Mr. Yarnall said. “Once we get those results, we can take it from there.”

WASHINGTON – Most parents know whether they want to vaccinate their child before the child is even conceived, a study showed.

“Is giving [vaccine] information out at … well-child visits in the pediatrician’s office too late? I think we’re still too early [in our research] to say if that’s the case,” said James N. Yarnall, a fourth-year medical student at the University of North Carolina at Chapel Hill.

The study grew out of talking to parents about their hesitancy toward the hepatitis B vaccine, recommended just after birth, said Mr. Yarnall, whose mentor, pediatrician Jacob Lohr of University of North Carolina Health Care, began asking parents why they were turning down the vaccine.

© javi_indy/ Thinkstock.com

“For a lot of them, they said, ‘We’ve known for a long time,’ ” Mr. Yarnall said.

The two gave surveys to 171 parents (56% of the 304 they asked) who had given birth to a child between February and April 2015 at the University of North Carolina Women’s Hospital in Chapel Hill. The parents answered the question, “When did you develop your preferences for all/certain vaccines for your new baby?”

Among all the parents, 72% said they had developed their vaccination preferences for their newborn before the child had been conceived. The parents reported that friends and family, medical staff, and government agencies such as the Centers for Disease Control and Prevention, played a role in their decisions about vaccines.

Two thirds (66%) of first-time parents reported developing immunization preferences before conception, while 77% of parents with previous children said they had, although the difference was not significant (P = .12). Fathers trended toward being slightly more likely than mothers to have decided their vaccine preferences preconception, but that finding was not significant and weakened further after demographic differences were accounted for.

Parents who had discussed vaccines with one another and who had higher levels of education also were more likely to have decided before conception whether they would vaccinate their newborn. Those who made their vaccine decisions before conception were significantly more likely to plan to vaccinate their children than to decline some or all vaccines (P = .01). Again, this finding was no longer significant following adjustment for demographic covariates.

Although these findings suggest that discussions about vaccines in the pediatrician’s office are coming long past the time when most parents have made up their minds, it’s less clear where to go from here, Mr. Yarnall said.

He and Dr. Lohr are working on a larger study with multiple sites through the Better Outcomes Through Research in Newborns (BORN) network to confirm these findings and determine what the next steps might be.

“We want to make sure the results from this pilot study are reproducible with more national sites,” Mr. Yarnall said. “Once we get those results, we can take it from there.”

WASHINGTON – Most parents know whether they want to vaccinate their child before the child is even conceived, a study showed.

“Is giving [vaccine] information out at … well-child visits in the pediatrician’s office too late? I think we’re still too early [in our research] to say if that’s the case,” said James N. Yarnall, a fourth-year medical student at the University of North Carolina at Chapel Hill.

The study grew out of talking to parents about their hesitancy toward the hepatitis B vaccine, recommended just after birth, said Mr. Yarnall, whose mentor, pediatrician Jacob Lohr of University of North Carolina Health Care, began asking parents why they were turning down the vaccine.

© javi_indy/ Thinkstock.com

“For a lot of them, they said, ‘We’ve known for a long time,’ ” Mr. Yarnall said.

The two gave surveys to 171 parents (56% of the 304 they asked) who had given birth to a child between February and April 2015 at the University of North Carolina Women’s Hospital in Chapel Hill. The parents answered the question, “When did you develop your preferences for all/certain vaccines for your new baby?”

Among all the parents, 72% said they had developed their vaccination preferences for their newborn before the child had been conceived. The parents reported that friends and family, medical staff, and government agencies such as the Centers for Disease Control and Prevention, played a role in their decisions about vaccines.

Two thirds (66%) of first-time parents reported developing immunization preferences before conception, while 77% of parents with previous children said they had, although the difference was not significant (P = .12). Fathers trended toward being slightly more likely than mothers to have decided their vaccine preferences preconception, but that finding was not significant and weakened further after demographic differences were accounted for.

Parents who had discussed vaccines with one another and who had higher levels of education also were more likely to have decided before conception whether they would vaccinate their newborn. Those who made their vaccine decisions before conception were significantly more likely to plan to vaccinate their children than to decline some or all vaccines (P = .01). Again, this finding was no longer significant following adjustment for demographic covariates.

Although these findings suggest that discussions about vaccines in the pediatrician’s office are coming long past the time when most parents have made up their minds, it’s less clear where to go from here, Mr. Yarnall said.

He and Dr. Lohr are working on a larger study with multiple sites through the Better Outcomes Through Research in Newborns (BORN) network to confirm these findings and determine what the next steps might be.

“We want to make sure the results from this pilot study are reproducible with more national sites,” Mr. Yarnall said. “Once we get those results, we can take it from there.”

WASHINGTON – The legal definition of what constitutes “reasonable” corporal punishment is contracting, making it more critical than ever to inquire about discipline, provide alternatives to corporal punishment, and address religious objections with culturally sensitive responses.

In delivering this message, Victor I. Vieth, J.D., founder and senior director of the Gundersen National Child Protection Training Center in La Crosse, Wisc., stressed that spanking and other forms of corporal punishment are still widely practiced, and that the many parents who employ this form of discipline are open to considering alternatives that they can learn and believe in.

“The vast majority of parents are doing the best they know how. … They don’t know the alternatives,” Mr. Vieth said.

©tzahiV/Thinkstock

“Reasonable” corporal punishment is lawful in all 50 states, but the definition of reasonable is narrowing. Courts now will consider the child’s size, frowning upon such punishment for children under the age of 2 years. They will consider where on the body the child is hit, generally viewing anything but the buttocks as unreasonable, and they’ll look at whether objects have been used.

Courts even appear willing today to consider the “nature of the child’s misbehavior,” which “opens the door to even mild corporal punishment cases sometimes being considered unlawful,” such as a parent hitting a child on the buttocks once or twice after milk is spilled, said Mr. Vieth, whose training center oversees a Center for Effective Discipline.

“Think about this as a mandatory reporter,” he said at the annual meeting of the American Academy of Pediatrics. “The vast majority of corporal punishment cases we see probably are running afoul of criminal or civil codes today.”

Shifts in case law are likely being driven by research showing that corporal punishment is a risk factor for both short-term and long-term physical and mental injury, he said. It has long been known that even mild forms of physical abuse – what’s been called “ordinary” physical punishment – can cause negative behavioral and psychological outcomes such as alcohol abuse, depression, behavioral problems, and low achievement.

More recent research has expanded the toll, linking acts such as pushing, grabbing, shoving, slapping, and hitting not only with higher risks of mental disorders and family dysfunction, but with higher risks of cardiovascular disease, arthritis, and obesity.

Ask parents about what form of discipline they’re using, and educate parents who indicate using corporal punishment about the medical risks and mental health risks in the short and long term. It’s important to then give parents “practical, concrete” tools that model alternative methods. Vanderbilt University’s Play Nicely free online parenting program is one that Mr. Vieth often recommends.

The parental response of “my parents hit me and I turned out just fine” is not uncommon, and it can be handled in various ways, he said.

You could segue into a discussion of risks by saying, for example, “Well, let’s explore that. I’ve known you for a long time, and I think you did turn out well. And that’s consistent with the research because the research doesn’t show that if you receive corporal punishment, you’re going to grow up to have negative outcomes. The research says that it’s a risk factor, and the more you hit and the longer you hit, the greater the risk will be.”

You also could compare corporal punishment research to research on smoking, Mr. Vieth said, by saying, “It’s not that different from smoking. One cigarette in the back of the school house won’t kill you, but two packs a day will dramatically increase the risk.”

Religion is a top reason – if not the No. 1 reason – for the use of corporal punishment, and it’s important to understand its influence on discipline and to develop culturally sensitive responses to parents who object for religious reasons to alternative approaches, Mr. Vieth said.

He recommended the following strategies when a parent cites religious grounds for physical discipline:

• Be aware of your own biases. Do not automatically label parents as neglectful or abusive.

• Refrain from pastoral work. “Assure the parent that you’re not trying to take away her religious beliefs, that you’re discussing religion because she’s speaking about discipline that must fit within her belief system.”

• Ask if the belief system “authorizes” or “requires” corporal punishment. If it is authorized, there’s a clear basis for working together.

• Try to distinguish between parents who need education and those who should be prosecuted. Some parents may accept and use corporal punishment, but may be amenable to discussion and education.

• Emphasize the patient’s strengths. Parental warmth, for instance, does not negate the risks of corporal punishment, but it can be a good foundation.

• Acknowledge the benefits of religion, such as its promotion of well-being and healthy behavior.

• Recognize the value of discipline and emphasize that you’re advocating for “effective” discipline with the fewest risk factors.

• “Play in the parent’s ball field.” If the parent believes she is God’s representative to the child, consider asking questions such as “What is your child learning about God when you hit her? What did you learn about God from being physically disciplined?” Parents often will pause and reflect.

Mr. Vieth told the story of Carol, a deeply religious single mother who was raised in a home with corporal discipline and who believed that God’s word in her Protestant faith told her that she must sometimes hit her 3-year-old son with an object. She confessed to a coworker that she was paddling her son on the buttocks, but did not like doing so and was scared of hurting him.

Carol’s coworker called Child Protective Services. The subsequent multidisciplinary team investigation chose not to file criminal charges, but to file a civil child protection petition. Carol pledged to improve her parenting, but was unwilling to forgo the practice altogether. Over time, it became apparent to the team working with Carol that she was heavily influenced by James Dobson, Ph.D., the founder of an organization called Focus on the Family. Unlike other more extreme advocates of corporal punishment, Dr. Dobson caps the number of spanks at two, with one for lesser infractions, and says spanking must never leave a bruise or injury (“From Sticks to Flowers: Guidelines for Child Protection Professionals Working with Parents Using Scripture to Justify Corporal Punishment,” [St. Paul, Minn.: William Mitchell Law Review, 2014, p. 923]), Mr. Vieth noted.

“For Carol, his views trumped all medical and health research,” Mr. Vieth said. “We had to figure out a way to play in her court.” Working with a social worker, he found passages in Dobson’s writing that conveyed the message that not every child needs corporal punishment.

“Once I started quoting Dobson, it changed the dynamic” and the team was able to work with her on embracing and learning alternative approaches. The petition was dropped, and Carol now is an advocate in her church for discipline methods other than corporal punishment.

Mr. Vieth reported having no relevant financial disclosures.

WASHINGTON – The legal definition of what constitutes “reasonable” corporal punishment is contracting, making it more critical than ever to inquire about discipline, provide alternatives to corporal punishment, and address religious objections with culturally sensitive responses.

In delivering this message, Victor I. Vieth, J.D., founder and senior director of the Gundersen National Child Protection Training Center in La Crosse, Wisc., stressed that spanking and other forms of corporal punishment are still widely practiced, and that the many parents who employ this form of discipline are open to considering alternatives that they can learn and believe in.

“The vast majority of parents are doing the best they know how. … They don’t know the alternatives,” Mr. Vieth said.

©tzahiV/Thinkstock

“Reasonable” corporal punishment is lawful in all 50 states, but the definition of reasonable is narrowing. Courts now will consider the child’s size, frowning upon such punishment for children under the age of 2 years. They will consider where on the body the child is hit, generally viewing anything but the buttocks as unreasonable, and they’ll look at whether objects have been used.

Courts even appear willing today to consider the “nature of the child’s misbehavior,” which “opens the door to even mild corporal punishment cases sometimes being considered unlawful,” such as a parent hitting a child on the buttocks once or twice after milk is spilled, said Mr. Vieth, whose training center oversees a Center for Effective Discipline.

“Think about this as a mandatory reporter,” he said at the annual meeting of the American Academy of Pediatrics. “The vast majority of corporal punishment cases we see probably are running afoul of criminal or civil codes today.”

Shifts in case law are likely being driven by research showing that corporal punishment is a risk factor for both short-term and long-term physical and mental injury, he said. It has long been known that even mild forms of physical abuse – what’s been called “ordinary” physical punishment – can cause negative behavioral and psychological outcomes such as alcohol abuse, depression, behavioral problems, and low achievement.

More recent research has expanded the toll, linking acts such as pushing, grabbing, shoving, slapping, and hitting not only with higher risks of mental disorders and family dysfunction, but with higher risks of cardiovascular disease, arthritis, and obesity.

Ask parents about what form of discipline they’re using, and educate parents who indicate using corporal punishment about the medical risks and mental health risks in the short and long term. It’s important to then give parents “practical, concrete” tools that model alternative methods. Vanderbilt University’s Play Nicely free online parenting program is one that Mr. Vieth often recommends.

The parental response of “my parents hit me and I turned out just fine” is not uncommon, and it can be handled in various ways, he said.

You could segue into a discussion of risks by saying, for example, “Well, let’s explore that. I’ve known you for a long time, and I think you did turn out well. And that’s consistent with the research because the research doesn’t show that if you receive corporal punishment, you’re going to grow up to have negative outcomes. The research says that it’s a risk factor, and the more you hit and the longer you hit, the greater the risk will be.”

You also could compare corporal punishment research to research on smoking, Mr. Vieth said, by saying, “It’s not that different from smoking. One cigarette in the back of the school house won’t kill you, but two packs a day will dramatically increase the risk.”

Religion is a top reason – if not the No. 1 reason – for the use of corporal punishment, and it’s important to understand its influence on discipline and to develop culturally sensitive responses to parents who object for religious reasons to alternative approaches, Mr. Vieth said.

He recommended the following strategies when a parent cites religious grounds for physical discipline:

• Be aware of your own biases. Do not automatically label parents as neglectful or abusive.

• Refrain from pastoral work. “Assure the parent that you’re not trying to take away her religious beliefs, that you’re discussing religion because she’s speaking about discipline that must fit within her belief system.”

• Ask if the belief system “authorizes” or “requires” corporal punishment. If it is authorized, there’s a clear basis for working together.

• Try to distinguish between parents who need education and those who should be prosecuted. Some parents may accept and use corporal punishment, but may be amenable to discussion and education.

• Emphasize the patient’s strengths. Parental warmth, for instance, does not negate the risks of corporal punishment, but it can be a good foundation.

• Acknowledge the benefits of religion, such as its promotion of well-being and healthy behavior.

• Recognize the value of discipline and emphasize that you’re advocating for “effective” discipline with the fewest risk factors.

• “Play in the parent’s ball field.” If the parent believes she is God’s representative to the child, consider asking questions such as “What is your child learning about God when you hit her? What did you learn about God from being physically disciplined?” Parents often will pause and reflect.

Mr. Vieth told the story of Carol, a deeply religious single mother who was raised in a home with corporal discipline and who believed that God’s word in her Protestant faith told her that she must sometimes hit her 3-year-old son with an object. She confessed to a coworker that she was paddling her son on the buttocks, but did not like doing so and was scared of hurting him.

Carol’s coworker called Child Protective Services. The subsequent multidisciplinary team investigation chose not to file criminal charges, but to file a civil child protection petition. Carol pledged to improve her parenting, but was unwilling to forgo the practice altogether. Over time, it became apparent to the team working with Carol that she was heavily influenced by James Dobson, Ph.D., the founder of an organization called Focus on the Family. Unlike other more extreme advocates of corporal punishment, Dr. Dobson caps the number of spanks at two, with one for lesser infractions, and says spanking must never leave a bruise or injury (“From Sticks to Flowers: Guidelines for Child Protection Professionals Working with Parents Using Scripture to Justify Corporal Punishment,” [St. Paul, Minn.: William Mitchell Law Review, 2014, p. 923]), Mr. Vieth noted.

“For Carol, his views trumped all medical and health research,” Mr. Vieth said. “We had to figure out a way to play in her court.” Working with a social worker, he found passages in Dobson’s writing that conveyed the message that not every child needs corporal punishment.

“Once I started quoting Dobson, it changed the dynamic” and the team was able to work with her on embracing and learning alternative approaches. The petition was dropped, and Carol now is an advocate in her church for discipline methods other than corporal punishment.

Mr. Vieth reported having no relevant financial disclosures.

WASHINGTON – The legal definition of what constitutes “reasonable” corporal punishment is contracting, making it more critical than ever to inquire about discipline, provide alternatives to corporal punishment, and address religious objections with culturally sensitive responses.

In delivering this message, Victor I. Vieth, J.D., founder and senior director of the Gundersen National Child Protection Training Center in La Crosse, Wisc., stressed that spanking and other forms of corporal punishment are still widely practiced, and that the many parents who employ this form of discipline are open to considering alternatives that they can learn and believe in.

“The vast majority of parents are doing the best they know how. … They don’t know the alternatives,” Mr. Vieth said.

©tzahiV/Thinkstock

“Reasonable” corporal punishment is lawful in all 50 states, but the definition of reasonable is narrowing. Courts now will consider the child’s size, frowning upon such punishment for children under the age of 2 years. They will consider where on the body the child is hit, generally viewing anything but the buttocks as unreasonable, and they’ll look at whether objects have been used.

Courts even appear willing today to consider the “nature of the child’s misbehavior,” which “opens the door to even mild corporal punishment cases sometimes being considered unlawful,” such as a parent hitting a child on the buttocks once or twice after milk is spilled, said Mr. Vieth, whose training center oversees a Center for Effective Discipline.

“Think about this as a mandatory reporter,” he said at the annual meeting of the American Academy of Pediatrics. “The vast majority of corporal punishment cases we see probably are running afoul of criminal or civil codes today.”

Shifts in case law are likely being driven by research showing that corporal punishment is a risk factor for both short-term and long-term physical and mental injury, he said. It has long been known that even mild forms of physical abuse – what’s been called “ordinary” physical punishment – can cause negative behavioral and psychological outcomes such as alcohol abuse, depression, behavioral problems, and low achievement.

More recent research has expanded the toll, linking acts such as pushing, grabbing, shoving, slapping, and hitting not only with higher risks of mental disorders and family dysfunction, but with higher risks of cardiovascular disease, arthritis, and obesity.

Ask parents about what form of discipline they’re using, and educate parents who indicate using corporal punishment about the medical risks and mental health risks in the short and long term. It’s important to then give parents “practical, concrete” tools that model alternative methods. Vanderbilt University’s Play Nicely free online parenting program is one that Mr. Vieth often recommends.

The parental response of “my parents hit me and I turned out just fine” is not uncommon, and it can be handled in various ways, he said.

You could segue into a discussion of risks by saying, for example, “Well, let’s explore that. I’ve known you for a long time, and I think you did turn out well. And that’s consistent with the research because the research doesn’t show that if you receive corporal punishment, you’re going to grow up to have negative outcomes. The research says that it’s a risk factor, and the more you hit and the longer you hit, the greater the risk will be.”

You also could compare corporal punishment research to research on smoking, Mr. Vieth said, by saying, “It’s not that different from smoking. One cigarette in the back of the school house won’t kill you, but two packs a day will dramatically increase the risk.”

Religion is a top reason – if not the No. 1 reason – for the use of corporal punishment, and it’s important to understand its influence on discipline and to develop culturally sensitive responses to parents who object for religious reasons to alternative approaches, Mr. Vieth said.

He recommended the following strategies when a parent cites religious grounds for physical discipline:

• Be aware of your own biases. Do not automatically label parents as neglectful or abusive.

• Refrain from pastoral work. “Assure the parent that you’re not trying to take away her religious beliefs, that you’re discussing religion because she’s speaking about discipline that must fit within her belief system.”

• Ask if the belief system “authorizes” or “requires” corporal punishment. If it is authorized, there’s a clear basis for working together.

• Try to distinguish between parents who need education and those who should be prosecuted. Some parents may accept and use corporal punishment, but may be amenable to discussion and education.

• Emphasize the patient’s strengths. Parental warmth, for instance, does not negate the risks of corporal punishment, but it can be a good foundation.

• Acknowledge the benefits of religion, such as its promotion of well-being and healthy behavior.

• Recognize the value of discipline and emphasize that you’re advocating for “effective” discipline with the fewest risk factors.

• “Play in the parent’s ball field.” If the parent believes she is God’s representative to the child, consider asking questions such as “What is your child learning about God when you hit her? What did you learn about God from being physically disciplined?” Parents often will pause and reflect.

Mr. Vieth told the story of Carol, a deeply religious single mother who was raised in a home with corporal discipline and who believed that God’s word in her Protestant faith told her that she must sometimes hit her 3-year-old son with an object. She confessed to a coworker that she was paddling her son on the buttocks, but did not like doing so and was scared of hurting him.

Carol’s coworker called Child Protective Services. The subsequent multidisciplinary team investigation chose not to file criminal charges, but to file a civil child protection petition. Carol pledged to improve her parenting, but was unwilling to forgo the practice altogether. Over time, it became apparent to the team working with Carol that she was heavily influenced by James Dobson, Ph.D., the founder of an organization called Focus on the Family. Unlike other more extreme advocates of corporal punishment, Dr. Dobson caps the number of spanks at two, with one for lesser infractions, and says spanking must never leave a bruise or injury (“From Sticks to Flowers: Guidelines for Child Protection Professionals Working with Parents Using Scripture to Justify Corporal Punishment,” [St. Paul, Minn.: William Mitchell Law Review, 2014, p. 923]), Mr. Vieth noted.

“For Carol, his views trumped all medical and health research,” Mr. Vieth said. “We had to figure out a way to play in her court.” Working with a social worker, he found passages in Dobson’s writing that conveyed the message that not every child needs corporal punishment.

“Once I started quoting Dobson, it changed the dynamic” and the team was able to work with her on embracing and learning alternative approaches. The petition was dropped, and Carol now is an advocate in her church for discipline methods other than corporal punishment.

Mr. Vieth reported having no relevant financial disclosures.