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American Academy of Pediatrics (AAP): 2017 National Conference and Exhibition
Almost 40% of pediatric residents experience burnout, study finds
, according to two Pediatrics articles highlighted by editor in chief Lewis R. First, MD, MS.
The studies investigated the prevalence and effects of burnout among pediatric residents, and all health care providers, working in intensive care units. They were among those published in 2017 that Dr. First deemed potentially practice changing – ones whose clinical implications may have immediate relevance in your daily work.
“There are a variety of ways to overcome burnout and promote our resiliency that starts with our ability to find joy in caring for children and our lifelong learning” through professional development sessions and academic journals, according to Dr. First, professor and chair of pediatrics at the University of Vermont in Burlington. He also serves as chief of pediatrics at the University of Vermont Children’s Hospital. He spoke at the 2017 annual meeting of the American Academy of Pediatrics and in later interviews.
High prevalence of burnout
The study by Baer et al. found that almost two in five pediatric residents experience burnout, often accompanied by poorer care of patients (Pediatrics. 2017. doi: 10.1542/peds.2016-2163). Using a 7-point Likert scale ranging from “never” to “every day,” 258 residents from 11 different residency programs filled out an anonymous Web-based survey on how often they felt emotional exhaustion (“I feel burnout from my work”) and depersonalization (“I’ve become more callous toward people since I took this job”). 
Of the 258 respondents, 39% had burnout, defined as answering affirmatively to either of the above questions with at least “weekly.” Most of the respondents were female, white, and married or in a long-term relationship without children, but the burnout rates did not vary across gender, race/ethnicity, relationship or parental status, or among different characteristics of the residency program and schedule. Higher burnout rates did occur among those feeling sleep deprived.
Those with burnout also had substantially higher odds of providing lower-quality care. Residents with burnout were seven times more likely to make treatment or medication errors not related to inadequate knowledge or experience, six times more likely to feel guilty about how they had treated a patient, more than four times more likely to report having little emotional reaction to a patient’s death, and four times more likely to discharge a patient earlier to make service more manageable. Burned-out residents had more than nine times greater odds of paying “little attention to the social or personal impact of an illness on a patient,” the study showed.
Burnout symptoms and solutions
Symptoms of potential burnout, Dr. First said in an interview, include emotional exhaustion, feeling a loss of meaning in work, feelings of ineffectiveness, a tendency to view people as objects instead of human beings, increasingly poor communication, and poor interpersonal and clinical skills and behaviors.
Other research also has found burnout linked to doctors’ errors, self-reported negative attitudes toward patients, and less time spent with patients, she said. “Thus physicians should be on the lookout for burnout within themselves as well as in their colleagues and medical trainees.”
Both Dr. Baer and Dr. First noted the importance of organizational leadership in preventing burnout.
The Association of Medical School Pediatric Department Chairs is sharing a toolbox of strategies that they have found effective for reducing burnout and developing wellness among physicians, Dr. First said in the interview.
“Some of those suggestions include personal attention to wellness via good nutrition, exercise, mindfulness for emotional self-regulation, and developing supportive relationships,” he noted. In addition to organizational mindfulness programs and ones that foster work-life integration and social activities, prevention programs should “create wellness and resilience, and a sense of pride and meaning in the work that is being done.”
Drs. First also pointed to ways of addressing triggers of burnout:
- Reduce the burden of bureaucratic tasks.
- Examine how many hours physicians spend at home or work at home.
- Improve efficiency, such as in EHR use.
- Provide individuals time to discuss stressors and ways to resolve them collaboratively with peers and leadership.
Burnout risk in the NICU
Similar interventions may help with burnout in neonatal ICUs (NICUs), the focus of the second study Dr. First discussed. Tawfik et al. surveyed 2,760 personnel from 41 NICUs in the United States to learn the prevalence of burnout and how it was associated with NICU organization (Pediatrics. 2017. doi: 10.1542/peds.2016-4134).
Among the 1,934 providers who replied (a response rate of 70%), 27% had burnout; at individual NICUs, burnout prevalence varied from 8% to 43%. The majority of respondents (72%) were registered nurses, followed by respiratory therapists, physicians, neonatal nurse practitioners, and others. The highest burnout rates occurred in NICUs with higher average daily admissions and higher average occupancy – and those using EHRs.
“Don’t assume that just because you use the EHR every day means you know how best to use this tool to improve your efficiency and effectiveness in generating and deriving information on your patients,” Dr. First said in the interview. He encouraged physicians to find out what resources their institutions might offer to help, such as EHR hospital teams or office support who can look at providers’ EHR usage, and show them shortcuts and time-savers to improve efficiency based on their usage patterns.
“Nursing burnout was more sensitive to the setting than physician burnout, especially in regard to average daily admissions, late transfer numbers, nursing hours per patient day, and mortality per 1,000 infants,” Dr. First noted.
Interestingly, burnout prevalence was not associated with the proportion of high-risk patients seen in the NICUs, the number of attending physicians in the unit, or whether the institution was a teaching hospital or not, he said.
Dr. First listed strategies to reduce burnout risk in NICUs that the study authors also described: expressing thankfulness each day, focusing on positive events at the start or end of each day, performing random acts of kindness for colleagues and staff, and encouraging providers to identify the strengths in one another.
Addressing burnout requires efforts from everyone
“Given the potential effects of burnout on patient care and professionalism and physician wellness, it is important for physicians to speak up if they have concerns about burnout in their colleagues,” Dr. Baer said in the interview.
Burnout is common, she said, occurring in more than half of physicians at some point in time, so a doctor experiencing it is almost certainly not alone among colleagues.
“Physicians can work together and with their leadership to prevent and mitigate the effects of burnout by promoting personal and professional wellness, effective teamwork, and reducing the administrative burdens that impact time spent directly with patients and have been demonstrated to contribute to physician burnout,” Dr. Baer noted.
She also pointed to the need to address it in medical education, given the downstream risks of burnout on the next generation of physicians.
“Medical schools and residency and fellowship programs should address the risks and signs of burnout, as medical students and trainees are likely seeing signs of burnout in some of their physician teachers and mentors,” Dr. Baer said in the interview.
Some burnout among providers may be inevitable at times, but it’s important to continue looking for ways to combat it.
“We need to do more to remind each other of why we chose our profession, and how good it makes us feel to strive to make a difference in our patients and families each and every day,” Dr. First said in the interview.
Dr. First reported having no disclosures and no external funding. The residents’ study by Baer et al. was funded by the Boston Children’s Hospital’s Fred Lovejoy Resident Research Award and a grant from the Health Resources and Services Administration. The NICU study by Tamfik et al. was funded by the National Institutes of Health, grants from the National Institute of Child Health and Human Development, and the Jackson Vaughan Critical Care Research Fund. The authors of both studies had no relevant financial disclosures.
, according to two Pediatrics articles highlighted by editor in chief Lewis R. First, MD, MS.
The studies investigated the prevalence and effects of burnout among pediatric residents, and all health care providers, working in intensive care units. They were among those published in 2017 that Dr. First deemed potentially practice changing – ones whose clinical implications may have immediate relevance in your daily work.
“There are a variety of ways to overcome burnout and promote our resiliency that starts with our ability to find joy in caring for children and our lifelong learning” through professional development sessions and academic journals, according to Dr. First, professor and chair of pediatrics at the University of Vermont in Burlington. He also serves as chief of pediatrics at the University of Vermont Children’s Hospital. He spoke at the 2017 annual meeting of the American Academy of Pediatrics and in later interviews.
High prevalence of burnout
The study by Baer et al. found that almost two in five pediatric residents experience burnout, often accompanied by poorer care of patients (Pediatrics. 2017. doi: 10.1542/peds.2016-2163). Using a 7-point Likert scale ranging from “never” to “every day,” 258 residents from 11 different residency programs filled out an anonymous Web-based survey on how often they felt emotional exhaustion (“I feel burnout from my work”) and depersonalization (“I’ve become more callous toward people since I took this job”).
Of the 258 respondents, 39% had burnout, defined as answering affirmatively to either of the above questions with at least “weekly.” Most of the respondents were female, white, and married or in a long-term relationship without children, but the burnout rates did not vary across gender, race/ethnicity, relationship or parental status, or among different characteristics of the residency program and schedule. Higher burnout rates did occur among those feeling sleep deprived.
Those with burnout also had substantially higher odds of providing lower-quality care. Residents with burnout were seven times more likely to make treatment or medication errors not related to inadequate knowledge or experience, six times more likely to feel guilty about how they had treated a patient, more than four times more likely to report having little emotional reaction to a patient’s death, and four times more likely to discharge a patient earlier to make service more manageable. Burned-out residents had more than nine times greater odds of paying “little attention to the social or personal impact of an illness on a patient,” the study showed.
Burnout symptoms and solutions
Symptoms of potential burnout, Dr. First said in an interview, include emotional exhaustion, feeling a loss of meaning in work, feelings of ineffectiveness, a tendency to view people as objects instead of human beings, increasingly poor communication, and poor interpersonal and clinical skills and behaviors.
Other research also has found burnout linked to doctors’ errors, self-reported negative attitudes toward patients, and less time spent with patients, she said. “Thus physicians should be on the lookout for burnout within themselves as well as in their colleagues and medical trainees.”
Both Dr. Baer and Dr. First noted the importance of organizational leadership in preventing burnout.
The Association of Medical School Pediatric Department Chairs is sharing a toolbox of strategies that they have found effective for reducing burnout and developing wellness among physicians, Dr. First said in the interview.
“Some of those suggestions include personal attention to wellness via good nutrition, exercise, mindfulness for emotional self-regulation, and developing supportive relationships,” he noted. In addition to organizational mindfulness programs and ones that foster work-life integration and social activities, prevention programs should “create wellness and resilience, and a sense of pride and meaning in the work that is being done.”
Drs. First also pointed to ways of addressing triggers of burnout:
- Reduce the burden of bureaucratic tasks.
- Examine how many hours physicians spend at home or work at home.
- Improve efficiency, such as in EHR use.
- Provide individuals time to discuss stressors and ways to resolve them collaboratively with peers and leadership.
Burnout risk in the NICU
Similar interventions may help with burnout in neonatal ICUs (NICUs), the focus of the second study Dr. First discussed. Tawfik et al. surveyed 2,760 personnel from 41 NICUs in the United States to learn the prevalence of burnout and how it was associated with NICU organization (Pediatrics. 2017. doi: 10.1542/peds.2016-4134).
Among the 1,934 providers who replied (a response rate of 70%), 27% had burnout; at individual NICUs, burnout prevalence varied from 8% to 43%. The majority of respondents (72%) were registered nurses, followed by respiratory therapists, physicians, neonatal nurse practitioners, and others. The highest burnout rates occurred in NICUs with higher average daily admissions and higher average occupancy – and those using EHRs.
“Don’t assume that just because you use the EHR every day means you know how best to use this tool to improve your efficiency and effectiveness in generating and deriving information on your patients,” Dr. First said in the interview. He encouraged physicians to find out what resources their institutions might offer to help, such as EHR hospital teams or office support who can look at providers’ EHR usage, and show them shortcuts and time-savers to improve efficiency based on their usage patterns.
“Nursing burnout was more sensitive to the setting than physician burnout, especially in regard to average daily admissions, late transfer numbers, nursing hours per patient day, and mortality per 1,000 infants,” Dr. First noted.
Interestingly, burnout prevalence was not associated with the proportion of high-risk patients seen in the NICUs, the number of attending physicians in the unit, or whether the institution was a teaching hospital or not, he said.
Dr. First listed strategies to reduce burnout risk in NICUs that the study authors also described: expressing thankfulness each day, focusing on positive events at the start or end of each day, performing random acts of kindness for colleagues and staff, and encouraging providers to identify the strengths in one another.
Addressing burnout requires efforts from everyone
“Given the potential effects of burnout on patient care and professionalism and physician wellness, it is important for physicians to speak up if they have concerns about burnout in their colleagues,” Dr. Baer said in the interview.
Burnout is common, she said, occurring in more than half of physicians at some point in time, so a doctor experiencing it is almost certainly not alone among colleagues.
“Physicians can work together and with their leadership to prevent and mitigate the effects of burnout by promoting personal and professional wellness, effective teamwork, and reducing the administrative burdens that impact time spent directly with patients and have been demonstrated to contribute to physician burnout,” Dr. Baer noted.
She also pointed to the need to address it in medical education, given the downstream risks of burnout on the next generation of physicians.
“Medical schools and residency and fellowship programs should address the risks and signs of burnout, as medical students and trainees are likely seeing signs of burnout in some of their physician teachers and mentors,” Dr. Baer said in the interview.
Some burnout among providers may be inevitable at times, but it’s important to continue looking for ways to combat it.
“We need to do more to remind each other of why we chose our profession, and how good it makes us feel to strive to make a difference in our patients and families each and every day,” Dr. First said in the interview.
Dr. First reported having no disclosures and no external funding. The residents’ study by Baer et al. was funded by the Boston Children’s Hospital’s Fred Lovejoy Resident Research Award and a grant from the Health Resources and Services Administration. The NICU study by Tamfik et al. was funded by the National Institutes of Health, grants from the National Institute of Child Health and Human Development, and the Jackson Vaughan Critical Care Research Fund. The authors of both studies had no relevant financial disclosures.
, according to two Pediatrics articles highlighted by editor in chief Lewis R. First, MD, MS.
The studies investigated the prevalence and effects of burnout among pediatric residents, and all health care providers, working in intensive care units. They were among those published in 2017 that Dr. First deemed potentially practice changing – ones whose clinical implications may have immediate relevance in your daily work.
“There are a variety of ways to overcome burnout and promote our resiliency that starts with our ability to find joy in caring for children and our lifelong learning” through professional development sessions and academic journals, according to Dr. First, professor and chair of pediatrics at the University of Vermont in Burlington. He also serves as chief of pediatrics at the University of Vermont Children’s Hospital. He spoke at the 2017 annual meeting of the American Academy of Pediatrics and in later interviews.
High prevalence of burnout
The study by Baer et al. found that almost two in five pediatric residents experience burnout, often accompanied by poorer care of patients (Pediatrics. 2017. doi: 10.1542/peds.2016-2163). Using a 7-point Likert scale ranging from “never” to “every day,” 258 residents from 11 different residency programs filled out an anonymous Web-based survey on how often they felt emotional exhaustion (“I feel burnout from my work”) and depersonalization (“I’ve become more callous toward people since I took this job”).
Of the 258 respondents, 39% had burnout, defined as answering affirmatively to either of the above questions with at least “weekly.” Most of the respondents were female, white, and married or in a long-term relationship without children, but the burnout rates did not vary across gender, race/ethnicity, relationship or parental status, or among different characteristics of the residency program and schedule. Higher burnout rates did occur among those feeling sleep deprived.
Those with burnout also had substantially higher odds of providing lower-quality care. Residents with burnout were seven times more likely to make treatment or medication errors not related to inadequate knowledge or experience, six times more likely to feel guilty about how they had treated a patient, more than four times more likely to report having little emotional reaction to a patient’s death, and four times more likely to discharge a patient earlier to make service more manageable. Burned-out residents had more than nine times greater odds of paying “little attention to the social or personal impact of an illness on a patient,” the study showed.
Burnout symptoms and solutions
Symptoms of potential burnout, Dr. First said in an interview, include emotional exhaustion, feeling a loss of meaning in work, feelings of ineffectiveness, a tendency to view people as objects instead of human beings, increasingly poor communication, and poor interpersonal and clinical skills and behaviors.
Other research also has found burnout linked to doctors’ errors, self-reported negative attitudes toward patients, and less time spent with patients, she said. “Thus physicians should be on the lookout for burnout within themselves as well as in their colleagues and medical trainees.”
Both Dr. Baer and Dr. First noted the importance of organizational leadership in preventing burnout.
The Association of Medical School Pediatric Department Chairs is sharing a toolbox of strategies that they have found effective for reducing burnout and developing wellness among physicians, Dr. First said in the interview.
“Some of those suggestions include personal attention to wellness via good nutrition, exercise, mindfulness for emotional self-regulation, and developing supportive relationships,” he noted. In addition to organizational mindfulness programs and ones that foster work-life integration and social activities, prevention programs should “create wellness and resilience, and a sense of pride and meaning in the work that is being done.”
Drs. First also pointed to ways of addressing triggers of burnout:
- Reduce the burden of bureaucratic tasks.
- Examine how many hours physicians spend at home or work at home.
- Improve efficiency, such as in EHR use.
- Provide individuals time to discuss stressors and ways to resolve them collaboratively with peers and leadership.
Burnout risk in the NICU
Similar interventions may help with burnout in neonatal ICUs (NICUs), the focus of the second study Dr. First discussed. Tawfik et al. surveyed 2,760 personnel from 41 NICUs in the United States to learn the prevalence of burnout and how it was associated with NICU organization (Pediatrics. 2017. doi: 10.1542/peds.2016-4134).
Among the 1,934 providers who replied (a response rate of 70%), 27% had burnout; at individual NICUs, burnout prevalence varied from 8% to 43%. The majority of respondents (72%) were registered nurses, followed by respiratory therapists, physicians, neonatal nurse practitioners, and others. The highest burnout rates occurred in NICUs with higher average daily admissions and higher average occupancy – and those using EHRs.
“Don’t assume that just because you use the EHR every day means you know how best to use this tool to improve your efficiency and effectiveness in generating and deriving information on your patients,” Dr. First said in the interview. He encouraged physicians to find out what resources their institutions might offer to help, such as EHR hospital teams or office support who can look at providers’ EHR usage, and show them shortcuts and time-savers to improve efficiency based on their usage patterns.
“Nursing burnout was more sensitive to the setting than physician burnout, especially in regard to average daily admissions, late transfer numbers, nursing hours per patient day, and mortality per 1,000 infants,” Dr. First noted.
Interestingly, burnout prevalence was not associated with the proportion of high-risk patients seen in the NICUs, the number of attending physicians in the unit, or whether the institution was a teaching hospital or not, he said.
Dr. First listed strategies to reduce burnout risk in NICUs that the study authors also described: expressing thankfulness each day, focusing on positive events at the start or end of each day, performing random acts of kindness for colleagues and staff, and encouraging providers to identify the strengths in one another.
Addressing burnout requires efforts from everyone
“Given the potential effects of burnout on patient care and professionalism and physician wellness, it is important for physicians to speak up if they have concerns about burnout in their colleagues,” Dr. Baer said in the interview.
Burnout is common, she said, occurring in more than half of physicians at some point in time, so a doctor experiencing it is almost certainly not alone among colleagues.
“Physicians can work together and with their leadership to prevent and mitigate the effects of burnout by promoting personal and professional wellness, effective teamwork, and reducing the administrative burdens that impact time spent directly with patients and have been demonstrated to contribute to physician burnout,” Dr. Baer noted.
She also pointed to the need to address it in medical education, given the downstream risks of burnout on the next generation of physicians.
“Medical schools and residency and fellowship programs should address the risks and signs of burnout, as medical students and trainees are likely seeing signs of burnout in some of their physician teachers and mentors,” Dr. Baer said in the interview.
Some burnout among providers may be inevitable at times, but it’s important to continue looking for ways to combat it.
“We need to do more to remind each other of why we chose our profession, and how good it makes us feel to strive to make a difference in our patients and families each and every day,” Dr. First said in the interview.
Dr. First reported having no disclosures and no external funding. The residents’ study by Baer et al. was funded by the Boston Children’s Hospital’s Fred Lovejoy Resident Research Award and a grant from the Health Resources and Services Administration. The NICU study by Tamfik et al. was funded by the National Institutes of Health, grants from the National Institute of Child Health and Human Development, and the Jackson Vaughan Critical Care Research Fund. The authors of both studies had no relevant financial disclosures.
You are an integral part of the epilepsy care team
CHICAGO – While neurologists treat children’s seizure conditions, you or an emergency physician usually sees the child first and must determine whether a seizure has occurred and how to proceed.
Knowing the characteristics of seizures – and their imitators – helps you appropriately evaluate and treat these children, said Sucheta Joshi, MD, of the University of Michigan, Ann Arbor, and Linda C. Laux, MD, the medical director of the Comprehensive Epilepsy Center at the Ann & Robert H. Lurie Children’s Hospital of Chicago. You also must consider the long-term management and well-being of a child with epilepsy.
A primer on seizures
Abnormal electrical discharges in the brain cause seizures, and various acute conditions can cause them, including fevers, infections, trauma, and metabolic abnormalities. But an epilepsy diagnosis requires at least two unprovoked seizures occurring more than 1 day apart. More than two dozen different epilepsy syndromes exist, determined based on age of onset, seizure type, the child’s development, and EEG patterns.
You also should be aware of what seizure imitators to rule out: movement disorders such as tics and Sandifer’s syndrome, daydreaming and inattention, fainting, migraines, panic attacks, psychogenic nonepileptic seizures (PNES), self-stimulatory behaviors, periods of the child holding her breath, and sleep parasomnias, such as night terrors, sleepwalking, and sleep myoclonus.
“It’s often difficult to tell if it’s a seizure or a nonepileptic paroxysmal event,” said Dr. Joshi. An interictal EEG can be helpful, but “there’s no reliable test to differentiate the two.”
Knowing the environment where the incident occurred, what provoking factors might have been present, what the seizure looked like, how long it lasted, and what happened afterward can help you differentiate paroxysmal spells from seizures.
Febrile seizures
About 4% of all children experience febrile seizures, particularly between 6 months and 6 years of age, Dr. Joshi said. The two types are simple and complex. A simple febrile seizure is generalized and brief, lasting less than 15 minutes, and is not followed by another within 24 hours. The child may have a family history of epilepsy but appear normal. Complex febrile seizures are focal, last more than 15 minutes, and occur more than once within 24 hours.
Although antipyretics may help the child feel better, fever control won’t always prevent seizures. Rectal or sometimes oral diazepam can prevent recurrent prolonged febrile seizures if necessary. You also may consider oral clonazepam as a rescue medication.
However, children with only simple febrile seizures are at no greater risk of developing epilepsy by age 7 years than are children in the general population, about 1%, according to the AAP’s clinical practice guideline for long-term management of children with simple febrile seizures (Pediatrics. 2008 Jun;121(6):1281-6.)
If a child has a family history of epilepsy, has their first febrile before 12 months of age, and has multiple simple febrile seizures, however, their risk of epilepsy more than doubles. An estimated 2.4% of these children will develop epilepsy by age 25 years.
“No study has demonstrated that successful treatment of simple febrile seizures can prevent this later development of epilepsy, and there currently is no evidence that simple febrile seizures cause structural damage to the brain,” the practice guideline states. “Indeed, it is most likely that the increased risk of epilepsy in this population is the result of genetic predisposition.”
Determining seizure causes
If the child’s seizure is not clearly febrile with a known cause, you should run through other possibilities. Did the child have head trauma? A central nervous system infection? Are metabolic abnormalities present, such as renal or hepatic disease or an electrolyte abnormality? Has the patient ingested something, such as a recreational drug or other toxic substance?
Lab work is unlikely to offer much information without clinical signs or symptoms present, but you may consider glucose, electrolytes, serum alcohol level, and a toxicology drug screen on a case-by-case basis: A child’s first unprovoked seizure should not lead to a lumbar puncture, Dr. Laux said. But if you suspect a CNS infection or the child is under 6 months old and does not return to baseline, you should consider a lumbar puncture. Modest increases in cerebrospinal fluid cell count (pleocytosis) occur after a seizure, but a “CSF above 20 WBC/mm3 or above 10 PMN/mm3 should not be attributed to a seizure,” she said.
An outpatient EEG, preferably performed within 24-48 hours, shows abnormalities 70% of the time after a seizure, but a normal EEG cannot rule out a seizure. EEG data also may suggest recurrence risk or a specific epilepsy syndrome and long-term prognosis.
Epilepsy management
After a second unprovoked seizure occurrs more than 24 hours after the first, you should diagnose new onset epilepsy, order an EEG and head MRI, and refer the child to a neurologist. Metabolic or genetic tests may be indicated depending on signs and symptoms.
Managing epilepsy requires much more than just treating seizures, Dr. Laux emphasized, so you play an important role in educating the family, considering safety issues, monitoring bone and reproductive health, and considering the condition’s effect on learning and mental, behavioral, and physical health.
Children with epilepsy and normal cognitive development have no greater rate of injuries than children without epilepsy, but risk increases as seizures increase, and if the child has ADHD, intellectual disability, or generalized-onset seizures, that can lead to falls.
Still, children with epilepsy can play contact sports such as soccer or volleyball without worrying it will cause a seizure. They also should always wear a helmet while bicycling, rollerblading, skating, and using scooters or anything else with wheels.
Swimming, water sports, harnessed rock climbing, horseback riding, and gymnastics also are fine with appropriate supervision. Showers are preferred to baths because of the risk of drowning should a seizure occur in the bathtub. Bathing and swimming require a specified supervisor.
Unsafe activities include free climbing, sky-diving, hang-gliding, and scuba diving. Parents should supervise their children around irons, hairdryers, curling irons, stove tops, camp fires, BBQs, and playground equipment. TV and video games are fine if children do not sit close to the screen and have ambient light in the room.
A teen with uncontrolled seizures should not drive, and pediatricians should be aware of their state’s laws related to epilepsy and driving (www.epilepsy.com/driving-laws). Pennsylvania, California, Delaware, Nevada, New Jersey, and Oregon, for example, have physician reporting laws.
Physical health and learning differences
Epilepsy increases risk of poor bone mineralization, and seizures can lead to falls and fractures. You therefore should keep tabs on the child’s vitamin D intake, physical activity levels, neuromotor dysfunction, and overall nutrition. Vitamin D insufficiency is more common in those with epilepsy than in the general population, particularly females and those with obesity. Evidence suggests both anticonvulsants and epilepsy syndromes contribute to low vitamin D levels, so daily supplements may be wise.
Antiepileptic drugs also reduce the effectiveness of hormonal contraception, and teens with epilepsy already have a higher risk for unplanned pregnancy. You should ensure that sexually active female teens get folic acid daily and educate them on valproate’s increased risk of causing birth defects. For pregnant teens, levetiracetam and lamotrigine present less risk to a fetus.
You should ask about the patient’s school performance and consider requesting an Individualized Education Plan or a 504 plan at school if it seems needed. Even in youths with a normal IQ and well-managed seizures, lower academic achievement and difficulties with memory and behavior are more likely. Risk increases in disorganized or unsupportive homes and with comorbidities. ADHD occurs in 38% of children with epilepsy, but stimulants such as methylphenidate are not contraindicated with epilepsy medications.
Epilepsy affects the whole family: About half of all mothers of children with epilepsy have depression – which can adversely affect her children – and risk increases for younger moms with lower education and income. Siblings have added burdens, too: In one study, 95% of siblings had witnessed a seizure, and 79% believed their siblings suffered during seizures. More than two-thirds (68%) say their sibling with epilepsy gets more attention, and 42% feel responsible for their sibling, often restricting their own activities. You should be considering all these factors in managing the well-being of a child with epilepsy.
Dr. Joshi summed up the complex management of epilepsy with an acrostic that may be helpful to share with parents:
• Education
• Parenting
• Independence (including driving)
• Learning
• Eating (nutrition and bone health)
• Pharmacotherapy (anticonvulsants)
• School
• You (the child’s caretakers).
Dr. Joshi and Dr. Laux reported having no relevant financial disclosures and no external funding.
CHICAGO – While neurologists treat children’s seizure conditions, you or an emergency physician usually sees the child first and must determine whether a seizure has occurred and how to proceed.
Knowing the characteristics of seizures – and their imitators – helps you appropriately evaluate and treat these children, said Sucheta Joshi, MD, of the University of Michigan, Ann Arbor, and Linda C. Laux, MD, the medical director of the Comprehensive Epilepsy Center at the Ann & Robert H. Lurie Children’s Hospital of Chicago. You also must consider the long-term management and well-being of a child with epilepsy.
A primer on seizures
Abnormal electrical discharges in the brain cause seizures, and various acute conditions can cause them, including fevers, infections, trauma, and metabolic abnormalities. But an epilepsy diagnosis requires at least two unprovoked seizures occurring more than 1 day apart. More than two dozen different epilepsy syndromes exist, determined based on age of onset, seizure type, the child’s development, and EEG patterns.
You also should be aware of what seizure imitators to rule out: movement disorders such as tics and Sandifer’s syndrome, daydreaming and inattention, fainting, migraines, panic attacks, psychogenic nonepileptic seizures (PNES), self-stimulatory behaviors, periods of the child holding her breath, and sleep parasomnias, such as night terrors, sleepwalking, and sleep myoclonus.
“It’s often difficult to tell if it’s a seizure or a nonepileptic paroxysmal event,” said Dr. Joshi. An interictal EEG can be helpful, but “there’s no reliable test to differentiate the two.”
Knowing the environment where the incident occurred, what provoking factors might have been present, what the seizure looked like, how long it lasted, and what happened afterward can help you differentiate paroxysmal spells from seizures.
Febrile seizures
About 4% of all children experience febrile seizures, particularly between 6 months and 6 years of age, Dr. Joshi said. The two types are simple and complex. A simple febrile seizure is generalized and brief, lasting less than 15 minutes, and is not followed by another within 24 hours. The child may have a family history of epilepsy but appear normal. Complex febrile seizures are focal, last more than 15 minutes, and occur more than once within 24 hours.
Although antipyretics may help the child feel better, fever control won’t always prevent seizures. Rectal or sometimes oral diazepam can prevent recurrent prolonged febrile seizures if necessary. You also may consider oral clonazepam as a rescue medication.
However, children with only simple febrile seizures are at no greater risk of developing epilepsy by age 7 years than are children in the general population, about 1%, according to the AAP’s clinical practice guideline for long-term management of children with simple febrile seizures (Pediatrics. 2008 Jun;121(6):1281-6.)
If a child has a family history of epilepsy, has their first febrile before 12 months of age, and has multiple simple febrile seizures, however, their risk of epilepsy more than doubles. An estimated 2.4% of these children will develop epilepsy by age 25 years.
“No study has demonstrated that successful treatment of simple febrile seizures can prevent this later development of epilepsy, and there currently is no evidence that simple febrile seizures cause structural damage to the brain,” the practice guideline states. “Indeed, it is most likely that the increased risk of epilepsy in this population is the result of genetic predisposition.”
Determining seizure causes
If the child’s seizure is not clearly febrile with a known cause, you should run through other possibilities. Did the child have head trauma? A central nervous system infection? Are metabolic abnormalities present, such as renal or hepatic disease or an electrolyte abnormality? Has the patient ingested something, such as a recreational drug or other toxic substance?
Lab work is unlikely to offer much information without clinical signs or symptoms present, but you may consider glucose, electrolytes, serum alcohol level, and a toxicology drug screen on a case-by-case basis: A child’s first unprovoked seizure should not lead to a lumbar puncture, Dr. Laux said. But if you suspect a CNS infection or the child is under 6 months old and does not return to baseline, you should consider a lumbar puncture. Modest increases in cerebrospinal fluid cell count (pleocytosis) occur after a seizure, but a “CSF above 20 WBC/mm3 or above 10 PMN/mm3 should not be attributed to a seizure,” she said.
An outpatient EEG, preferably performed within 24-48 hours, shows abnormalities 70% of the time after a seizure, but a normal EEG cannot rule out a seizure. EEG data also may suggest recurrence risk or a specific epilepsy syndrome and long-term prognosis.
Epilepsy management
After a second unprovoked seizure occurrs more than 24 hours after the first, you should diagnose new onset epilepsy, order an EEG and head MRI, and refer the child to a neurologist. Metabolic or genetic tests may be indicated depending on signs and symptoms.
Managing epilepsy requires much more than just treating seizures, Dr. Laux emphasized, so you play an important role in educating the family, considering safety issues, monitoring bone and reproductive health, and considering the condition’s effect on learning and mental, behavioral, and physical health.
Children with epilepsy and normal cognitive development have no greater rate of injuries than children without epilepsy, but risk increases as seizures increase, and if the child has ADHD, intellectual disability, or generalized-onset seizures, that can lead to falls.
Still, children with epilepsy can play contact sports such as soccer or volleyball without worrying it will cause a seizure. They also should always wear a helmet while bicycling, rollerblading, skating, and using scooters or anything else with wheels.
Swimming, water sports, harnessed rock climbing, horseback riding, and gymnastics also are fine with appropriate supervision. Showers are preferred to baths because of the risk of drowning should a seizure occur in the bathtub. Bathing and swimming require a specified supervisor.
Unsafe activities include free climbing, sky-diving, hang-gliding, and scuba diving. Parents should supervise their children around irons, hairdryers, curling irons, stove tops, camp fires, BBQs, and playground equipment. TV and video games are fine if children do not sit close to the screen and have ambient light in the room.
A teen with uncontrolled seizures should not drive, and pediatricians should be aware of their state’s laws related to epilepsy and driving (www.epilepsy.com/driving-laws). Pennsylvania, California, Delaware, Nevada, New Jersey, and Oregon, for example, have physician reporting laws.
Physical health and learning differences
Epilepsy increases risk of poor bone mineralization, and seizures can lead to falls and fractures. You therefore should keep tabs on the child’s vitamin D intake, physical activity levels, neuromotor dysfunction, and overall nutrition. Vitamin D insufficiency is more common in those with epilepsy than in the general population, particularly females and those with obesity. Evidence suggests both anticonvulsants and epilepsy syndromes contribute to low vitamin D levels, so daily supplements may be wise.
Antiepileptic drugs also reduce the effectiveness of hormonal contraception, and teens with epilepsy already have a higher risk for unplanned pregnancy. You should ensure that sexually active female teens get folic acid daily and educate them on valproate’s increased risk of causing birth defects. For pregnant teens, levetiracetam and lamotrigine present less risk to a fetus.
You should ask about the patient’s school performance and consider requesting an Individualized Education Plan or a 504 plan at school if it seems needed. Even in youths with a normal IQ and well-managed seizures, lower academic achievement and difficulties with memory and behavior are more likely. Risk increases in disorganized or unsupportive homes and with comorbidities. ADHD occurs in 38% of children with epilepsy, but stimulants such as methylphenidate are not contraindicated with epilepsy medications.
Epilepsy affects the whole family: About half of all mothers of children with epilepsy have depression – which can adversely affect her children – and risk increases for younger moms with lower education and income. Siblings have added burdens, too: In one study, 95% of siblings had witnessed a seizure, and 79% believed their siblings suffered during seizures. More than two-thirds (68%) say their sibling with epilepsy gets more attention, and 42% feel responsible for their sibling, often restricting their own activities. You should be considering all these factors in managing the well-being of a child with epilepsy.
Dr. Joshi summed up the complex management of epilepsy with an acrostic that may be helpful to share with parents:
• Education
• Parenting
• Independence (including driving)
• Learning
• Eating (nutrition and bone health)
• Pharmacotherapy (anticonvulsants)
• School
• You (the child’s caretakers).
Dr. Joshi and Dr. Laux reported having no relevant financial disclosures and no external funding.
CHICAGO – While neurologists treat children’s seizure conditions, you or an emergency physician usually sees the child first and must determine whether a seizure has occurred and how to proceed.
Knowing the characteristics of seizures – and their imitators – helps you appropriately evaluate and treat these children, said Sucheta Joshi, MD, of the University of Michigan, Ann Arbor, and Linda C. Laux, MD, the medical director of the Comprehensive Epilepsy Center at the Ann & Robert H. Lurie Children’s Hospital of Chicago. You also must consider the long-term management and well-being of a child with epilepsy.
A primer on seizures
Abnormal electrical discharges in the brain cause seizures, and various acute conditions can cause them, including fevers, infections, trauma, and metabolic abnormalities. But an epilepsy diagnosis requires at least two unprovoked seizures occurring more than 1 day apart. More than two dozen different epilepsy syndromes exist, determined based on age of onset, seizure type, the child’s development, and EEG patterns.
You also should be aware of what seizure imitators to rule out: movement disorders such as tics and Sandifer’s syndrome, daydreaming and inattention, fainting, migraines, panic attacks, psychogenic nonepileptic seizures (PNES), self-stimulatory behaviors, periods of the child holding her breath, and sleep parasomnias, such as night terrors, sleepwalking, and sleep myoclonus.
“It’s often difficult to tell if it’s a seizure or a nonepileptic paroxysmal event,” said Dr. Joshi. An interictal EEG can be helpful, but “there’s no reliable test to differentiate the two.”
Knowing the environment where the incident occurred, what provoking factors might have been present, what the seizure looked like, how long it lasted, and what happened afterward can help you differentiate paroxysmal spells from seizures.
Febrile seizures
About 4% of all children experience febrile seizures, particularly between 6 months and 6 years of age, Dr. Joshi said. The two types are simple and complex. A simple febrile seizure is generalized and brief, lasting less than 15 minutes, and is not followed by another within 24 hours. The child may have a family history of epilepsy but appear normal. Complex febrile seizures are focal, last more than 15 minutes, and occur more than once within 24 hours.
Although antipyretics may help the child feel better, fever control won’t always prevent seizures. Rectal or sometimes oral diazepam can prevent recurrent prolonged febrile seizures if necessary. You also may consider oral clonazepam as a rescue medication.
However, children with only simple febrile seizures are at no greater risk of developing epilepsy by age 7 years than are children in the general population, about 1%, according to the AAP’s clinical practice guideline for long-term management of children with simple febrile seizures (Pediatrics. 2008 Jun;121(6):1281-6.)
If a child has a family history of epilepsy, has their first febrile before 12 months of age, and has multiple simple febrile seizures, however, their risk of epilepsy more than doubles. An estimated 2.4% of these children will develop epilepsy by age 25 years.
“No study has demonstrated that successful treatment of simple febrile seizures can prevent this later development of epilepsy, and there currently is no evidence that simple febrile seizures cause structural damage to the brain,” the practice guideline states. “Indeed, it is most likely that the increased risk of epilepsy in this population is the result of genetic predisposition.”
Determining seizure causes
If the child’s seizure is not clearly febrile with a known cause, you should run through other possibilities. Did the child have head trauma? A central nervous system infection? Are metabolic abnormalities present, such as renal or hepatic disease or an electrolyte abnormality? Has the patient ingested something, such as a recreational drug or other toxic substance?
Lab work is unlikely to offer much information without clinical signs or symptoms present, but you may consider glucose, electrolytes, serum alcohol level, and a toxicology drug screen on a case-by-case basis: A child’s first unprovoked seizure should not lead to a lumbar puncture, Dr. Laux said. But if you suspect a CNS infection or the child is under 6 months old and does not return to baseline, you should consider a lumbar puncture. Modest increases in cerebrospinal fluid cell count (pleocytosis) occur after a seizure, but a “CSF above 20 WBC/mm3 or above 10 PMN/mm3 should not be attributed to a seizure,” she said.
An outpatient EEG, preferably performed within 24-48 hours, shows abnormalities 70% of the time after a seizure, but a normal EEG cannot rule out a seizure. EEG data also may suggest recurrence risk or a specific epilepsy syndrome and long-term prognosis.
Epilepsy management
After a second unprovoked seizure occurrs more than 24 hours after the first, you should diagnose new onset epilepsy, order an EEG and head MRI, and refer the child to a neurologist. Metabolic or genetic tests may be indicated depending on signs and symptoms.
Managing epilepsy requires much more than just treating seizures, Dr. Laux emphasized, so you play an important role in educating the family, considering safety issues, monitoring bone and reproductive health, and considering the condition’s effect on learning and mental, behavioral, and physical health.
Children with epilepsy and normal cognitive development have no greater rate of injuries than children without epilepsy, but risk increases as seizures increase, and if the child has ADHD, intellectual disability, or generalized-onset seizures, that can lead to falls.
Still, children with epilepsy can play contact sports such as soccer or volleyball without worrying it will cause a seizure. They also should always wear a helmet while bicycling, rollerblading, skating, and using scooters or anything else with wheels.
Swimming, water sports, harnessed rock climbing, horseback riding, and gymnastics also are fine with appropriate supervision. Showers are preferred to baths because of the risk of drowning should a seizure occur in the bathtub. Bathing and swimming require a specified supervisor.
Unsafe activities include free climbing, sky-diving, hang-gliding, and scuba diving. Parents should supervise their children around irons, hairdryers, curling irons, stove tops, camp fires, BBQs, and playground equipment. TV and video games are fine if children do not sit close to the screen and have ambient light in the room.
A teen with uncontrolled seizures should not drive, and pediatricians should be aware of their state’s laws related to epilepsy and driving (www.epilepsy.com/driving-laws). Pennsylvania, California, Delaware, Nevada, New Jersey, and Oregon, for example, have physician reporting laws.
Physical health and learning differences
Epilepsy increases risk of poor bone mineralization, and seizures can lead to falls and fractures. You therefore should keep tabs on the child’s vitamin D intake, physical activity levels, neuromotor dysfunction, and overall nutrition. Vitamin D insufficiency is more common in those with epilepsy than in the general population, particularly females and those with obesity. Evidence suggests both anticonvulsants and epilepsy syndromes contribute to low vitamin D levels, so daily supplements may be wise.
Antiepileptic drugs also reduce the effectiveness of hormonal contraception, and teens with epilepsy already have a higher risk for unplanned pregnancy. You should ensure that sexually active female teens get folic acid daily and educate them on valproate’s increased risk of causing birth defects. For pregnant teens, levetiracetam and lamotrigine present less risk to a fetus.
You should ask about the patient’s school performance and consider requesting an Individualized Education Plan or a 504 plan at school if it seems needed. Even in youths with a normal IQ and well-managed seizures, lower academic achievement and difficulties with memory and behavior are more likely. Risk increases in disorganized or unsupportive homes and with comorbidities. ADHD occurs in 38% of children with epilepsy, but stimulants such as methylphenidate are not contraindicated with epilepsy medications.
Epilepsy affects the whole family: About half of all mothers of children with epilepsy have depression – which can adversely affect her children – and risk increases for younger moms with lower education and income. Siblings have added burdens, too: In one study, 95% of siblings had witnessed a seizure, and 79% believed their siblings suffered during seizures. More than two-thirds (68%) say their sibling with epilepsy gets more attention, and 42% feel responsible for their sibling, often restricting their own activities. You should be considering all these factors in managing the well-being of a child with epilepsy.
Dr. Joshi summed up the complex management of epilepsy with an acrostic that may be helpful to share with parents:
• Education
• Parenting
• Independence (including driving)
• Learning
• Eating (nutrition and bone health)
• Pharmacotherapy (anticonvulsants)
• School
• You (the child’s caretakers).
Dr. Joshi and Dr. Laux reported having no relevant financial disclosures and no external funding.
EXPERT ANALYSIS FROM AAP 2017
Behavioral issues, anorexia may presage celiac disease
The clinical challenges of celiac disease go beyond identifying the condition and helping families adjust to a child’s gluten-free diet. Behavioral problems and/or an eating disorder may predate celiac disease, according to Alex R. Kemper, MD, MPH, division chief of ambulatory pediatrics at Nationwide Children’s Hospital, Columbus, Ohio, and deputy editor of Pediatrics.
“We are learning more and more about celiac disease. The presentation and implication of celiac disease can involve more than the gastrointestinal tract,” Dr. Kemper noted. “Figuring out who to screen for celiac disease and how best to do so is complex, and we are always learning more about the best way to provide care after celiac disease is diagnosed.”
Impact of undiagnosed celiac disease on behavior
At the 2017 annual meeting of the American Academy of Pediatrics and, in a later interview, Dr. Kemper discussed a study that explored how behavior and celiac disease might be interrelated, particularly among children whose families don’t yet know their child has the condition.
“It’s challenging to assess the psychological impact of celiac disease autoimmunity when families aren’t aware a child has it, because prospective studies are difficult to do and recall bias can distort findings,” he noted.
Smith et al. used data from a prospective international study, The Environment Determinants of Diabetes in the Young (TEDDY), designed to learn about factors associated with type 1 diabetes and celiac disease over a 15-year follow-up period (Pediatrics. 2017 Mar. doi: 10.1542/peds.2016-2848).
TEDDY tracked 8,676 infants deemed at high risk for celiac autoimmunity based on their human leukocyte antigen (HLA) antigen status at birth. The investigators regularly measured celiac disease autoimmunity based on tissue transglutaminase antibodies (tTGA), beginning at age 2 years. They assessed the children’s behavior at ages 3.5 years and 4.5 years using the Achenbach System of Empirically Based Assessment. If a child was found to have celiac disease, the researchers revisited the earlier behavior scores reported by their mothers before their children’s status were known.
When the children were 3.5 years old, 66 had celiac disease that their mothers were not yet aware of and 440 children had diagnosed celiac disease. The 66 mothers unaware of their child’s condition reported more anxiety, depression, aggression, and sleep problems in their children than did the 440 mothers who knew their child’s diagnosis or the 3,651 mothers of children without celiac disease. The differences were subclinical but statistically significant.
“It is important to recognize that the magnitude of the psychological problems in the 3.5 year olds was small,” Dr. Kemper said in an interview. “Parents might not recognize these symptoms.”
When the researchers looked at child behavior reports only among the mothers who knew their children had celiac disease, no differences existed regardless of the children’s tTGA levels or whether they were following a gluten-free diet. Then, when the children were 4.5 years old and all mothers were aware of their child’s status, no significant differences in mothers’ reporting of child behavior existed across any of the groups.
“Perhaps the knowledge of the child’s celiac disease autoimmunity increases a parent’s sensitivity to physical discomforts of their child while providing an alternative explanation for any psychological symptoms the child exhibits,” the researchers offered.
“Pediatricians should be aware of this association and consider testing young children with a family history of celiac disease if there are concerns,” Dr. Kemper said in an interview. “Because the magnitude of change was subclinical, this study does not suggest the need for more extensive screening of all children.”
Link between celiac disease and anorexia nervosa
The eating disorders study Dr. Kemper discussed examined possible associations between celiac disease and anorexia nervosa (Pediatrics. 2017. doi: 10.1542/peds.2016-4367). Researchers compared 17,959 Swedish females diagnosed with celiac disease between 1969 and 2008, at a median 28 years old, to 89,379 controls matched by sex and age.
Anorexia occurred more often among those with celiac disease than those without: a rate of 27 girls per 100,000 with celiac disease developed anorexia per year, compared with 18 of 100,000 without celiac disease, for a hazard ratio for an anorexia nervosa diagnosis of 1.46 (95% confidence interval, 1.08-1.98). In addition, girls whose celiac disease had not yet been identified had more than double the odds of developing anorexia before diagnosis than did those without celiac disease (odds ratio, 2.13).
Females with celiac disease therefore were more likely to have anorexia both before and after their celiac diagnosis, although the authors noted that surveillance bias may have made it more likely for either of the patients’ conditions to be identified after the first was. Another possible explanation is shared genetic risk factors, the authors wrote.
Dr. Kemper also offered possible reasons, including one related to the child behavior study.
“It could be that girls with celiac disease might develop anorexia because of the need to focus on their diet,” he said in an interview. “Celiac disease has been associated with psychological problems, and so that could contribute.”
Until further research can shed light on the reasons for the associations, physicians simply should be aware of the study’s clinical implications.
“Pediatricians should be aware of the bidirectional association between celiac disease and anorexia nervosa in teens and young adult women, and be prepared to evaluate for celiac disease or treat anorexia,” Dr. Kemper said.
He noted the need for more research to learn “what pediatricians can do to help to either prevent these problems from developing in the first place, or identify and treat celiac disease or anorexia nervosa early to prevent long-term complications.”
Dr. Kemper reported having no relevant financial disclosures and no external funding. Ketil Stordal, MD, PhD, of the anorexia study received funding from the OAK foundation in Switzerland, and Cynthia M. Bulik, PhD, from the same study received funding from the Swedish Research Council, and has consulted for and received a grant from Shire. The remaining authors of the anorexia study had no relevant financial disclosures. The behavioral study was funded by the National Institutes of Health, the Juvenile Diabetes Research Foundation and the Centers for Disease Control and Prevention. The authors from the behavioral study had no relevant financial disclosures.
The clinical challenges of celiac disease go beyond identifying the condition and helping families adjust to a child’s gluten-free diet. Behavioral problems and/or an eating disorder may predate celiac disease, according to Alex R. Kemper, MD, MPH, division chief of ambulatory pediatrics at Nationwide Children’s Hospital, Columbus, Ohio, and deputy editor of Pediatrics.
“We are learning more and more about celiac disease. The presentation and implication of celiac disease can involve more than the gastrointestinal tract,” Dr. Kemper noted. “Figuring out who to screen for celiac disease and how best to do so is complex, and we are always learning more about the best way to provide care after celiac disease is diagnosed.”
Impact of undiagnosed celiac disease on behavior
At the 2017 annual meeting of the American Academy of Pediatrics and, in a later interview, Dr. Kemper discussed a study that explored how behavior and celiac disease might be interrelated, particularly among children whose families don’t yet know their child has the condition.
“It’s challenging to assess the psychological impact of celiac disease autoimmunity when families aren’t aware a child has it, because prospective studies are difficult to do and recall bias can distort findings,” he noted.
Smith et al. used data from a prospective international study, The Environment Determinants of Diabetes in the Young (TEDDY), designed to learn about factors associated with type 1 diabetes and celiac disease over a 15-year follow-up period (Pediatrics. 2017 Mar. doi: 10.1542/peds.2016-2848).
TEDDY tracked 8,676 infants deemed at high risk for celiac autoimmunity based on their human leukocyte antigen (HLA) antigen status at birth. The investigators regularly measured celiac disease autoimmunity based on tissue transglutaminase antibodies (tTGA), beginning at age 2 years. They assessed the children’s behavior at ages 3.5 years and 4.5 years using the Achenbach System of Empirically Based Assessment. If a child was found to have celiac disease, the researchers revisited the earlier behavior scores reported by their mothers before their children’s status were known.
When the children were 3.5 years old, 66 had celiac disease that their mothers were not yet aware of and 440 children had diagnosed celiac disease. The 66 mothers unaware of their child’s condition reported more anxiety, depression, aggression, and sleep problems in their children than did the 440 mothers who knew their child’s diagnosis or the 3,651 mothers of children without celiac disease. The differences were subclinical but statistically significant.
“It is important to recognize that the magnitude of the psychological problems in the 3.5 year olds was small,” Dr. Kemper said in an interview. “Parents might not recognize these symptoms.”
When the researchers looked at child behavior reports only among the mothers who knew their children had celiac disease, no differences existed regardless of the children’s tTGA levels or whether they were following a gluten-free diet. Then, when the children were 4.5 years old and all mothers were aware of their child’s status, no significant differences in mothers’ reporting of child behavior existed across any of the groups.
“Perhaps the knowledge of the child’s celiac disease autoimmunity increases a parent’s sensitivity to physical discomforts of their child while providing an alternative explanation for any psychological symptoms the child exhibits,” the researchers offered.
“Pediatricians should be aware of this association and consider testing young children with a family history of celiac disease if there are concerns,” Dr. Kemper said in an interview. “Because the magnitude of change was subclinical, this study does not suggest the need for more extensive screening of all children.”
Link between celiac disease and anorexia nervosa
The eating disorders study Dr. Kemper discussed examined possible associations between celiac disease and anorexia nervosa (Pediatrics. 2017. doi: 10.1542/peds.2016-4367). Researchers compared 17,959 Swedish females diagnosed with celiac disease between 1969 and 2008, at a median 28 years old, to 89,379 controls matched by sex and age.
Anorexia occurred more often among those with celiac disease than those without: a rate of 27 girls per 100,000 with celiac disease developed anorexia per year, compared with 18 of 100,000 without celiac disease, for a hazard ratio for an anorexia nervosa diagnosis of 1.46 (95% confidence interval, 1.08-1.98). In addition, girls whose celiac disease had not yet been identified had more than double the odds of developing anorexia before diagnosis than did those without celiac disease (odds ratio, 2.13).
Females with celiac disease therefore were more likely to have anorexia both before and after their celiac diagnosis, although the authors noted that surveillance bias may have made it more likely for either of the patients’ conditions to be identified after the first was. Another possible explanation is shared genetic risk factors, the authors wrote.
Dr. Kemper also offered possible reasons, including one related to the child behavior study.
“It could be that girls with celiac disease might develop anorexia because of the need to focus on their diet,” he said in an interview. “Celiac disease has been associated with psychological problems, and so that could contribute.”
Until further research can shed light on the reasons for the associations, physicians simply should be aware of the study’s clinical implications.
“Pediatricians should be aware of the bidirectional association between celiac disease and anorexia nervosa in teens and young adult women, and be prepared to evaluate for celiac disease or treat anorexia,” Dr. Kemper said.
He noted the need for more research to learn “what pediatricians can do to help to either prevent these problems from developing in the first place, or identify and treat celiac disease or anorexia nervosa early to prevent long-term complications.”
Dr. Kemper reported having no relevant financial disclosures and no external funding. Ketil Stordal, MD, PhD, of the anorexia study received funding from the OAK foundation in Switzerland, and Cynthia M. Bulik, PhD, from the same study received funding from the Swedish Research Council, and has consulted for and received a grant from Shire. The remaining authors of the anorexia study had no relevant financial disclosures. The behavioral study was funded by the National Institutes of Health, the Juvenile Diabetes Research Foundation and the Centers for Disease Control and Prevention. The authors from the behavioral study had no relevant financial disclosures.
The clinical challenges of celiac disease go beyond identifying the condition and helping families adjust to a child’s gluten-free diet. Behavioral problems and/or an eating disorder may predate celiac disease, according to Alex R. Kemper, MD, MPH, division chief of ambulatory pediatrics at Nationwide Children’s Hospital, Columbus, Ohio, and deputy editor of Pediatrics.
“We are learning more and more about celiac disease. The presentation and implication of celiac disease can involve more than the gastrointestinal tract,” Dr. Kemper noted. “Figuring out who to screen for celiac disease and how best to do so is complex, and we are always learning more about the best way to provide care after celiac disease is diagnosed.”
Impact of undiagnosed celiac disease on behavior
At the 2017 annual meeting of the American Academy of Pediatrics and, in a later interview, Dr. Kemper discussed a study that explored how behavior and celiac disease might be interrelated, particularly among children whose families don’t yet know their child has the condition.
“It’s challenging to assess the psychological impact of celiac disease autoimmunity when families aren’t aware a child has it, because prospective studies are difficult to do and recall bias can distort findings,” he noted.
Smith et al. used data from a prospective international study, The Environment Determinants of Diabetes in the Young (TEDDY), designed to learn about factors associated with type 1 diabetes and celiac disease over a 15-year follow-up period (Pediatrics. 2017 Mar. doi: 10.1542/peds.2016-2848).
TEDDY tracked 8,676 infants deemed at high risk for celiac autoimmunity based on their human leukocyte antigen (HLA) antigen status at birth. The investigators regularly measured celiac disease autoimmunity based on tissue transglutaminase antibodies (tTGA), beginning at age 2 years. They assessed the children’s behavior at ages 3.5 years and 4.5 years using the Achenbach System of Empirically Based Assessment. If a child was found to have celiac disease, the researchers revisited the earlier behavior scores reported by their mothers before their children’s status were known.
When the children were 3.5 years old, 66 had celiac disease that their mothers were not yet aware of and 440 children had diagnosed celiac disease. The 66 mothers unaware of their child’s condition reported more anxiety, depression, aggression, and sleep problems in their children than did the 440 mothers who knew their child’s diagnosis or the 3,651 mothers of children without celiac disease. The differences were subclinical but statistically significant.
“It is important to recognize that the magnitude of the psychological problems in the 3.5 year olds was small,” Dr. Kemper said in an interview. “Parents might not recognize these symptoms.”
When the researchers looked at child behavior reports only among the mothers who knew their children had celiac disease, no differences existed regardless of the children’s tTGA levels or whether they were following a gluten-free diet. Then, when the children were 4.5 years old and all mothers were aware of their child’s status, no significant differences in mothers’ reporting of child behavior existed across any of the groups.
“Perhaps the knowledge of the child’s celiac disease autoimmunity increases a parent’s sensitivity to physical discomforts of their child while providing an alternative explanation for any psychological symptoms the child exhibits,” the researchers offered.
“Pediatricians should be aware of this association and consider testing young children with a family history of celiac disease if there are concerns,” Dr. Kemper said in an interview. “Because the magnitude of change was subclinical, this study does not suggest the need for more extensive screening of all children.”
Link between celiac disease and anorexia nervosa
The eating disorders study Dr. Kemper discussed examined possible associations between celiac disease and anorexia nervosa (Pediatrics. 2017. doi: 10.1542/peds.2016-4367). Researchers compared 17,959 Swedish females diagnosed with celiac disease between 1969 and 2008, at a median 28 years old, to 89,379 controls matched by sex and age.
Anorexia occurred more often among those with celiac disease than those without: a rate of 27 girls per 100,000 with celiac disease developed anorexia per year, compared with 18 of 100,000 without celiac disease, for a hazard ratio for an anorexia nervosa diagnosis of 1.46 (95% confidence interval, 1.08-1.98). In addition, girls whose celiac disease had not yet been identified had more than double the odds of developing anorexia before diagnosis than did those without celiac disease (odds ratio, 2.13).
Females with celiac disease therefore were more likely to have anorexia both before and after their celiac diagnosis, although the authors noted that surveillance bias may have made it more likely for either of the patients’ conditions to be identified after the first was. Another possible explanation is shared genetic risk factors, the authors wrote.
Dr. Kemper also offered possible reasons, including one related to the child behavior study.
“It could be that girls with celiac disease might develop anorexia because of the need to focus on their diet,” he said in an interview. “Celiac disease has been associated with psychological problems, and so that could contribute.”
Until further research can shed light on the reasons for the associations, physicians simply should be aware of the study’s clinical implications.
“Pediatricians should be aware of the bidirectional association between celiac disease and anorexia nervosa in teens and young adult women, and be prepared to evaluate for celiac disease or treat anorexia,” Dr. Kemper said.
He noted the need for more research to learn “what pediatricians can do to help to either prevent these problems from developing in the first place, or identify and treat celiac disease or anorexia nervosa early to prevent long-term complications.”
Dr. Kemper reported having no relevant financial disclosures and no external funding. Ketil Stordal, MD, PhD, of the anorexia study received funding from the OAK foundation in Switzerland, and Cynthia M. Bulik, PhD, from the same study received funding from the Swedish Research Council, and has consulted for and received a grant from Shire. The remaining authors of the anorexia study had no relevant financial disclosures. The behavioral study was funded by the National Institutes of Health, the Juvenile Diabetes Research Foundation and the Centers for Disease Control and Prevention. The authors from the behavioral study had no relevant financial disclosures.
Teens with PID underscreened for HIV, syphilis
CHICAGO – Adolescents with pelvic inflammatory disease (PID) were unlikely to be screened for HIV or syphilis, and many didn’t receive an appropriate antibiotic regimen, according to a recent study reported at the annual meeting of the American Academy of Pediatrics.
Patients who were sent home rather than admitted were especially likely to miss screening, as were Hispanic patients and those with private insurance.
The Centers for Disease Control and Prevention strongly recommends that all women diagnosed with PID be tested for HIV, and that high-risk individuals also be tested for syphilis, wrote Amanda Jichlinski, MD, and her coauthors at Children’s National Health System, Washington.
The study, presented during a poster session, used data from the national Pediatric Health Information System database from 2010 to 2015. A total of 10,698 records with a diagnostic code for PID were included; patients were females aged 12-21 years seen in a pediatric emergency department.
In addition to the primary outcome of syphilis and HIV testing, the authors also looked at whether antibiotic administration for PID was in line with CDC recommendations – and it wasn’t. “Fewer than half of patients in the ED received antibiotic regimens adherent to CDC guidelines,” wrote Dr. Jichlinski and her coauthors.
Forty-six percent of patients received ceftriaxone and doxycycline, 21% received ceftriaxone and azithromycin, and 6% received ceftriaxone and metronidazole. Ceftriaxone monotherapy was given to 15% of patients. One in 10 patients with a PID diagnosis received no antibiotic at all; 2% of patients received some other regimen.
The researchers used multivariable analysis to examine separately which patient and hospital characteristics were associated with an increased likelihood of testing for both HIV and syphilis. With white, non-Hispanic adolescents used as the referent, Hispanic females with PID were less likely to receive screening for either HIV or syphilis (adjusted odds ratio, 0.8 for both; 95% confidence interval, 0.7-1.0 for both).
In contrast, black non-Hispanic females were screened more often; the aOR for HIV screening was 1.4 (95% CI, 1.2-1.6), and the aOR for syphilis screening was 1.8 (95% CI, 1.6-2.0) for this group of adolescents.
Patients were dichotomized into older (17-21 years of age; n = 4,737, 44%) and younger (12-16 years of age; n = 5,961, 56%) age groups; younger patients were slightly more likely to receive HIV (aOR, 1.2) and syphilis (aOR, 1.1) screening.
Just under a third of patients in the study were seen in a hospital with fewer than 300 beds, and these facilities were more likely to screen for HIV (aOR, 1.4) and syphilis (aOR, 1.1) than the larger hospitals.
By far the largest predictor of whether HIV and syphilis screening was done, though, was a hospital admission. Patients who were admitted (n = 4,043, 38%) were 7 times more likely to be screened for HIV and 4.6 times more likely to be screened for syphilis than those who were sent home from the emergency department.
Although the large, nationally representative study had many strengths, Dr. Jichlinski and her coauthors acknowledged that the data they were provided couldn’t account for medication that was prescribed, rather than administered in the emergency department. Also, the results may not be generalizable to adolescents treated in nonpediatric emergency departments or other facilities, such as urgent care centers.
“Adolescents with PID are underscreened for HIV and syphilis,” wrote Dr. Jichlinski and her coauthors. They called for pediatricians to receive more education about management of PID in adolescents. From a practical perspective, the investigators also suggested incorporating order sets for sexually transmitted infection testing and antibiotic administration into electronic medical records; in this way, a PID diagnosis code would trigger simplified testing and treatment choices.
Dr. Jichlinski reported no conflicts of interest. Dr. Monika Goyal, MD, senior author on the study, reported funding support by the National Institute of Child Health and Human Development. Dr. Goyal also holds an appointment at the George Washington University, Washington.
SOURCE: Jichlinski A et al. AAP 2017 Abstract 5, AAP Section on Emergency Medicine.
CHICAGO – Adolescents with pelvic inflammatory disease (PID) were unlikely to be screened for HIV or syphilis, and many didn’t receive an appropriate antibiotic regimen, according to a recent study reported at the annual meeting of the American Academy of Pediatrics.
Patients who were sent home rather than admitted were especially likely to miss screening, as were Hispanic patients and those with private insurance.
The Centers for Disease Control and Prevention strongly recommends that all women diagnosed with PID be tested for HIV, and that high-risk individuals also be tested for syphilis, wrote Amanda Jichlinski, MD, and her coauthors at Children’s National Health System, Washington.
The study, presented during a poster session, used data from the national Pediatric Health Information System database from 2010 to 2015. A total of 10,698 records with a diagnostic code for PID were included; patients were females aged 12-21 years seen in a pediatric emergency department.
In addition to the primary outcome of syphilis and HIV testing, the authors also looked at whether antibiotic administration for PID was in line with CDC recommendations – and it wasn’t. “Fewer than half of patients in the ED received antibiotic regimens adherent to CDC guidelines,” wrote Dr. Jichlinski and her coauthors.
Forty-six percent of patients received ceftriaxone and doxycycline, 21% received ceftriaxone and azithromycin, and 6% received ceftriaxone and metronidazole. Ceftriaxone monotherapy was given to 15% of patients. One in 10 patients with a PID diagnosis received no antibiotic at all; 2% of patients received some other regimen.
The researchers used multivariable analysis to examine separately which patient and hospital characteristics were associated with an increased likelihood of testing for both HIV and syphilis. With white, non-Hispanic adolescents used as the referent, Hispanic females with PID were less likely to receive screening for either HIV or syphilis (adjusted odds ratio, 0.8 for both; 95% confidence interval, 0.7-1.0 for both).
In contrast, black non-Hispanic females were screened more often; the aOR for HIV screening was 1.4 (95% CI, 1.2-1.6), and the aOR for syphilis screening was 1.8 (95% CI, 1.6-2.0) for this group of adolescents.
Patients were dichotomized into older (17-21 years of age; n = 4,737, 44%) and younger (12-16 years of age; n = 5,961, 56%) age groups; younger patients were slightly more likely to receive HIV (aOR, 1.2) and syphilis (aOR, 1.1) screening.
Just under a third of patients in the study were seen in a hospital with fewer than 300 beds, and these facilities were more likely to screen for HIV (aOR, 1.4) and syphilis (aOR, 1.1) than the larger hospitals.
By far the largest predictor of whether HIV and syphilis screening was done, though, was a hospital admission. Patients who were admitted (n = 4,043, 38%) were 7 times more likely to be screened for HIV and 4.6 times more likely to be screened for syphilis than those who were sent home from the emergency department.
Although the large, nationally representative study had many strengths, Dr. Jichlinski and her coauthors acknowledged that the data they were provided couldn’t account for medication that was prescribed, rather than administered in the emergency department. Also, the results may not be generalizable to adolescents treated in nonpediatric emergency departments or other facilities, such as urgent care centers.
“Adolescents with PID are underscreened for HIV and syphilis,” wrote Dr. Jichlinski and her coauthors. They called for pediatricians to receive more education about management of PID in adolescents. From a practical perspective, the investigators also suggested incorporating order sets for sexually transmitted infection testing and antibiotic administration into electronic medical records; in this way, a PID diagnosis code would trigger simplified testing and treatment choices.
Dr. Jichlinski reported no conflicts of interest. Dr. Monika Goyal, MD, senior author on the study, reported funding support by the National Institute of Child Health and Human Development. Dr. Goyal also holds an appointment at the George Washington University, Washington.
SOURCE: Jichlinski A et al. AAP 2017 Abstract 5, AAP Section on Emergency Medicine.
CHICAGO – Adolescents with pelvic inflammatory disease (PID) were unlikely to be screened for HIV or syphilis, and many didn’t receive an appropriate antibiotic regimen, according to a recent study reported at the annual meeting of the American Academy of Pediatrics.
Patients who were sent home rather than admitted were especially likely to miss screening, as were Hispanic patients and those with private insurance.
The Centers for Disease Control and Prevention strongly recommends that all women diagnosed with PID be tested for HIV, and that high-risk individuals also be tested for syphilis, wrote Amanda Jichlinski, MD, and her coauthors at Children’s National Health System, Washington.
The study, presented during a poster session, used data from the national Pediatric Health Information System database from 2010 to 2015. A total of 10,698 records with a diagnostic code for PID were included; patients were females aged 12-21 years seen in a pediatric emergency department.
In addition to the primary outcome of syphilis and HIV testing, the authors also looked at whether antibiotic administration for PID was in line with CDC recommendations – and it wasn’t. “Fewer than half of patients in the ED received antibiotic regimens adherent to CDC guidelines,” wrote Dr. Jichlinski and her coauthors.
Forty-six percent of patients received ceftriaxone and doxycycline, 21% received ceftriaxone and azithromycin, and 6% received ceftriaxone and metronidazole. Ceftriaxone monotherapy was given to 15% of patients. One in 10 patients with a PID diagnosis received no antibiotic at all; 2% of patients received some other regimen.
The researchers used multivariable analysis to examine separately which patient and hospital characteristics were associated with an increased likelihood of testing for both HIV and syphilis. With white, non-Hispanic adolescents used as the referent, Hispanic females with PID were less likely to receive screening for either HIV or syphilis (adjusted odds ratio, 0.8 for both; 95% confidence interval, 0.7-1.0 for both).
In contrast, black non-Hispanic females were screened more often; the aOR for HIV screening was 1.4 (95% CI, 1.2-1.6), and the aOR for syphilis screening was 1.8 (95% CI, 1.6-2.0) for this group of adolescents.
Patients were dichotomized into older (17-21 years of age; n = 4,737, 44%) and younger (12-16 years of age; n = 5,961, 56%) age groups; younger patients were slightly more likely to receive HIV (aOR, 1.2) and syphilis (aOR, 1.1) screening.
Just under a third of patients in the study were seen in a hospital with fewer than 300 beds, and these facilities were more likely to screen for HIV (aOR, 1.4) and syphilis (aOR, 1.1) than the larger hospitals.
By far the largest predictor of whether HIV and syphilis screening was done, though, was a hospital admission. Patients who were admitted (n = 4,043, 38%) were 7 times more likely to be screened for HIV and 4.6 times more likely to be screened for syphilis than those who were sent home from the emergency department.
Although the large, nationally representative study had many strengths, Dr. Jichlinski and her coauthors acknowledged that the data they were provided couldn’t account for medication that was prescribed, rather than administered in the emergency department. Also, the results may not be generalizable to adolescents treated in nonpediatric emergency departments or other facilities, such as urgent care centers.
“Adolescents with PID are underscreened for HIV and syphilis,” wrote Dr. Jichlinski and her coauthors. They called for pediatricians to receive more education about management of PID in adolescents. From a practical perspective, the investigators also suggested incorporating order sets for sexually transmitted infection testing and antibiotic administration into electronic medical records; in this way, a PID diagnosis code would trigger simplified testing and treatment choices.
Dr. Jichlinski reported no conflicts of interest. Dr. Monika Goyal, MD, senior author on the study, reported funding support by the National Institute of Child Health and Human Development. Dr. Goyal also holds an appointment at the George Washington University, Washington.
SOURCE: Jichlinski A et al. AAP 2017 Abstract 5, AAP Section on Emergency Medicine.
REPORTING FROM AAP 2017
Key clinical point:
Major finding: Hispanic females were least likely to be screened (adjusted OR, 0.8), compared with non-Hispanic white females.
Study details: Retrospective study of 10,698 adolescent patients with PID from a national database.
Disclosures: The study was funded in part by the National Institute of Child Health and Development. The authors had no relevant financial disclosures.
Source: Jichlinski A et al. AAP 2017 Abstract 5, AAP Section on Emergency Medicine
Bright Futures 4th Edition gets a clinical refresher
CHICAGO – Bracing his audience for a whirlwind tour of the many updates to the fourth edition of Bright Futures, Joseph F. Hagan Jr., MD, said that it’s still completely possible to fit Bright Futures visits into a clinic day.
“I practice primary care pediatrics,” said Dr. Hagan, a pediatrician in private practice and clinical professor of pediatrics at the University of Vermont, both in Burlington. “I said to my Bright Futures colleagues, if I didn’t think I could do this in 18 minutes, I wouldn’t ask you to do it.”
The Bright Futures framework, described by Dr. Hagan as the health prevention and disease prevention component of the medical home for children and youth, emerges in the Fourth Edition with a significant evidence-based refresher. The changes and updates are built within the existing framework and encompass surveillance and screening recommendations as well as anticipatory guidance. All content, including family handouts, has been updated, said Dr. Hagan, a coeditor of the Fourth Edition of Bright Futures. He spoke at the annual meeting of the American Academy of Pediatrics.
New clinical content
“What’s new? Maternal depression screening is new,” said Dr. Hagan, noting that the recommendation has long been under discussion. Now, supported by a 2016 United States Preventative Task Force (USPSTF) recommendation that carries a grade B level of evidence, all mothers should be screened for depression at the 1-, 2-, 4-, and 6-month Bright Futures visits.
However, he said, know your local regulations. “State mandates to do more might overrule this.” And conversely, “Just because we’re doing it universally until 6 months doesn’t mean you couldn’t selectively screen later if you have concerns.”
Safe sleep is another area with new clinical focus, he said. The new recommendation for the child to sleep in the parent’s room for “at least 6 months” draws on data from European studies showing lower mortality for children who share a room with parents during this period.
Clinicians should continue to recommend that parents not sleep with their infants in couches, chairs, or beds. As before, parents should be told not to have loose blankets, stuffed toys, or crib bumpers in their babies’ cribs. Another key message, said Dr. Hagan, is that “There is no such thing as safe ‘breast-sleeping.’ ”
Parents should be reminded not to swaddle at nap – or bedtime. The risk is that even a 2-month-old infant may be capable of wriggling over from back to front, and a swaddled infant whose hands are trapped may not be able to move to protect her airway once prone. “Swaddle for comfort, swaddle for crying, swaddle for nursing, but don’t swaddle for sleep” is the message, said Dr. Hagan.
For breast-fed babies, iron supplementation should begin at the 4-month visit. The notion is to prevent progression from iron deficiency to frank anemia, said Dr. Hagan. “We know that we screen for iron deficiency anemia … but we also know that before you’re iron deficient anemic, you’re iron deficient,” he said, and iron’s also critical to brain development. For convenience, switching from vitamin D alone to a multivitamin drop with iron at 4 months is a practical choice.
New dental health recommendations bring prevention to the pediatrician’s office. “Fluoride varnish? Do it!” said Dr. Hagan. Although the USPSTF made a 2014 grade B recommendation that primary care clinicians apply fluoride varnish to primary teeth as soon as they erupt, “It’s new to the Bright Futures periodicity schedule,” he said; parents can be assured that fluoride varnish does not cause fluorosis.
The good news for clinicians, he noted. “Once it hits the periodicity schedule, now, it’s a billable service that must be paid” under Affordable Care Act regulations, said Dr. Hagan. “Don’t let your insurer say, ‘That’s part of what you’re already being paid for.’ ” He recommends avoiding the pressure to bundle this important service. Use the discrete CPT code 99188, “Application of a fluoride varnish by a physician or other qualified health care professional.”
Although Bright Futures has updated recommendations for dyslipidemia blood screening, the USPSTF found insufficient evidence to back lipid screening for those younger than 20 years of age, citing an inability to assess the balance of benefits and harms for universal, rather than risk-based, screening. However, said Dr. Hagan, the American Academy of Pediatrics (AAP), and the National Heart, Lung, and Blood Institute (NHLBI) were looking at this issue at about the same time, and they “did a really good job of showing their work,” to show that if family history alone guided screening in the pediatric population, it “just wasn’t getting done.” And AAP and NHLBI did demonstrate evidence sufficient to support this recommendation.
Accordingly, Bright Futures recommends one screening between ages 9 and 11 years and an additional screening between ages 17 and 21. These windows are designed to bracket puberty, said Dr. Hagan, because values can be skewed during that period. “It’s billable, it’s not bundle-able, and I’d recommend that you do it,” he said.
Developmental surveillance and screening
What’s new with developmental surveillance and screening? “Well, we could argue that the milestones are something to think about, because the milestones are the cornerstone of developmental surveillance,” said Dr. Hagan. “You’re in the room with the child. You’re trained, you’re experienced, you’re smart, your gestalt tells you if their development is good or bad.” 
As important as surveillance is, though, he said, it is “nowhere near as important as screening.” Surveillance happens at every well-child visit, but there’s no substitute for formal developmental screening. For the Fourth Edition guidance and toolkit, gross motor milestones have been adjusted to reflect what’s really being seen as more parents adopt the Back to Sleep recommendations as well.
A standardized developmental screening tool is used at the 9-, 18-, and 30-month visits, and when parents or caregivers express concern about development. Autism-specific screening happens at 18 and 24 months.
“Remember this, if you remember nothing else: If the screening is positive, and you believe there’s a problem, you’re going to refer,” not just to the appropriate specialist but also for early intervention services, so time isn’t lost as the child is waiting for further evaluation and a formal diagnosis, said Dr. Hagan. This coordinated effort appropriately places the responsibility for early identification of developmental delays and disorders at the doorstep of the child’s medical home.
The federally-coordinated Birth to 5: Watch Me Thrive! effort has aggregated research-based screening tools, users’ guides targeted at a variety of audiences, and resources to help caregivers, said Dr. Hagan.
Four commonly-used tools to consider using during the visit are the Parents’ Evaluation of Developmental Status, the Ages and Stages Questionnaire, the Child Health and Development Interactive System, and the Survey of Wellbeing of Young Children. Of these, said Dr. Hagan, the latter is the only tool that’s in the public domain. However, he said, they are “all really good.”
Consider having parents fill out screening questionnaires in the waiting room before the visit, said Dr. Hagan. “I always tell my colleagues, ‘Have them start the visit without you, if you want to get it done in 18 minutes.’ ”
Two questionnaires per visit are available in the Bright Futures toolkit. One questionnaire asks developmental surveillance and risk assessment questions for selective screening. The second questionnaire asks prescreening questions to help with the anticipatory guidance part of the visit, he said. Having families do these ahead of time, said Dr. Hagan, “allows you to become more focused.”
Paying attention to practicalities can make all this go more smoothly, and maximize reimbursement as well. In his own practice, Dr. Hagan said, screening tools and questionnaires are integrated into the EHR system, so that appropriate paperwork prints automatically ahead of the visit.
It’s also worth reviewing billing practices to make sure that CPT code 96110 is used when administering screening with a standardized instrument and completing scoring and documentation. According to the Bright Futures periodicity schedule, this may be done at the 9-, 18-, and 30-month visits for developmental screening, as well as at 18 and 24 months for autism-specific screening.
Promoting lifelong health
Since the initial Bright Futures guidelines were published in the late 1990s, said Dr. Hagan, the focus has always been on seeing the child as part of the family, who, in turn, are part of the community, forming a framework that addresses the social components of child health. “If you’re not looking at the whole picture, you’re not promoting health,” he said. “It’s no big surprise that we now have a specific, called-out focus on promoting lifelong health.”
In the Fourth Edition, the theme of promoting lifelong health for families and communities is woven throughout, with social determinants of health being a specific visit priority. For example, questions about food insecurity have been drawn from the published literature and are included. Also, said Dr. Hagan, there’s specific anticipatory guidance content that’s clearly marked as addressing social determinants of health.
The fundamental importance of socioeconomic status as a social determinant of health was brought home by the Robert Wood Johnson Foundation’s Commission to Build a Healthier America, which demonstrated that, “Your ZIP code is more important to your health than your genetic code,” said Dr. Hagan. “So your work in health supervision is important, and you have been leaders in this effort.”
Research guides Bright Futures updates
The fourth edition of Bright Futures builds on health promotion themes to support the mental and physical health of children and adolescents, and has a robust framework of evidence underpinning the guidelines, said Dr. Hagan.
The goal is for clinicians to “use evidence to decide upon content of their own health supervision visits,” he explained.
The chapter of the Bright Futures guidelines that addresses the evidence and rationale for the guidelines has been expanded to better answer two questions, said Dr. Hagan: “What evidence grounds our recommendations?” and “What rationale did we use when evidence was insufficient or lacking?”
When possible, the editors of the guidelines used evidence-based sources such as recommendations from the USPSTF, the Centers for Disease Control Community Guide, and the Cochrane Collaboration.
There were many more evidence-based recommendations available to those working on the 4th edition than there had been when writing the previous edition, when, said Dr. Hagan, the USPSTF had exactly two recommendations for those under the age of 21 years. The current expanded number of USPSTF pediatric recommendations was due in part to the attention the AAP was able to bring regarding the need for evidence-based recommendations in pediatrics, he said.
When guidelines were not available, the editors also turned to high quality studies from peer reviewed publications. When such high quality evidence was lacking in a particular area, the guidelines make clear what rationale was used to formulate a given recommendation, and that some recommendations should be interpreted with a degree of caution.
And, said Dr. Hagan, even science-based guidelines will change as more data accumulates. “Don’t forget about peanuts!” he said. “It was really logical 15 years ago when we said don’t give peanut products until 1 year of age. And about 2 years ago, we found out that it really didn’t work.”
Although there are specific updates to clinical content, there also were changes made in broader strokes throughout the 4th edition. One of these shifts embeds social determinants of health in many visits. This adjustment acknowledges the growing body of knowledge that “strengths and protective factors make a difference, and risk factors make a difference” in pediatric outcomes.
A greater focus on lifelong physical and mental health is included under the general rubric of promoting lifelong health for families and communities. More emphasis is placed on promoting health for children and youth who have special health care needs as well.
Nuts-and-bolts changes in the updated 4th edition include updates for milestones of development and accompanying developmental surveillance questions, new clinical content and guidance for implementation that have been added based on strong evidence, and a variety of updates for adolescent screenings in particular.
The full 4th edition Bright Futures toolkit will be available for use in 2018.
Dr. Hagan was a coeditor of the Fourth Edition of Bright Futures.
*This article was updated on December 21, 2017
CHICAGO – Bracing his audience for a whirlwind tour of the many updates to the fourth edition of Bright Futures, Joseph F. Hagan Jr., MD, said that it’s still completely possible to fit Bright Futures visits into a clinic day.
“I practice primary care pediatrics,” said Dr. Hagan, a pediatrician in private practice and clinical professor of pediatrics at the University of Vermont, both in Burlington. “I said to my Bright Futures colleagues, if I didn’t think I could do this in 18 minutes, I wouldn’t ask you to do it.”
The Bright Futures framework, described by Dr. Hagan as the health prevention and disease prevention component of the medical home for children and youth, emerges in the Fourth Edition with a significant evidence-based refresher. The changes and updates are built within the existing framework and encompass surveillance and screening recommendations as well as anticipatory guidance. All content, including family handouts, has been updated, said Dr. Hagan, a coeditor of the Fourth Edition of Bright Futures. He spoke at the annual meeting of the American Academy of Pediatrics.
New clinical content
“What’s new? Maternal depression screening is new,” said Dr. Hagan, noting that the recommendation has long been under discussion. Now, supported by a 2016 United States Preventative Task Force (USPSTF) recommendation that carries a grade B level of evidence, all mothers should be screened for depression at the 1-, 2-, 4-, and 6-month Bright Futures visits.
However, he said, know your local regulations. “State mandates to do more might overrule this.” And conversely, “Just because we’re doing it universally until 6 months doesn’t mean you couldn’t selectively screen later if you have concerns.”
Safe sleep is another area with new clinical focus, he said. The new recommendation for the child to sleep in the parent’s room for “at least 6 months” draws on data from European studies showing lower mortality for children who share a room with parents during this period.
Clinicians should continue to recommend that parents not sleep with their infants in couches, chairs, or beds. As before, parents should be told not to have loose blankets, stuffed toys, or crib bumpers in their babies’ cribs. Another key message, said Dr. Hagan, is that “There is no such thing as safe ‘breast-sleeping.’ ”
Parents should be reminded not to swaddle at nap – or bedtime. The risk is that even a 2-month-old infant may be capable of wriggling over from back to front, and a swaddled infant whose hands are trapped may not be able to move to protect her airway once prone. “Swaddle for comfort, swaddle for crying, swaddle for nursing, but don’t swaddle for sleep” is the message, said Dr. Hagan.
For breast-fed babies, iron supplementation should begin at the 4-month visit. The notion is to prevent progression from iron deficiency to frank anemia, said Dr. Hagan. “We know that we screen for iron deficiency anemia … but we also know that before you’re iron deficient anemic, you’re iron deficient,” he said, and iron’s also critical to brain development. For convenience, switching from vitamin D alone to a multivitamin drop with iron at 4 months is a practical choice.
New dental health recommendations bring prevention to the pediatrician’s office. “Fluoride varnish? Do it!” said Dr. Hagan. Although the USPSTF made a 2014 grade B recommendation that primary care clinicians apply fluoride varnish to primary teeth as soon as they erupt, “It’s new to the Bright Futures periodicity schedule,” he said; parents can be assured that fluoride varnish does not cause fluorosis.
The good news for clinicians, he noted. “Once it hits the periodicity schedule, now, it’s a billable service that must be paid” under Affordable Care Act regulations, said Dr. Hagan. “Don’t let your insurer say, ‘That’s part of what you’re already being paid for.’ ” He recommends avoiding the pressure to bundle this important service. Use the discrete CPT code 99188, “Application of a fluoride varnish by a physician or other qualified health care professional.”
Although Bright Futures has updated recommendations for dyslipidemia blood screening, the USPSTF found insufficient evidence to back lipid screening for those younger than 20 years of age, citing an inability to assess the balance of benefits and harms for universal, rather than risk-based, screening. However, said Dr. Hagan, the American Academy of Pediatrics (AAP), and the National Heart, Lung, and Blood Institute (NHLBI) were looking at this issue at about the same time, and they “did a really good job of showing their work,” to show that if family history alone guided screening in the pediatric population, it “just wasn’t getting done.” And AAP and NHLBI did demonstrate evidence sufficient to support this recommendation.
Accordingly, Bright Futures recommends one screening between ages 9 and 11 years and an additional screening between ages 17 and 21. These windows are designed to bracket puberty, said Dr. Hagan, because values can be skewed during that period. “It’s billable, it’s not bundle-able, and I’d recommend that you do it,” he said.
Developmental surveillance and screening
What’s new with developmental surveillance and screening? “Well, we could argue that the milestones are something to think about, because the milestones are the cornerstone of developmental surveillance,” said Dr. Hagan. “You’re in the room with the child. You’re trained, you’re experienced, you’re smart, your gestalt tells you if their development is good or bad.”
As important as surveillance is, though, he said, it is “nowhere near as important as screening.” Surveillance happens at every well-child visit, but there’s no substitute for formal developmental screening. For the Fourth Edition guidance and toolkit, gross motor milestones have been adjusted to reflect what’s really being seen as more parents adopt the Back to Sleep recommendations as well.
A standardized developmental screening tool is used at the 9-, 18-, and 30-month visits, and when parents or caregivers express concern about development. Autism-specific screening happens at 18 and 24 months.
“Remember this, if you remember nothing else: If the screening is positive, and you believe there’s a problem, you’re going to refer,” not just to the appropriate specialist but also for early intervention services, so time isn’t lost as the child is waiting for further evaluation and a formal diagnosis, said Dr. Hagan. This coordinated effort appropriately places the responsibility for early identification of developmental delays and disorders at the doorstep of the child’s medical home.
The federally-coordinated Birth to 5: Watch Me Thrive! effort has aggregated research-based screening tools, users’ guides targeted at a variety of audiences, and resources to help caregivers, said Dr. Hagan.
Four commonly-used tools to consider using during the visit are the Parents’ Evaluation of Developmental Status, the Ages and Stages Questionnaire, the Child Health and Development Interactive System, and the Survey of Wellbeing of Young Children. Of these, said Dr. Hagan, the latter is the only tool that’s in the public domain. However, he said, they are “all really good.”
Consider having parents fill out screening questionnaires in the waiting room before the visit, said Dr. Hagan. “I always tell my colleagues, ‘Have them start the visit without you, if you want to get it done in 18 minutes.’ ”
Two questionnaires per visit are available in the Bright Futures toolkit. One questionnaire asks developmental surveillance and risk assessment questions for selective screening. The second questionnaire asks prescreening questions to help with the anticipatory guidance part of the visit, he said. Having families do these ahead of time, said Dr. Hagan, “allows you to become more focused.”
Paying attention to practicalities can make all this go more smoothly, and maximize reimbursement as well. In his own practice, Dr. Hagan said, screening tools and questionnaires are integrated into the EHR system, so that appropriate paperwork prints automatically ahead of the visit.
It’s also worth reviewing billing practices to make sure that CPT code 96110 is used when administering screening with a standardized instrument and completing scoring and documentation. According to the Bright Futures periodicity schedule, this may be done at the 9-, 18-, and 30-month visits for developmental screening, as well as at 18 and 24 months for autism-specific screening.
Promoting lifelong health
Since the initial Bright Futures guidelines were published in the late 1990s, said Dr. Hagan, the focus has always been on seeing the child as part of the family, who, in turn, are part of the community, forming a framework that addresses the social components of child health. “If you’re not looking at the whole picture, you’re not promoting health,” he said. “It’s no big surprise that we now have a specific, called-out focus on promoting lifelong health.”
In the Fourth Edition, the theme of promoting lifelong health for families and communities is woven throughout, with social determinants of health being a specific visit priority. For example, questions about food insecurity have been drawn from the published literature and are included. Also, said Dr. Hagan, there’s specific anticipatory guidance content that’s clearly marked as addressing social determinants of health.
The fundamental importance of socioeconomic status as a social determinant of health was brought home by the Robert Wood Johnson Foundation’s Commission to Build a Healthier America, which demonstrated that, “Your ZIP code is more important to your health than your genetic code,” said Dr. Hagan. “So your work in health supervision is important, and you have been leaders in this effort.”
Research guides Bright Futures updates
The fourth edition of Bright Futures builds on health promotion themes to support the mental and physical health of children and adolescents, and has a robust framework of evidence underpinning the guidelines, said Dr. Hagan.
The goal is for clinicians to “use evidence to decide upon content of their own health supervision visits,” he explained.
The chapter of the Bright Futures guidelines that addresses the evidence and rationale for the guidelines has been expanded to better answer two questions, said Dr. Hagan: “What evidence grounds our recommendations?” and “What rationale did we use when evidence was insufficient or lacking?”
When possible, the editors of the guidelines used evidence-based sources such as recommendations from the USPSTF, the Centers for Disease Control Community Guide, and the Cochrane Collaboration.
There were many more evidence-based recommendations available to those working on the 4th edition than there had been when writing the previous edition, when, said Dr. Hagan, the USPSTF had exactly two recommendations for those under the age of 21 years. The current expanded number of USPSTF pediatric recommendations was due in part to the attention the AAP was able to bring regarding the need for evidence-based recommendations in pediatrics, he said.
When guidelines were not available, the editors also turned to high quality studies from peer reviewed publications. When such high quality evidence was lacking in a particular area, the guidelines make clear what rationale was used to formulate a given recommendation, and that some recommendations should be interpreted with a degree of caution.
And, said Dr. Hagan, even science-based guidelines will change as more data accumulates. “Don’t forget about peanuts!” he said. “It was really logical 15 years ago when we said don’t give peanut products until 1 year of age. And about 2 years ago, we found out that it really didn’t work.”
Although there are specific updates to clinical content, there also were changes made in broader strokes throughout the 4th edition. One of these shifts embeds social determinants of health in many visits. This adjustment acknowledges the growing body of knowledge that “strengths and protective factors make a difference, and risk factors make a difference” in pediatric outcomes.
A greater focus on lifelong physical and mental health is included under the general rubric of promoting lifelong health for families and communities. More emphasis is placed on promoting health for children and youth who have special health care needs as well.
Nuts-and-bolts changes in the updated 4th edition include updates for milestones of development and accompanying developmental surveillance questions, new clinical content and guidance for implementation that have been added based on strong evidence, and a variety of updates for adolescent screenings in particular.
The full 4th edition Bright Futures toolkit will be available for use in 2018.
Dr. Hagan was a coeditor of the Fourth Edition of Bright Futures.
*This article was updated on December 21, 2017
CHICAGO – Bracing his audience for a whirlwind tour of the many updates to the fourth edition of Bright Futures, Joseph F. Hagan Jr., MD, said that it’s still completely possible to fit Bright Futures visits into a clinic day.
“I practice primary care pediatrics,” said Dr. Hagan, a pediatrician in private practice and clinical professor of pediatrics at the University of Vermont, both in Burlington. “I said to my Bright Futures colleagues, if I didn’t think I could do this in 18 minutes, I wouldn’t ask you to do it.”
The Bright Futures framework, described by Dr. Hagan as the health prevention and disease prevention component of the medical home for children and youth, emerges in the Fourth Edition with a significant evidence-based refresher. The changes and updates are built within the existing framework and encompass surveillance and screening recommendations as well as anticipatory guidance. All content, including family handouts, has been updated, said Dr. Hagan, a coeditor of the Fourth Edition of Bright Futures. He spoke at the annual meeting of the American Academy of Pediatrics.
New clinical content
“What’s new? Maternal depression screening is new,” said Dr. Hagan, noting that the recommendation has long been under discussion. Now, supported by a 2016 United States Preventative Task Force (USPSTF) recommendation that carries a grade B level of evidence, all mothers should be screened for depression at the 1-, 2-, 4-, and 6-month Bright Futures visits.
However, he said, know your local regulations. “State mandates to do more might overrule this.” And conversely, “Just because we’re doing it universally until 6 months doesn’t mean you couldn’t selectively screen later if you have concerns.”
Safe sleep is another area with new clinical focus, he said. The new recommendation for the child to sleep in the parent’s room for “at least 6 months” draws on data from European studies showing lower mortality for children who share a room with parents during this period.
Clinicians should continue to recommend that parents not sleep with their infants in couches, chairs, or beds. As before, parents should be told not to have loose blankets, stuffed toys, or crib bumpers in their babies’ cribs. Another key message, said Dr. Hagan, is that “There is no such thing as safe ‘breast-sleeping.’ ”
Parents should be reminded not to swaddle at nap – or bedtime. The risk is that even a 2-month-old infant may be capable of wriggling over from back to front, and a swaddled infant whose hands are trapped may not be able to move to protect her airway once prone. “Swaddle for comfort, swaddle for crying, swaddle for nursing, but don’t swaddle for sleep” is the message, said Dr. Hagan.
For breast-fed babies, iron supplementation should begin at the 4-month visit. The notion is to prevent progression from iron deficiency to frank anemia, said Dr. Hagan. “We know that we screen for iron deficiency anemia … but we also know that before you’re iron deficient anemic, you’re iron deficient,” he said, and iron’s also critical to brain development. For convenience, switching from vitamin D alone to a multivitamin drop with iron at 4 months is a practical choice.
New dental health recommendations bring prevention to the pediatrician’s office. “Fluoride varnish? Do it!” said Dr. Hagan. Although the USPSTF made a 2014 grade B recommendation that primary care clinicians apply fluoride varnish to primary teeth as soon as they erupt, “It’s new to the Bright Futures periodicity schedule,” he said; parents can be assured that fluoride varnish does not cause fluorosis.
The good news for clinicians, he noted. “Once it hits the periodicity schedule, now, it’s a billable service that must be paid” under Affordable Care Act regulations, said Dr. Hagan. “Don’t let your insurer say, ‘That’s part of what you’re already being paid for.’ ” He recommends avoiding the pressure to bundle this important service. Use the discrete CPT code 99188, “Application of a fluoride varnish by a physician or other qualified health care professional.”
Although Bright Futures has updated recommendations for dyslipidemia blood screening, the USPSTF found insufficient evidence to back lipid screening for those younger than 20 years of age, citing an inability to assess the balance of benefits and harms for universal, rather than risk-based, screening. However, said Dr. Hagan, the American Academy of Pediatrics (AAP), and the National Heart, Lung, and Blood Institute (NHLBI) were looking at this issue at about the same time, and they “did a really good job of showing their work,” to show that if family history alone guided screening in the pediatric population, it “just wasn’t getting done.” And AAP and NHLBI did demonstrate evidence sufficient to support this recommendation.
Accordingly, Bright Futures recommends one screening between ages 9 and 11 years and an additional screening between ages 17 and 21. These windows are designed to bracket puberty, said Dr. Hagan, because values can be skewed during that period. “It’s billable, it’s not bundle-able, and I’d recommend that you do it,” he said.
Developmental surveillance and screening
What’s new with developmental surveillance and screening? “Well, we could argue that the milestones are something to think about, because the milestones are the cornerstone of developmental surveillance,” said Dr. Hagan. “You’re in the room with the child. You’re trained, you’re experienced, you’re smart, your gestalt tells you if their development is good or bad.”
As important as surveillance is, though, he said, it is “nowhere near as important as screening.” Surveillance happens at every well-child visit, but there’s no substitute for formal developmental screening. For the Fourth Edition guidance and toolkit, gross motor milestones have been adjusted to reflect what’s really being seen as more parents adopt the Back to Sleep recommendations as well.
A standardized developmental screening tool is used at the 9-, 18-, and 30-month visits, and when parents or caregivers express concern about development. Autism-specific screening happens at 18 and 24 months.
“Remember this, if you remember nothing else: If the screening is positive, and you believe there’s a problem, you’re going to refer,” not just to the appropriate specialist but also for early intervention services, so time isn’t lost as the child is waiting for further evaluation and a formal diagnosis, said Dr. Hagan. This coordinated effort appropriately places the responsibility for early identification of developmental delays and disorders at the doorstep of the child’s medical home.
The federally-coordinated Birth to 5: Watch Me Thrive! effort has aggregated research-based screening tools, users’ guides targeted at a variety of audiences, and resources to help caregivers, said Dr. Hagan.
Four commonly-used tools to consider using during the visit are the Parents’ Evaluation of Developmental Status, the Ages and Stages Questionnaire, the Child Health and Development Interactive System, and the Survey of Wellbeing of Young Children. Of these, said Dr. Hagan, the latter is the only tool that’s in the public domain. However, he said, they are “all really good.”
Consider having parents fill out screening questionnaires in the waiting room before the visit, said Dr. Hagan. “I always tell my colleagues, ‘Have them start the visit without you, if you want to get it done in 18 minutes.’ ”
Two questionnaires per visit are available in the Bright Futures toolkit. One questionnaire asks developmental surveillance and risk assessment questions for selective screening. The second questionnaire asks prescreening questions to help with the anticipatory guidance part of the visit, he said. Having families do these ahead of time, said Dr. Hagan, “allows you to become more focused.”
Paying attention to practicalities can make all this go more smoothly, and maximize reimbursement as well. In his own practice, Dr. Hagan said, screening tools and questionnaires are integrated into the EHR system, so that appropriate paperwork prints automatically ahead of the visit.
It’s also worth reviewing billing practices to make sure that CPT code 96110 is used when administering screening with a standardized instrument and completing scoring and documentation. According to the Bright Futures periodicity schedule, this may be done at the 9-, 18-, and 30-month visits for developmental screening, as well as at 18 and 24 months for autism-specific screening.
Promoting lifelong health
Since the initial Bright Futures guidelines were published in the late 1990s, said Dr. Hagan, the focus has always been on seeing the child as part of the family, who, in turn, are part of the community, forming a framework that addresses the social components of child health. “If you’re not looking at the whole picture, you’re not promoting health,” he said. “It’s no big surprise that we now have a specific, called-out focus on promoting lifelong health.”
In the Fourth Edition, the theme of promoting lifelong health for families and communities is woven throughout, with social determinants of health being a specific visit priority. For example, questions about food insecurity have been drawn from the published literature and are included. Also, said Dr. Hagan, there’s specific anticipatory guidance content that’s clearly marked as addressing social determinants of health.
The fundamental importance of socioeconomic status as a social determinant of health was brought home by the Robert Wood Johnson Foundation’s Commission to Build a Healthier America, which demonstrated that, “Your ZIP code is more important to your health than your genetic code,” said Dr. Hagan. “So your work in health supervision is important, and you have been leaders in this effort.”
Research guides Bright Futures updates
The fourth edition of Bright Futures builds on health promotion themes to support the mental and physical health of children and adolescents, and has a robust framework of evidence underpinning the guidelines, said Dr. Hagan.
The goal is for clinicians to “use evidence to decide upon content of their own health supervision visits,” he explained.
The chapter of the Bright Futures guidelines that addresses the evidence and rationale for the guidelines has been expanded to better answer two questions, said Dr. Hagan: “What evidence grounds our recommendations?” and “What rationale did we use when evidence was insufficient or lacking?”
When possible, the editors of the guidelines used evidence-based sources such as recommendations from the USPSTF, the Centers for Disease Control Community Guide, and the Cochrane Collaboration.
There were many more evidence-based recommendations available to those working on the 4th edition than there had been when writing the previous edition, when, said Dr. Hagan, the USPSTF had exactly two recommendations for those under the age of 21 years. The current expanded number of USPSTF pediatric recommendations was due in part to the attention the AAP was able to bring regarding the need for evidence-based recommendations in pediatrics, he said.
When guidelines were not available, the editors also turned to high quality studies from peer reviewed publications. When such high quality evidence was lacking in a particular area, the guidelines make clear what rationale was used to formulate a given recommendation, and that some recommendations should be interpreted with a degree of caution.
And, said Dr. Hagan, even science-based guidelines will change as more data accumulates. “Don’t forget about peanuts!” he said. “It was really logical 15 years ago when we said don’t give peanut products until 1 year of age. And about 2 years ago, we found out that it really didn’t work.”
Although there are specific updates to clinical content, there also were changes made in broader strokes throughout the 4th edition. One of these shifts embeds social determinants of health in many visits. This adjustment acknowledges the growing body of knowledge that “strengths and protective factors make a difference, and risk factors make a difference” in pediatric outcomes.
A greater focus on lifelong physical and mental health is included under the general rubric of promoting lifelong health for families and communities. More emphasis is placed on promoting health for children and youth who have special health care needs as well.
Nuts-and-bolts changes in the updated 4th edition include updates for milestones of development and accompanying developmental surveillance questions, new clinical content and guidance for implementation that have been added based on strong evidence, and a variety of updates for adolescent screenings in particular.
The full 4th edition Bright Futures toolkit will be available for use in 2018.
Dr. Hagan was a coeditor of the Fourth Edition of Bright Futures.
*This article was updated on December 21, 2017
EXPERT ANALYSIS FROM AAP 2017
Screening for postpartum depression is essential
CHICAGO – according to Nerissa S. Bauer, MD, MPH.
Postpartum depression is the best known mood disorder related to pregnancy, but it’s not the only one. Perinatal mood and anxiety disorders exist along a spectrum, she told attendees at the American Academy of Pediatrics annual meeting. That spectrum includes prenatal depression, prenatal anxiety, “baby blues,” postpartum depression, posttraumatic stress disorder (PSTD), and postpartum anxiety with panic attacks and/or obsessive-compulsive disorder (OCD).
Postpartum mood disorders
Postpartum depression (PPD), however, is serious and requires intervention. An estimated 10%-20% of new mothers experience PPD, but the numbers are much higher in at-risk communities. Up to 48% of mothers in low-income households and 40%-60% of adolescent mothers in low-income households experience it. Yet only about 15% of these higher-risk women seek treatment for PPD (Pediatrics. 2010 Nov;126[5]:1032-9).
PPD symptoms are similar to the usual symptoms of a depressive disorder: depressed mood, irritability, changes in sleep and/or appetite, fatigue, sleepiness, loss of interest in activities, inability to feel pleasure in everyday life, guilt, difficulty concentrating, indecisiveness, low energy, despair, and feelings of worthlessness. The biggest difference – and most important symptom – is that women with PPD may have thoughts about harming not only themselves but also their child. This symptom calls for immediate intervention and sometimes can be a sign of postpartum psychosis.
Postpartum psychosis is rare, occurring in about 1-3 out of 1,000 women, but its seriousness requires immediate medical attention, including hospitalization in most cases. The best established risk factor is preexisting bipolar disorder. Postpartum psychosis usually occurs in the first 4 weeks after delivery, with symptoms that include paranoia, severe mood shifts, hallucinations, delusions, and suicidal and/or homicidal thoughts.
Fathers also can experience depression after a baby’s birth: An estimated 6% of fathers develop paternal depression, but the numbers are triple that among fathers whose children are enrolled in Early Head Start programs, Dr. Bauer said. Paternal depression often co-occurs with postpartum maternal depression, particularly when poverty and substance abuse are contributing factors.
Fewer practitioners may be aware of postpartum anxiety disorders, even though they affect 9%-30% of women. These disorders include generalized anxiety disorder, OCD, and PTSD, either as a preexisting diagnosis or occurring after delivery. Women develop an intensive fear about their child’s well-being and worry that they aren’t able to parent adequately or effectively (Zero to Three. 2009 May:1-6).
Your role in screening mothers
It’s essential that you screen parents for depression, particularly mothers for PPD, because of the potential negative consequences for the child. Research has shown that children of mothers with PPD are at risk for failure to thrive, and have a greater likelihood of mental health conditions, developmental delays, lower IQ scores, sleep problems, and difficulties at school (Infant Behav Dev. 2011 Feb;34[1]:1-14). Further, mothers with PPD are less likely to breastfeed and more likely to stop breastfeeding early, studies have shown (Arch Pediatr Adolesc Med. 2006 Mar;160[3]:279-84).
The risk factors for PPD often occur together, with each additional one adding to the overall risk. As incidence estimates show, teens and those with low income are at higher risk, as are those with less education and any type of additional financial hardship. Other factors that increase women’s risk include interpersonal violence, a lack of social support, a history or family history of anxiety or depression, poor physical or mental health in general, and substance abuse (Depress Anxiety. 2017 Feb;34[2]:178-87).
“Early treatment shows best results,” Dr. Bauer said. Yet less than half of mothers experiencing PPD seek treatment for it.
“Mothers may feel they ‘are strong enough’ and do not need help,” Dr. Bauer said. Or they feel they have to use what limited energy they have on their baby, or they worry about being “labeled as crazy or unable to care for their baby,” she said. Cultural factors also can play a role in this reticence to seek help (Qual Health Res. 2008 Sep;18[9]:1161-73).
“However, mothers are receptive to communication with their child’s pediatrician,” Dr. Bauer said, creating an opportunity for screening that mothers may not otherwise get.
Screening tools and procedures
Despite the risks to infants from maternal depression, less than half of pediatricians screen mothers for PPD, Dr. Bauer said. American Academy of Pediatrics surveys of 778 pediatricians in 2004 and 2013 found that the proportion of pediatricians screening or asking mothers about depression increased from 33% to 44% during that decade, driven partly by the “belief that family screening is in the scope of practice,” she explained. Physicians who asked about the child’s mood were more likely to ask mothers about their mood too, the surveys found (J Dev Behav Pediatr. 2016 Feb-Mar;37[2]:113-20).
Medical organizations differ in their screening recommendations, although all agree screening is important. The American College of Obstetricians and Gynecologists and the U.S. Preventive Services Task Force recommend screening mothers at least once in the perinatal period (Obstet Gynecol. 2015;125:1268–71; JAMA. 2016;315[4]:388-406). The AAP advocates a more aggressive approach, recommending screening at each of the 1, 2, 4, and 6-month child well-visits (“Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents,” 4th Edition [Elk Grove Village, Ill.: American Academy of Pediatrics Publishing, 2017]).
The two preferred screening tools for PPD are the Edinburgh Postpartum Depression Scale (EPDS) and the Patient Health Questionnaire (PHQ).
The former is fast and simple, requiring less than 5 minutes for mothers to answer 10 items about their symptoms in the previous 7 days. The EPDS has a maximum score of 30; anything above 12-13 should prompt further examination or referral. Women scoring a 10 should be reassessed 2 weeks later, unless they answer affirmatively to item 10 on suicidal ideation, in which case they should be referred immediately.
You also can use a shortened form of the EPDS as a first step, asking about the three EPDS items related to anxiety: “self-blame, feeling panicky, and [feeling] anxious or worried for no good reason,” Dr. Bauer said, explaining “the score should be multiplied by 10 and divided by 3, so the cutoff is greater than or equal to 10.”
The PHQ-9 asks about symptoms in the previous 2 weeks. Scores of 10-14 indicate minor depression or mild major depression, and scores of 15-19 indicate moderate depression. Mothers require intervention if they score at least 20, or in the case of teenage mothers, if they score at least 11 or have suicidal thoughts. Like the shortened EPDS-3, the PHQ has a shortened two-question option you can use as surveillance before fully screening mothers: 1. Have you felt down, depressed, or hopeless in the past 2 weeks? 2. Have you felt little interest or pleasure in doing things in the past 2 weeks?
If mothers have a positive screen, Dr. Bauer recommended that practices document it, according to protocols they’ve already set up.
“It’s not unlike domestic violence, maternal substance abuse, or parental smoking habits,” she said. “The score need not be noted, but [should] include details such as the name of the screener used, interpretation of the results, and when a referral was made.”
After making a referral to her ob.gyn. or a mental health professional, you can continue to help mothers by offering support and reassurance, reminding them that they are not alone and not to blame for depression, and that treatment can help them. Encourage parents to seek your advice and support as a pediatrician and use you as a resource to refer them to services that can help, such as lactation consultants and home-visiting programs.
Dr. Bauer offerred the following recommendations for clinical practice:
- Choose a validated screener for postpartum depression.
- Share the tool with everyone in your practice.
- Identify ways to integrate the screening tool into daily work flow.
- Collect data.
- Implement and assess how it went after a short time, using plan-do-study-act cycles.
Dr. Bauer advised consulting the following websites for information regarding postpartum depression:
- AAP Screening and Technical Assistance and Resource (STAR) Center. This AAP website recommends validated screening tools for maternal depression and has them available on the site ().
- Postpartum Support International (PSI). This website offers information and resources for women, family, and professionals (). PSI can also be reached by calling 800-944-4773.
- PSI Support Coordinator Network. This network can provide referrals for specialized support, such as for members of the military, for fathers, when there are legal concerns, or when psychosis is present, and serves all 50 states and 40 countries ().
- PostpartumDads. This website has recommendations for partners of women with postpartum depression, offering recommendations on how dads can help themselves and the mothers ().
Dr. Bauer said she had no relevant financial disclosures. She reported that her spouse is an employee of Anthem and holds Anthem stocks/bonds. No external funding was used for the presentation.
CHICAGO – according to Nerissa S. Bauer, MD, MPH.
Postpartum depression is the best known mood disorder related to pregnancy, but it’s not the only one. Perinatal mood and anxiety disorders exist along a spectrum, she told attendees at the American Academy of Pediatrics annual meeting. That spectrum includes prenatal depression, prenatal anxiety, “baby blues,” postpartum depression, posttraumatic stress disorder (PSTD), and postpartum anxiety with panic attacks and/or obsessive-compulsive disorder (OCD).
Postpartum mood disorders
Postpartum depression (PPD), however, is serious and requires intervention. An estimated 10%-20% of new mothers experience PPD, but the numbers are much higher in at-risk communities. Up to 48% of mothers in low-income households and 40%-60% of adolescent mothers in low-income households experience it. Yet only about 15% of these higher-risk women seek treatment for PPD (Pediatrics. 2010 Nov;126[5]:1032-9).
PPD symptoms are similar to the usual symptoms of a depressive disorder: depressed mood, irritability, changes in sleep and/or appetite, fatigue, sleepiness, loss of interest in activities, inability to feel pleasure in everyday life, guilt, difficulty concentrating, indecisiveness, low energy, despair, and feelings of worthlessness. The biggest difference – and most important symptom – is that women with PPD may have thoughts about harming not only themselves but also their child. This symptom calls for immediate intervention and sometimes can be a sign of postpartum psychosis.
Postpartum psychosis is rare, occurring in about 1-3 out of 1,000 women, but its seriousness requires immediate medical attention, including hospitalization in most cases. The best established risk factor is preexisting bipolar disorder. Postpartum psychosis usually occurs in the first 4 weeks after delivery, with symptoms that include paranoia, severe mood shifts, hallucinations, delusions, and suicidal and/or homicidal thoughts.
Fathers also can experience depression after a baby’s birth: An estimated 6% of fathers develop paternal depression, but the numbers are triple that among fathers whose children are enrolled in Early Head Start programs, Dr. Bauer said. Paternal depression often co-occurs with postpartum maternal depression, particularly when poverty and substance abuse are contributing factors.
Fewer practitioners may be aware of postpartum anxiety disorders, even though they affect 9%-30% of women. These disorders include generalized anxiety disorder, OCD, and PTSD, either as a preexisting diagnosis or occurring after delivery. Women develop an intensive fear about their child’s well-being and worry that they aren’t able to parent adequately or effectively (Zero to Three. 2009 May:1-6).
Your role in screening mothers
It’s essential that you screen parents for depression, particularly mothers for PPD, because of the potential negative consequences for the child. Research has shown that children of mothers with PPD are at risk for failure to thrive, and have a greater likelihood of mental health conditions, developmental delays, lower IQ scores, sleep problems, and difficulties at school (Infant Behav Dev. 2011 Feb;34[1]:1-14). Further, mothers with PPD are less likely to breastfeed and more likely to stop breastfeeding early, studies have shown (Arch Pediatr Adolesc Med. 2006 Mar;160[3]:279-84).
The risk factors for PPD often occur together, with each additional one adding to the overall risk. As incidence estimates show, teens and those with low income are at higher risk, as are those with less education and any type of additional financial hardship. Other factors that increase women’s risk include interpersonal violence, a lack of social support, a history or family history of anxiety or depression, poor physical or mental health in general, and substance abuse (Depress Anxiety. 2017 Feb;34[2]:178-87).
“Early treatment shows best results,” Dr. Bauer said. Yet less than half of mothers experiencing PPD seek treatment for it.
“Mothers may feel they ‘are strong enough’ and do not need help,” Dr. Bauer said. Or they feel they have to use what limited energy they have on their baby, or they worry about being “labeled as crazy or unable to care for their baby,” she said. Cultural factors also can play a role in this reticence to seek help (Qual Health Res. 2008 Sep;18[9]:1161-73).
“However, mothers are receptive to communication with their child’s pediatrician,” Dr. Bauer said, creating an opportunity for screening that mothers may not otherwise get.
Screening tools and procedures
Despite the risks to infants from maternal depression, less than half of pediatricians screen mothers for PPD, Dr. Bauer said. American Academy of Pediatrics surveys of 778 pediatricians in 2004 and 2013 found that the proportion of pediatricians screening or asking mothers about depression increased from 33% to 44% during that decade, driven partly by the “belief that family screening is in the scope of practice,” she explained. Physicians who asked about the child’s mood were more likely to ask mothers about their mood too, the surveys found (J Dev Behav Pediatr. 2016 Feb-Mar;37[2]:113-20).
Medical organizations differ in their screening recommendations, although all agree screening is important. The American College of Obstetricians and Gynecologists and the U.S. Preventive Services Task Force recommend screening mothers at least once in the perinatal period (Obstet Gynecol. 2015;125:1268–71; JAMA. 2016;315[4]:388-406). The AAP advocates a more aggressive approach, recommending screening at each of the 1, 2, 4, and 6-month child well-visits (“Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents,” 4th Edition [Elk Grove Village, Ill.: American Academy of Pediatrics Publishing, 2017]).
The two preferred screening tools for PPD are the Edinburgh Postpartum Depression Scale (EPDS) and the Patient Health Questionnaire (PHQ).
The former is fast and simple, requiring less than 5 minutes for mothers to answer 10 items about their symptoms in the previous 7 days. The EPDS has a maximum score of 30; anything above 12-13 should prompt further examination or referral. Women scoring a 10 should be reassessed 2 weeks later, unless they answer affirmatively to item 10 on suicidal ideation, in which case they should be referred immediately.
You also can use a shortened form of the EPDS as a first step, asking about the three EPDS items related to anxiety: “self-blame, feeling panicky, and [feeling] anxious or worried for no good reason,” Dr. Bauer said, explaining “the score should be multiplied by 10 and divided by 3, so the cutoff is greater than or equal to 10.”
The PHQ-9 asks about symptoms in the previous 2 weeks. Scores of 10-14 indicate minor depression or mild major depression, and scores of 15-19 indicate moderate depression. Mothers require intervention if they score at least 20, or in the case of teenage mothers, if they score at least 11 or have suicidal thoughts. Like the shortened EPDS-3, the PHQ has a shortened two-question option you can use as surveillance before fully screening mothers: 1. Have you felt down, depressed, or hopeless in the past 2 weeks? 2. Have you felt little interest or pleasure in doing things in the past 2 weeks?
If mothers have a positive screen, Dr. Bauer recommended that practices document it, according to protocols they’ve already set up.
“It’s not unlike domestic violence, maternal substance abuse, or parental smoking habits,” she said. “The score need not be noted, but [should] include details such as the name of the screener used, interpretation of the results, and when a referral was made.”
After making a referral to her ob.gyn. or a mental health professional, you can continue to help mothers by offering support and reassurance, reminding them that they are not alone and not to blame for depression, and that treatment can help them. Encourage parents to seek your advice and support as a pediatrician and use you as a resource to refer them to services that can help, such as lactation consultants and home-visiting programs.
Dr. Bauer offerred the following recommendations for clinical practice:
- Choose a validated screener for postpartum depression.
- Share the tool with everyone in your practice.
- Identify ways to integrate the screening tool into daily work flow.
- Collect data.
- Implement and assess how it went after a short time, using plan-do-study-act cycles.
Dr. Bauer advised consulting the following websites for information regarding postpartum depression:
- AAP Screening and Technical Assistance and Resource (STAR) Center. This AAP website recommends validated screening tools for maternal depression and has them available on the site ().
- Postpartum Support International (PSI). This website offers information and resources for women, family, and professionals (). PSI can also be reached by calling 800-944-4773.
- PSI Support Coordinator Network. This network can provide referrals for specialized support, such as for members of the military, for fathers, when there are legal concerns, or when psychosis is present, and serves all 50 states and 40 countries ().
- PostpartumDads. This website has recommendations for partners of women with postpartum depression, offering recommendations on how dads can help themselves and the mothers ().
Dr. Bauer said she had no relevant financial disclosures. She reported that her spouse is an employee of Anthem and holds Anthem stocks/bonds. No external funding was used for the presentation.
CHICAGO – according to Nerissa S. Bauer, MD, MPH.
Postpartum depression is the best known mood disorder related to pregnancy, but it’s not the only one. Perinatal mood and anxiety disorders exist along a spectrum, she told attendees at the American Academy of Pediatrics annual meeting. That spectrum includes prenatal depression, prenatal anxiety, “baby blues,” postpartum depression, posttraumatic stress disorder (PSTD), and postpartum anxiety with panic attacks and/or obsessive-compulsive disorder (OCD).
Postpartum mood disorders
Postpartum depression (PPD), however, is serious and requires intervention. An estimated 10%-20% of new mothers experience PPD, but the numbers are much higher in at-risk communities. Up to 48% of mothers in low-income households and 40%-60% of adolescent mothers in low-income households experience it. Yet only about 15% of these higher-risk women seek treatment for PPD (Pediatrics. 2010 Nov;126[5]:1032-9).
PPD symptoms are similar to the usual symptoms of a depressive disorder: depressed mood, irritability, changes in sleep and/or appetite, fatigue, sleepiness, loss of interest in activities, inability to feel pleasure in everyday life, guilt, difficulty concentrating, indecisiveness, low energy, despair, and feelings of worthlessness. The biggest difference – and most important symptom – is that women with PPD may have thoughts about harming not only themselves but also their child. This symptom calls for immediate intervention and sometimes can be a sign of postpartum psychosis.
Postpartum psychosis is rare, occurring in about 1-3 out of 1,000 women, but its seriousness requires immediate medical attention, including hospitalization in most cases. The best established risk factor is preexisting bipolar disorder. Postpartum psychosis usually occurs in the first 4 weeks after delivery, with symptoms that include paranoia, severe mood shifts, hallucinations, delusions, and suicidal and/or homicidal thoughts.
Fathers also can experience depression after a baby’s birth: An estimated 6% of fathers develop paternal depression, but the numbers are triple that among fathers whose children are enrolled in Early Head Start programs, Dr. Bauer said. Paternal depression often co-occurs with postpartum maternal depression, particularly when poverty and substance abuse are contributing factors.
Fewer practitioners may be aware of postpartum anxiety disorders, even though they affect 9%-30% of women. These disorders include generalized anxiety disorder, OCD, and PTSD, either as a preexisting diagnosis or occurring after delivery. Women develop an intensive fear about their child’s well-being and worry that they aren’t able to parent adequately or effectively (Zero to Three. 2009 May:1-6).
Your role in screening mothers
It’s essential that you screen parents for depression, particularly mothers for PPD, because of the potential negative consequences for the child. Research has shown that children of mothers with PPD are at risk for failure to thrive, and have a greater likelihood of mental health conditions, developmental delays, lower IQ scores, sleep problems, and difficulties at school (Infant Behav Dev. 2011 Feb;34[1]:1-14). Further, mothers with PPD are less likely to breastfeed and more likely to stop breastfeeding early, studies have shown (Arch Pediatr Adolesc Med. 2006 Mar;160[3]:279-84).
The risk factors for PPD often occur together, with each additional one adding to the overall risk. As incidence estimates show, teens and those with low income are at higher risk, as are those with less education and any type of additional financial hardship. Other factors that increase women’s risk include interpersonal violence, a lack of social support, a history or family history of anxiety or depression, poor physical or mental health in general, and substance abuse (Depress Anxiety. 2017 Feb;34[2]:178-87).
“Early treatment shows best results,” Dr. Bauer said. Yet less than half of mothers experiencing PPD seek treatment for it.
“Mothers may feel they ‘are strong enough’ and do not need help,” Dr. Bauer said. Or they feel they have to use what limited energy they have on their baby, or they worry about being “labeled as crazy or unable to care for their baby,” she said. Cultural factors also can play a role in this reticence to seek help (Qual Health Res. 2008 Sep;18[9]:1161-73).
“However, mothers are receptive to communication with their child’s pediatrician,” Dr. Bauer said, creating an opportunity for screening that mothers may not otherwise get.
Screening tools and procedures
Despite the risks to infants from maternal depression, less than half of pediatricians screen mothers for PPD, Dr. Bauer said. American Academy of Pediatrics surveys of 778 pediatricians in 2004 and 2013 found that the proportion of pediatricians screening or asking mothers about depression increased from 33% to 44% during that decade, driven partly by the “belief that family screening is in the scope of practice,” she explained. Physicians who asked about the child’s mood were more likely to ask mothers about their mood too, the surveys found (J Dev Behav Pediatr. 2016 Feb-Mar;37[2]:113-20).
Medical organizations differ in their screening recommendations, although all agree screening is important. The American College of Obstetricians and Gynecologists and the U.S. Preventive Services Task Force recommend screening mothers at least once in the perinatal period (Obstet Gynecol. 2015;125:1268–71; JAMA. 2016;315[4]:388-406). The AAP advocates a more aggressive approach, recommending screening at each of the 1, 2, 4, and 6-month child well-visits (“Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents,” 4th Edition [Elk Grove Village, Ill.: American Academy of Pediatrics Publishing, 2017]).
The two preferred screening tools for PPD are the Edinburgh Postpartum Depression Scale (EPDS) and the Patient Health Questionnaire (PHQ).
The former is fast and simple, requiring less than 5 minutes for mothers to answer 10 items about their symptoms in the previous 7 days. The EPDS has a maximum score of 30; anything above 12-13 should prompt further examination or referral. Women scoring a 10 should be reassessed 2 weeks later, unless they answer affirmatively to item 10 on suicidal ideation, in which case they should be referred immediately.
You also can use a shortened form of the EPDS as a first step, asking about the three EPDS items related to anxiety: “self-blame, feeling panicky, and [feeling] anxious or worried for no good reason,” Dr. Bauer said, explaining “the score should be multiplied by 10 and divided by 3, so the cutoff is greater than or equal to 10.”
The PHQ-9 asks about symptoms in the previous 2 weeks. Scores of 10-14 indicate minor depression or mild major depression, and scores of 15-19 indicate moderate depression. Mothers require intervention if they score at least 20, or in the case of teenage mothers, if they score at least 11 or have suicidal thoughts. Like the shortened EPDS-3, the PHQ has a shortened two-question option you can use as surveillance before fully screening mothers: 1. Have you felt down, depressed, or hopeless in the past 2 weeks? 2. Have you felt little interest or pleasure in doing things in the past 2 weeks?
If mothers have a positive screen, Dr. Bauer recommended that practices document it, according to protocols they’ve already set up.
“It’s not unlike domestic violence, maternal substance abuse, or parental smoking habits,” she said. “The score need not be noted, but [should] include details such as the name of the screener used, interpretation of the results, and when a referral was made.”
After making a referral to her ob.gyn. or a mental health professional, you can continue to help mothers by offering support and reassurance, reminding them that they are not alone and not to blame for depression, and that treatment can help them. Encourage parents to seek your advice and support as a pediatrician and use you as a resource to refer them to services that can help, such as lactation consultants and home-visiting programs.
Dr. Bauer offerred the following recommendations for clinical practice:
- Choose a validated screener for postpartum depression.
- Share the tool with everyone in your practice.
- Identify ways to integrate the screening tool into daily work flow.
- Collect data.
- Implement and assess how it went after a short time, using plan-do-study-act cycles.
Dr. Bauer advised consulting the following websites for information regarding postpartum depression:
- AAP Screening and Technical Assistance and Resource (STAR) Center. This AAP website recommends validated screening tools for maternal depression and has them available on the site ().
- Postpartum Support International (PSI). This website offers information and resources for women, family, and professionals (). PSI can also be reached by calling 800-944-4773.
- PSI Support Coordinator Network. This network can provide referrals for specialized support, such as for members of the military, for fathers, when there are legal concerns, or when psychosis is present, and serves all 50 states and 40 countries ().
- PostpartumDads. This website has recommendations for partners of women with postpartum depression, offering recommendations on how dads can help themselves and the mothers ().
Dr. Bauer said she had no relevant financial disclosures. She reported that her spouse is an employee of Anthem and holds Anthem stocks/bonds. No external funding was used for the presentation.
EXPERT ANALYSIS FROM AAP 2017
Two changes are made to resuscitation practice in delivery room
CHICAGO – , according to Gary M. Weiner, MD, of the department of pediatrics and neonatal-perinatal medicine at the University of Michigan and C.S. Mott Children’s Hospital in Ann Arbor.
One is recommending an electronic cardiac (EC) monitor to assess heart rate during resuscitation instead of relying on pulse oximetry, and the other is no longer recommending routine tracheal suction in nonvigorous babies with meconium-stained fluid, he told attendees at the American Academy of Pediatrics annual meeting.
About two-thirds of all births have a risk factor for needing resuscitation, and about 10%-20% of babies with a risk factor will need positive pressure ventilation (PPV). But risk factors do not identify all newborns who will need it. The risk is greatest for newborns less than 36 weeks’ or greater than 40 weeks’ gestational age, but 7% of term newborns will need PPV despite having no risk factors.
Situations in which there is the highest risk for advanced resuscitation include the following:
- Fetal bradycardia: 24-fold greater odds.
- Intrauterine growth restriction (IUGR): 20-fold greater odds.
- Clinical chorioamnionitis: 17-fold greater odds.
- Forceps or vacuum: 17-fold greater odds.
- Meconium-stained amniotic fluid (MSAF): 17-fold greater odds.
- Gestational diabetes: 16-fold greater odds.
- Abruption: 12-fold greater odds.
- General anesthesia: 11-fold greater odds.
These risks were determined in a prospective multicenter, case-control study of 61,593 births (Arch Dis Child Fetal Neonatal Ed. 2017 Jan;102[1]:F44-F50).
Assembling a team and using checklists
Teamwork and communication are key in delivery room emergencies, and teams should debrief afterward, ideally having videotaped the resuscitation, if possible, Dr. Weiner said.
He discussed preparation for a very-low-birth-weight birth, a “routine emergency” requiring many tasks in a short period of time: 130 tasks in the first hour and 40 in the first 3 minutes.
“Decisions made during the first hour have long-term implications, so you need multiple caregivers and a high-performance team,” Dr. Weiner said. In addition to a thorough understanding of the clinical situation, a high-performance team should have both effective leadership, and clearly defined roles and responsibilities for each member. Clinicians on the team need highly developed technical skills that they reliably and consistently execute with precision. “Practice, refine, practice, refine,” he emphasized.
It’s also important to make use of preset protocols, scripts, and checklists, Dr. Weiner said. These tools assure consistency, facilitate communication among team members, and improve outcomes. Research has shown that use of protocols, scripts, and checklists leads to improved stroke and trauma care, decreased complications during intubation, fewer central-line complications, and decreased perioperative mortality and complications.
He also recommended implementing a standardized equipment check and team briefing “time-out,” similar to a surgical time-out. This time-out gives teams an opportunity to identify a team leader, define member roles and responsibilities, check all equipment and supplies, discuss risk factors and possible scenarios, talk with the obstetrician and, if possible, introduce the leader or another team member to the parents.
In a study from University of California, San Diego, Medical Center, using checklists as part of resuscitation of potentially high-risk infants reduced the occurrence of communication problems from 24% to 4% of resuscitations (P less than 0.001) over a 3-year period (Resuscitation. 2013 Nov;84[11]:1552-7).
Delayed cord clamping
Dr. Weiner also discussed the benefits of placental transfusion. The fetal-placental unit includes approximately 110 mL/kg of blood, and about one-third of its volume remains in the placenta immediately after birth. Immediate cord clamping means a loss of 10-20 mL/kg of “potential” newborn blood volume, and could contribute to unstable pulmonary blood flow or a carotid artery pressure spike (Matern Health Neonatol Perinatol. 2016. doi: 10.1186/s40748-016-0032-y).
“Umbilical blood flow is complex,” he said. Blood flows toward the baby via the umbilical vein during inhalation, but stops or reverses during crying. The umbilical artery primarily carries blood to the placenta, and flow stops after about 4 minutes in more than half of infants. Gravity’s role in blood flow is controversial (Lancet. 2014 Jul 19;384[9939]:235-40).
The two options for placental transfusion are delayed cord clamping and milking the umbilical cord (also called “stripping”). In vaginal births, delayed clamping allows 20 mL/kg blood to transfer to the baby by 3 minutes after birth, with 90% of that reaching the baby in the first minute (Lancet. 1969 Oct 25;294[7626]:871-3).
Blood transfer is less efficient in cesarean births, so milking may be more efficient than simply delaying clamping, according to a small randomized controlled trial of preterm infants around 28 weeks’ gestational age. No difference between the methods was seen in vaginal births. To milk the cord, pinch it near the placenta and squeeze it toward the newborn for 2 seconds; then release, refill and repeat.
The biggest benefits in delayed cord clamping or milking occur among preterm infants: decreased mortality, higher mean arterial pressure on day 1, and a lower risk of blood transfusion, necrotizing enterocolitis, and a Bayley Motor score below 85 at 18-22 months. Term babies also get benefits, though: increased hemoglobin at birth (approximately 2 g/dL), a 0.5- to 5-point average increase in boys’ Ages & Stages fine motor and social domain scores at age 4 years, and among high-risk infants, a lower risk of iron deficiency anemia at age 1 year (JAMA Pediatr. 2017;171[3]:264-70).
According to current guidelines from the American Academy of Pediatrics, “delayed cord clamping longer than 30 seconds is reasonable for both term and preterm infants who do not require resuscitation at birth,” but “there is insufficient evidence to recommend an approach to cord clamping for infants who require resuscitation.” They also recommend against routine milking for newborns less than 29 weeks’ gestation (Pediatrics. 2015 Nov;136 Suppl 2:S196-218).
Meconium-related complications
Meconium-stained amniotic fluid (MSAF) is common, occurring in about 8% of deliveries and increasing with gestational age, but meconium aspiration syndrome (MAS) is less common, occurring in about 2% of all MSAF cases (Int J Pediatr. 2012. doi: 10.1155/2012/321545).
Risk factors for severe MAS include thick meconium and an abnormal fetal heart rate. But about two-thirds of MAS cases are mild, not requiring ventilation or continuous positive airway pressure (CPAP), Dr. Weiner said. Practice should be driven by evidence from randomized controlled trials (RCTs).
“Nonrandomized observational studies can be misleading, and rational conjecture has led to many mistakes in medicine,” he said. “Be willing to challenge conventional wisdom.”
For example, the standard of care in the 1970s, based on two nonrandomized retrospective reviews of 175 babies, included orapharyngeal and nasopharyngeal suction by the obstetrician and endotracheal tube (ETT) suction by the pediatrician. In the 2000s, however, an RCT of 2,500 infants found no benefit from orapharyngeal and nasopharyngeal suction, even with thick MSAF, (Lancet. 2004 Aug 14-20;364[9434]:597-602) and another RCT with 2,100 infants found no benefit from ETT suction (Pediatrics. 2000 Jan;105[1 Pt 1]:1-7).
More recent, smaller studies have confirmed those conclusions and found similar lack of benefit from ETT in non-vigorous infants, contributing to the new recommendation (Resuscitation. 2016 Aug;105:79-84; Indian J Pediatr. 2016 Oct;83[10]:1125-30).
“Routine tracheal suction is no longer recommended for nonvigorous babies with meconium stained fluid,” Dr. Weiner said. Since MSAF is risk factor for resuscitation, though, at least two clinicians with Neonatal Resuscitation Program (NRP) training should be present, as well as a full team if resuscitation is expected.
Heart rate assessment and tracking
“The baby’s heart rate needs to be monitored during PPV [positive pressure ventilation] because a prompt increase in the baby’s heart rate is the most important indicator of effective PPV,” Dr. Weiner said in an interview. “Half of errors made during NRP [Neonatal Resuscitation Program] simulations are the result of incorrect heart rate assessment.”
Recent evidence comparing pulse oximetry to an EC monitor favored the latter for tracking heart rate, leading to the other new recommendation.
“The baby’s heart rate can be monitored using the pulse oximeter,” Dr. Weiner said. “However, health providers should consider using an electronic cardiac monitor in addition to pulse oximetry because studies show that it achieves a reliable signal faster.” He cited a study of 20 newborns that showed an EC monitor determined the heart rate in a median 34 seconds, compared with 122 seconds with the pulse oximeter (Pediatr Int. 2012 Apr;54[2]:205-7).
Pulse oximetry takes 90-120 seconds to attain a reliable signal and may not work if there’s poor perfusion, but an EC monitor provides continuous heart rate monitoring even with poor perfusion. So an initial heart rate assessment by auscultation is fine, but if PPV begins, EC monitoring may be better and is the preferred method with anticipated resuscitation or chest compressions.
However, pulse oximetry is still recommended “whenever positive pressure ventilation is started or oxygen is administered in order to guide the appropriate amount of oxygen supplementation,” Dr. Weiner noted.
He added that “preliminary studies suggest that handheld Doppler fetal heart monitors correlate well with ECG, provide a rapid audible heart rate and may be a promising alternative in the future” (Pediatr Int. 2017 Oct;59[10]:1069-73).
Correct ventilation techniques
“Ventilation of the lungs is the single most important and most effective step in cardiopulmonary resuscitation of the compromised newborn,” Dr. Weiner said. “If the heart rate is not rapidly increasing, ask if the chest is moving.”
He emphasized that no compressions should occur until after at least 30 seconds of PPV that moves the chest. He provided a “MR. SOPA” acronym: Mask adjustment, Reposition airway, Suction, Open mouth, Pressure increase, Alternative airway.
You also should be aware of possible leaking or obstruction around the mask, which is common, he said, so monitor pressure instead of volume.
“We are not good at identifying leak, obstruction, or adequate tidal volume,” Dr. Weiner said. “A colorimetric CO2 detector attached to the mask is a simple indicator of gas exchange” (Resuscitation. 2014 Nov;85[11]:1568-72).
He also strongly recommended inserting an alternative airway before starting chest compressions with either intubation or a laryngeal mask.
Dr. Weiner concluded with the following list of clinical practice changes you may consider:
- Use a standardized equipment checklist.
- Develop and practice standardized scripts.
- Debrief after all resuscitations; use videotape if you can.
- Delay cord clamping for most term and preterm babies.
- Do not routinely intubate/suction nonvigorous newborns with MSAF. Initiate resuscitation.
- Use an electronic cardiac monitor if resuscitation is required.
- Use a colorimetric CO2 detector with PPV.
- Intubate or place a laryngeal mask before starting compressions.
Dr. Weiner reported having no disclosures, and no external funding was used for the presentation.
CHICAGO – , according to Gary M. Weiner, MD, of the department of pediatrics and neonatal-perinatal medicine at the University of Michigan and C.S. Mott Children’s Hospital in Ann Arbor.
One is recommending an electronic cardiac (EC) monitor to assess heart rate during resuscitation instead of relying on pulse oximetry, and the other is no longer recommending routine tracheal suction in nonvigorous babies with meconium-stained fluid, he told attendees at the American Academy of Pediatrics annual meeting.
About two-thirds of all births have a risk factor for needing resuscitation, and about 10%-20% of babies with a risk factor will need positive pressure ventilation (PPV). But risk factors do not identify all newborns who will need it. The risk is greatest for newborns less than 36 weeks’ or greater than 40 weeks’ gestational age, but 7% of term newborns will need PPV despite having no risk factors.
Situations in which there is the highest risk for advanced resuscitation include the following:
- Fetal bradycardia: 24-fold greater odds.
- Intrauterine growth restriction (IUGR): 20-fold greater odds.
- Clinical chorioamnionitis: 17-fold greater odds.
- Forceps or vacuum: 17-fold greater odds.
- Meconium-stained amniotic fluid (MSAF): 17-fold greater odds.
- Gestational diabetes: 16-fold greater odds.
- Abruption: 12-fold greater odds.
- General anesthesia: 11-fold greater odds.
These risks were determined in a prospective multicenter, case-control study of 61,593 births (Arch Dis Child Fetal Neonatal Ed. 2017 Jan;102[1]:F44-F50).
Assembling a team and using checklists
Teamwork and communication are key in delivery room emergencies, and teams should debrief afterward, ideally having videotaped the resuscitation, if possible, Dr. Weiner said.
He discussed preparation for a very-low-birth-weight birth, a “routine emergency” requiring many tasks in a short period of time: 130 tasks in the first hour and 40 in the first 3 minutes.
“Decisions made during the first hour have long-term implications, so you need multiple caregivers and a high-performance team,” Dr. Weiner said. In addition to a thorough understanding of the clinical situation, a high-performance team should have both effective leadership, and clearly defined roles and responsibilities for each member. Clinicians on the team need highly developed technical skills that they reliably and consistently execute with precision. “Practice, refine, practice, refine,” he emphasized.
It’s also important to make use of preset protocols, scripts, and checklists, Dr. Weiner said. These tools assure consistency, facilitate communication among team members, and improve outcomes. Research has shown that use of protocols, scripts, and checklists leads to improved stroke and trauma care, decreased complications during intubation, fewer central-line complications, and decreased perioperative mortality and complications.
He also recommended implementing a standardized equipment check and team briefing “time-out,” similar to a surgical time-out. This time-out gives teams an opportunity to identify a team leader, define member roles and responsibilities, check all equipment and supplies, discuss risk factors and possible scenarios, talk with the obstetrician and, if possible, introduce the leader or another team member to the parents.
In a study from University of California, San Diego, Medical Center, using checklists as part of resuscitation of potentially high-risk infants reduced the occurrence of communication problems from 24% to 4% of resuscitations (P less than 0.001) over a 3-year period (Resuscitation. 2013 Nov;84[11]:1552-7).
Delayed cord clamping
Dr. Weiner also discussed the benefits of placental transfusion. The fetal-placental unit includes approximately 110 mL/kg of blood, and about one-third of its volume remains in the placenta immediately after birth. Immediate cord clamping means a loss of 10-20 mL/kg of “potential” newborn blood volume, and could contribute to unstable pulmonary blood flow or a carotid artery pressure spike (Matern Health Neonatol Perinatol. 2016. doi: 10.1186/s40748-016-0032-y).
“Umbilical blood flow is complex,” he said. Blood flows toward the baby via the umbilical vein during inhalation, but stops or reverses during crying. The umbilical artery primarily carries blood to the placenta, and flow stops after about 4 minutes in more than half of infants. Gravity’s role in blood flow is controversial (Lancet. 2014 Jul 19;384[9939]:235-40).
The two options for placental transfusion are delayed cord clamping and milking the umbilical cord (also called “stripping”). In vaginal births, delayed clamping allows 20 mL/kg blood to transfer to the baby by 3 minutes after birth, with 90% of that reaching the baby in the first minute (Lancet. 1969 Oct 25;294[7626]:871-3).
Blood transfer is less efficient in cesarean births, so milking may be more efficient than simply delaying clamping, according to a small randomized controlled trial of preterm infants around 28 weeks’ gestational age. No difference between the methods was seen in vaginal births. To milk the cord, pinch it near the placenta and squeeze it toward the newborn for 2 seconds; then release, refill and repeat.
The biggest benefits in delayed cord clamping or milking occur among preterm infants: decreased mortality, higher mean arterial pressure on day 1, and a lower risk of blood transfusion, necrotizing enterocolitis, and a Bayley Motor score below 85 at 18-22 months. Term babies also get benefits, though: increased hemoglobin at birth (approximately 2 g/dL), a 0.5- to 5-point average increase in boys’ Ages & Stages fine motor and social domain scores at age 4 years, and among high-risk infants, a lower risk of iron deficiency anemia at age 1 year (JAMA Pediatr. 2017;171[3]:264-70).
According to current guidelines from the American Academy of Pediatrics, “delayed cord clamping longer than 30 seconds is reasonable for both term and preterm infants who do not require resuscitation at birth,” but “there is insufficient evidence to recommend an approach to cord clamping for infants who require resuscitation.” They also recommend against routine milking for newborns less than 29 weeks’ gestation (Pediatrics. 2015 Nov;136 Suppl 2:S196-218).
Meconium-related complications
Meconium-stained amniotic fluid (MSAF) is common, occurring in about 8% of deliveries and increasing with gestational age, but meconium aspiration syndrome (MAS) is less common, occurring in about 2% of all MSAF cases (Int J Pediatr. 2012. doi: 10.1155/2012/321545).
Risk factors for severe MAS include thick meconium and an abnormal fetal heart rate. But about two-thirds of MAS cases are mild, not requiring ventilation or continuous positive airway pressure (CPAP), Dr. Weiner said. Practice should be driven by evidence from randomized controlled trials (RCTs).
“Nonrandomized observational studies can be misleading, and rational conjecture has led to many mistakes in medicine,” he said. “Be willing to challenge conventional wisdom.”
For example, the standard of care in the 1970s, based on two nonrandomized retrospective reviews of 175 babies, included orapharyngeal and nasopharyngeal suction by the obstetrician and endotracheal tube (ETT) suction by the pediatrician. In the 2000s, however, an RCT of 2,500 infants found no benefit from orapharyngeal and nasopharyngeal suction, even with thick MSAF, (Lancet. 2004 Aug 14-20;364[9434]:597-602) and another RCT with 2,100 infants found no benefit from ETT suction (Pediatrics. 2000 Jan;105[1 Pt 1]:1-7).
More recent, smaller studies have confirmed those conclusions and found similar lack of benefit from ETT in non-vigorous infants, contributing to the new recommendation (Resuscitation. 2016 Aug;105:79-84; Indian J Pediatr. 2016 Oct;83[10]:1125-30).
“Routine tracheal suction is no longer recommended for nonvigorous babies with meconium stained fluid,” Dr. Weiner said. Since MSAF is risk factor for resuscitation, though, at least two clinicians with Neonatal Resuscitation Program (NRP) training should be present, as well as a full team if resuscitation is expected.
Heart rate assessment and tracking
“The baby’s heart rate needs to be monitored during PPV [positive pressure ventilation] because a prompt increase in the baby’s heart rate is the most important indicator of effective PPV,” Dr. Weiner said in an interview. “Half of errors made during NRP [Neonatal Resuscitation Program] simulations are the result of incorrect heart rate assessment.”
Recent evidence comparing pulse oximetry to an EC monitor favored the latter for tracking heart rate, leading to the other new recommendation.
“The baby’s heart rate can be monitored using the pulse oximeter,” Dr. Weiner said. “However, health providers should consider using an electronic cardiac monitor in addition to pulse oximetry because studies show that it achieves a reliable signal faster.” He cited a study of 20 newborns that showed an EC monitor determined the heart rate in a median 34 seconds, compared with 122 seconds with the pulse oximeter (Pediatr Int. 2012 Apr;54[2]:205-7).
Pulse oximetry takes 90-120 seconds to attain a reliable signal and may not work if there’s poor perfusion, but an EC monitor provides continuous heart rate monitoring even with poor perfusion. So an initial heart rate assessment by auscultation is fine, but if PPV begins, EC monitoring may be better and is the preferred method with anticipated resuscitation or chest compressions.
However, pulse oximetry is still recommended “whenever positive pressure ventilation is started or oxygen is administered in order to guide the appropriate amount of oxygen supplementation,” Dr. Weiner noted.
He added that “preliminary studies suggest that handheld Doppler fetal heart monitors correlate well with ECG, provide a rapid audible heart rate and may be a promising alternative in the future” (Pediatr Int. 2017 Oct;59[10]:1069-73).
Correct ventilation techniques
“Ventilation of the lungs is the single most important and most effective step in cardiopulmonary resuscitation of the compromised newborn,” Dr. Weiner said. “If the heart rate is not rapidly increasing, ask if the chest is moving.”
He emphasized that no compressions should occur until after at least 30 seconds of PPV that moves the chest. He provided a “MR. SOPA” acronym: Mask adjustment, Reposition airway, Suction, Open mouth, Pressure increase, Alternative airway.
You also should be aware of possible leaking or obstruction around the mask, which is common, he said, so monitor pressure instead of volume.
“We are not good at identifying leak, obstruction, or adequate tidal volume,” Dr. Weiner said. “A colorimetric CO2 detector attached to the mask is a simple indicator of gas exchange” (Resuscitation. 2014 Nov;85[11]:1568-72).
He also strongly recommended inserting an alternative airway before starting chest compressions with either intubation or a laryngeal mask.
Dr. Weiner concluded with the following list of clinical practice changes you may consider:
- Use a standardized equipment checklist.
- Develop and practice standardized scripts.
- Debrief after all resuscitations; use videotape if you can.
- Delay cord clamping for most term and preterm babies.
- Do not routinely intubate/suction nonvigorous newborns with MSAF. Initiate resuscitation.
- Use an electronic cardiac monitor if resuscitation is required.
- Use a colorimetric CO2 detector with PPV.
- Intubate or place a laryngeal mask before starting compressions.
Dr. Weiner reported having no disclosures, and no external funding was used for the presentation.
CHICAGO – , according to Gary M. Weiner, MD, of the department of pediatrics and neonatal-perinatal medicine at the University of Michigan and C.S. Mott Children’s Hospital in Ann Arbor.
One is recommending an electronic cardiac (EC) monitor to assess heart rate during resuscitation instead of relying on pulse oximetry, and the other is no longer recommending routine tracheal suction in nonvigorous babies with meconium-stained fluid, he told attendees at the American Academy of Pediatrics annual meeting.
About two-thirds of all births have a risk factor for needing resuscitation, and about 10%-20% of babies with a risk factor will need positive pressure ventilation (PPV). But risk factors do not identify all newborns who will need it. The risk is greatest for newborns less than 36 weeks’ or greater than 40 weeks’ gestational age, but 7% of term newborns will need PPV despite having no risk factors.
Situations in which there is the highest risk for advanced resuscitation include the following:
- Fetal bradycardia: 24-fold greater odds.
- Intrauterine growth restriction (IUGR): 20-fold greater odds.
- Clinical chorioamnionitis: 17-fold greater odds.
- Forceps or vacuum: 17-fold greater odds.
- Meconium-stained amniotic fluid (MSAF): 17-fold greater odds.
- Gestational diabetes: 16-fold greater odds.
- Abruption: 12-fold greater odds.
- General anesthesia: 11-fold greater odds.
These risks were determined in a prospective multicenter, case-control study of 61,593 births (Arch Dis Child Fetal Neonatal Ed. 2017 Jan;102[1]:F44-F50).
Assembling a team and using checklists
Teamwork and communication are key in delivery room emergencies, and teams should debrief afterward, ideally having videotaped the resuscitation, if possible, Dr. Weiner said.
He discussed preparation for a very-low-birth-weight birth, a “routine emergency” requiring many tasks in a short period of time: 130 tasks in the first hour and 40 in the first 3 minutes.
“Decisions made during the first hour have long-term implications, so you need multiple caregivers and a high-performance team,” Dr. Weiner said. In addition to a thorough understanding of the clinical situation, a high-performance team should have both effective leadership, and clearly defined roles and responsibilities for each member. Clinicians on the team need highly developed technical skills that they reliably and consistently execute with precision. “Practice, refine, practice, refine,” he emphasized.
It’s also important to make use of preset protocols, scripts, and checklists, Dr. Weiner said. These tools assure consistency, facilitate communication among team members, and improve outcomes. Research has shown that use of protocols, scripts, and checklists leads to improved stroke and trauma care, decreased complications during intubation, fewer central-line complications, and decreased perioperative mortality and complications.
He also recommended implementing a standardized equipment check and team briefing “time-out,” similar to a surgical time-out. This time-out gives teams an opportunity to identify a team leader, define member roles and responsibilities, check all equipment and supplies, discuss risk factors and possible scenarios, talk with the obstetrician and, if possible, introduce the leader or another team member to the parents.
In a study from University of California, San Diego, Medical Center, using checklists as part of resuscitation of potentially high-risk infants reduced the occurrence of communication problems from 24% to 4% of resuscitations (P less than 0.001) over a 3-year period (Resuscitation. 2013 Nov;84[11]:1552-7).
Delayed cord clamping
Dr. Weiner also discussed the benefits of placental transfusion. The fetal-placental unit includes approximately 110 mL/kg of blood, and about one-third of its volume remains in the placenta immediately after birth. Immediate cord clamping means a loss of 10-20 mL/kg of “potential” newborn blood volume, and could contribute to unstable pulmonary blood flow or a carotid artery pressure spike (Matern Health Neonatol Perinatol. 2016. doi: 10.1186/s40748-016-0032-y).
“Umbilical blood flow is complex,” he said. Blood flows toward the baby via the umbilical vein during inhalation, but stops or reverses during crying. The umbilical artery primarily carries blood to the placenta, and flow stops after about 4 minutes in more than half of infants. Gravity’s role in blood flow is controversial (Lancet. 2014 Jul 19;384[9939]:235-40).
The two options for placental transfusion are delayed cord clamping and milking the umbilical cord (also called “stripping”). In vaginal births, delayed clamping allows 20 mL/kg blood to transfer to the baby by 3 minutes after birth, with 90% of that reaching the baby in the first minute (Lancet. 1969 Oct 25;294[7626]:871-3).
Blood transfer is less efficient in cesarean births, so milking may be more efficient than simply delaying clamping, according to a small randomized controlled trial of preterm infants around 28 weeks’ gestational age. No difference between the methods was seen in vaginal births. To milk the cord, pinch it near the placenta and squeeze it toward the newborn for 2 seconds; then release, refill and repeat.
The biggest benefits in delayed cord clamping or milking occur among preterm infants: decreased mortality, higher mean arterial pressure on day 1, and a lower risk of blood transfusion, necrotizing enterocolitis, and a Bayley Motor score below 85 at 18-22 months. Term babies also get benefits, though: increased hemoglobin at birth (approximately 2 g/dL), a 0.5- to 5-point average increase in boys’ Ages & Stages fine motor and social domain scores at age 4 years, and among high-risk infants, a lower risk of iron deficiency anemia at age 1 year (JAMA Pediatr. 2017;171[3]:264-70).
According to current guidelines from the American Academy of Pediatrics, “delayed cord clamping longer than 30 seconds is reasonable for both term and preterm infants who do not require resuscitation at birth,” but “there is insufficient evidence to recommend an approach to cord clamping for infants who require resuscitation.” They also recommend against routine milking for newborns less than 29 weeks’ gestation (Pediatrics. 2015 Nov;136 Suppl 2:S196-218).
Meconium-related complications
Meconium-stained amniotic fluid (MSAF) is common, occurring in about 8% of deliveries and increasing with gestational age, but meconium aspiration syndrome (MAS) is less common, occurring in about 2% of all MSAF cases (Int J Pediatr. 2012. doi: 10.1155/2012/321545).
Risk factors for severe MAS include thick meconium and an abnormal fetal heart rate. But about two-thirds of MAS cases are mild, not requiring ventilation or continuous positive airway pressure (CPAP), Dr. Weiner said. Practice should be driven by evidence from randomized controlled trials (RCTs).
“Nonrandomized observational studies can be misleading, and rational conjecture has led to many mistakes in medicine,” he said. “Be willing to challenge conventional wisdom.”
For example, the standard of care in the 1970s, based on two nonrandomized retrospective reviews of 175 babies, included orapharyngeal and nasopharyngeal suction by the obstetrician and endotracheal tube (ETT) suction by the pediatrician. In the 2000s, however, an RCT of 2,500 infants found no benefit from orapharyngeal and nasopharyngeal suction, even with thick MSAF, (Lancet. 2004 Aug 14-20;364[9434]:597-602) and another RCT with 2,100 infants found no benefit from ETT suction (Pediatrics. 2000 Jan;105[1 Pt 1]:1-7).
More recent, smaller studies have confirmed those conclusions and found similar lack of benefit from ETT in non-vigorous infants, contributing to the new recommendation (Resuscitation. 2016 Aug;105:79-84; Indian J Pediatr. 2016 Oct;83[10]:1125-30).
“Routine tracheal suction is no longer recommended for nonvigorous babies with meconium stained fluid,” Dr. Weiner said. Since MSAF is risk factor for resuscitation, though, at least two clinicians with Neonatal Resuscitation Program (NRP) training should be present, as well as a full team if resuscitation is expected.
Heart rate assessment and tracking
“The baby’s heart rate needs to be monitored during PPV [positive pressure ventilation] because a prompt increase in the baby’s heart rate is the most important indicator of effective PPV,” Dr. Weiner said in an interview. “Half of errors made during NRP [Neonatal Resuscitation Program] simulations are the result of incorrect heart rate assessment.”
Recent evidence comparing pulse oximetry to an EC monitor favored the latter for tracking heart rate, leading to the other new recommendation.
“The baby’s heart rate can be monitored using the pulse oximeter,” Dr. Weiner said. “However, health providers should consider using an electronic cardiac monitor in addition to pulse oximetry because studies show that it achieves a reliable signal faster.” He cited a study of 20 newborns that showed an EC monitor determined the heart rate in a median 34 seconds, compared with 122 seconds with the pulse oximeter (Pediatr Int. 2012 Apr;54[2]:205-7).
Pulse oximetry takes 90-120 seconds to attain a reliable signal and may not work if there’s poor perfusion, but an EC monitor provides continuous heart rate monitoring even with poor perfusion. So an initial heart rate assessment by auscultation is fine, but if PPV begins, EC monitoring may be better and is the preferred method with anticipated resuscitation or chest compressions.
However, pulse oximetry is still recommended “whenever positive pressure ventilation is started or oxygen is administered in order to guide the appropriate amount of oxygen supplementation,” Dr. Weiner noted.
He added that “preliminary studies suggest that handheld Doppler fetal heart monitors correlate well with ECG, provide a rapid audible heart rate and may be a promising alternative in the future” (Pediatr Int. 2017 Oct;59[10]:1069-73).
Correct ventilation techniques
“Ventilation of the lungs is the single most important and most effective step in cardiopulmonary resuscitation of the compromised newborn,” Dr. Weiner said. “If the heart rate is not rapidly increasing, ask if the chest is moving.”
He emphasized that no compressions should occur until after at least 30 seconds of PPV that moves the chest. He provided a “MR. SOPA” acronym: Mask adjustment, Reposition airway, Suction, Open mouth, Pressure increase, Alternative airway.
You also should be aware of possible leaking or obstruction around the mask, which is common, he said, so monitor pressure instead of volume.
“We are not good at identifying leak, obstruction, or adequate tidal volume,” Dr. Weiner said. “A colorimetric CO2 detector attached to the mask is a simple indicator of gas exchange” (Resuscitation. 2014 Nov;85[11]:1568-72).
He also strongly recommended inserting an alternative airway before starting chest compressions with either intubation or a laryngeal mask.
Dr. Weiner concluded with the following list of clinical practice changes you may consider:
- Use a standardized equipment checklist.
- Develop and practice standardized scripts.
- Debrief after all resuscitations; use videotape if you can.
- Delay cord clamping for most term and preterm babies.
- Do not routinely intubate/suction nonvigorous newborns with MSAF. Initiate resuscitation.
- Use an electronic cardiac monitor if resuscitation is required.
- Use a colorimetric CO2 detector with PPV.
- Intubate or place a laryngeal mask before starting compressions.
Dr. Weiner reported having no disclosures, and no external funding was used for the presentation.
EXPERT ANALYSIS FROM AAP 2017
Herbal supplements offer value with cautions, caveats
CHICAGO – Nearly one in five people who take prescription medications also take herbal or mineral supplements, so emphasized Cora Breuner, MD, MPH, a professor of pediatrics at the University of Washington in Seattle.
“In chronically ill children, almost 80% to 90% of kids are using supplements, so it’s really almost imperative that this be asked when you’re taking your histories, not in the social history, but when you’re asking about medications,” Dr. Breuner told attendees at the annual meeting of the American Academy of Pediatrics. “Remember to ask it, and remember to ask it every time because it makes the patient actually realize it’s something like a medication, and so you can get the drug-herb interactions.”
Providers also should be familiar with the evidence base for complementary and alternative medicine (CAM). According to the 2012 U.S. National Health Interview Survey, which included 10,218 youths, 11.6% of those aged 4-17 years had taken or used some type of complementary health product within the previous year. Fish oil/omega-3 fatty acid supplements, melatonin, probiotics/prebiotics, and echinacea topped the list.
“For children, complementary approaches were most often used for back or neck pain, other musculoskeletal conditions, head or chest colds, anxiety or stress, attention-deficit hyperactivity disorder [ADHD], and insomnia or trouble sleeping,” Dr. Breuner said.
Regulation of herbal and other supplements
Dietary supplements, including vitamins, minerals, and herbal remedies, are regulated under the Dietary Supplement Health and Education Act of 1994 (DSHEA) – not the Food and Drug Administration. Not only can products enter the market without any testing for efficacy, but companies only have to provide “reasonable assurance” of a product’s safety, not proof.
“Supplements do not have to be manufactured according to any standards,” Dr. Breuner said, although reputable manufacturers support standards. “It’s basically up to the company that manufactures it to make sure the product is not contaminated and that the product is basically consistent. There’s no need whatsoever for the company to make sure it works.”
Yet many patients and parents don’t realize that, she said.
“It’s important for people to be aware that this is not a regulated industry per se by the federal government,” she said. “Patients really do think that it is.”
One voluntary quality indicator is the United States Pharmacopeia Dietary Supplement Verification Program, identified by a USP “dietary supplement verified” logo. ConsumerLab.com also provides an “approved quality” logo, tests samples voluntarily sent by manufacturers, and rates the quality of different brands.
“Supplements may not claim to cure or prevent a disease, but they can say how it affects the body’s structure and function,” she said, and companies do not need FDA approval for packaging or marketing claims. In this low regulatory environment, substantial variations exist in the quality and quantity of biological ingredients in marketed supplements.
Risks from herbal supplements
Dr. Breuner cited a 2011 study finding that 75% of 68 products tested had no key safety messages, including all 12 ginkgo products and all but 1 of the 21 garlic and seven Asian ginseng products tested. Most of the 13 echinacea products also lacked safety messages, but two-thirds of the 12 St John’s wort products did have safety information.
Risks can include contamination, inadequate packaging information, and unknown toxicities and interactions. Adverse reactions should be reported to the Food and Drug Administration’s MedWatch at 800-FDA-1088 (fax: 800-FDA-0178) and to Poison Control at 800-222-1222.
Two popular herbal remedies that are unsafe for children include licorice and ephedra. Although it is used for peptic ulcers, licorice lacks much evidence backing it and also shouldn’t be used (or eaten) during pregnancy. Ephedra (ma huang), an appetite suppressant and decongestant, can cause heart palpitations, heart attacks, and death.
“You can still get ephedra over the Internet, but it’s very, very dangerous,” Dr. Breuner said.
Dr. Breuner listed other herbal products available online but deemed unsafe for children: aconite (also known as bushi), species from the genus Aristolochia, belladonna, blue cohosh, borage, broom, calamus, chaparral, coltsfoot, comfrey, germander, life root, lobelia, pennyroyal, poke root, sassafras, skullcap, tansy ragwort, and wormwood.
Another set of herbs can be dangerous prior to surgery, she said, noting that an estimated 26% of patients scheduled for surgery use herbal products.
“Many, many of the herbs cause platelet aggregation issues,” Dr. Breuner said, so it’s very important to ask about different herbs before surgeries. Patients should discontinue echinacea, ephedra, garlic, ginkgo, ginseng, kava, St. John’s wort, and valerian before surgery. Risks include cardiovascular instability, prolonged sedation, bleeding, electrolyte disturbances, and immunosuppression. Additionally, four supplements also adversely interact with warfarin: garlic, ginger, and feverfew have additive effects (although small dietary amounts of ginger and garlic are fine), and St. John’s wort can decrease warfarin’s effects.
Dr. Breuner urged attendees to use resources like PubMed Dietary Supplement Subset to find out more about supplements; this subset limits results of a PubMed search of citations and abstracts to just those related to dietary supplements. It was created through a partnership between the Office of Dietary Supplements and the National Library of Medicine, both parts of the National Institutes of Health.
Information on specific herbs
Ginkgo. Although commonly used to boost memory and concentration, only limited studies in adults shows some potential benefit from ginkgo at 40 mg three times a day. “There isn’t any evidence to show any reason to use it in children,” Dr. Breuner said. Adverse effects can include gastrointestinal irritation, headache, bleeding, and contact dermatitis.
Echinacea. Although people use echinacea to treat or prevent the common cold or upper respiratory infections, the evidence does not show significant reductions of incidence, duration, or severity of upper respiratory infections and common colds. Anyone immunocompromised with an allergy or autoimmune disease should not take it.
Zinc. Some evidence from a pediatric Cochrane Review, albeit with heterogeneous studies, supports using 75 mg of zinc a day to reduce duration of common cold and sore throat symptoms in healthy people. Adverse effects include a bad taste, nausea, and anosmia.
Valerian. Children can take 400 mg nightly of valerian to help with sleep, although there are some caveats.
“The problem with Valerian is that it takes 2-6 weeks before it has any effect,” Breuner said. “It tastes terrible, and it’s only in a capsule form. It isn’t dosed for age at all, so you have to be careful about this, and it’s not like Ambien,” she added. It does not work instantaneously, and stopping it abruptly can cause withdrawal symptoms, although she would recommend it over melatonin. Despite its use for sleep, it can have adverse effects, such as anxiety, restlessness, and heart palpitations, and it can interfere with barbiturates.
St. John’s wort. No one is quite sure how it works, but research has shown St. John’s wort extracts can treat mild to moderate depression about as well as standard antidepressants. However, the dose is 300 mg three times a day. “There’s no St. John’s XL,” Dr. Breuner joked. It can also interfere with a wide range of prescribed medications, including oral contraception.
Butterbur. Those taking pyrrolizidine alkaloids should avoid butterbur, but it otherwise can help prevent migraine when dosed at 50-75 mg daily divided up into 2-3 for ages 8-9 years and 100-150 mg daily divided up into 2-3 for ages 10-17 years. “Most of the neurologists at my institution are recommending butterbur,” Dr. Breuner said. “It’s not an abortive, but it’s a preventive, with decreased intensity and severity in childhood migraine 6 weeks after using it. This is absolutely something to consider in your patients with chronic headaches.” Adverse effects include diarrhea, stomach upset, belching, and dermal and allergic symptoms, such as itchy eyes, asthma, and rash.
Magnesium. Also recommended by pediatric neurologists at her institution, 300-500 mg daily of magnesium can reduce migraine incidence, but doses should be titrated up at first. “Don’t start with the higher doses,” she said. “You have to be careful about starting at too high of a dose because of diarrhea,” which is its primary adverse effect. Magnesium also can interfere with bisphosphonates, antibiotics, and diuretics; proton pump inhibitors may reduce magnesium levels.
Melatonin. Unlike most supplements that are herbal or mineral, melatonin is a synthetic hormone, but Dr. Breuner said many patients don’t realize that. “Because it’s a hormone, I’m very, very careful about it,” she said, never recommending more than 0.5 to 5 mg a night for help falling asleep. “I’m really not a fan of melatonin,” she said. “You develop a tolerance to it, and this is not something parents or children should be taking chronically because we do not know long-term outcomes at all. It’s not benign even though you can just toss it into your grocery basket.”
She briefly wrapped up with mentions of omega-3 fatty acid supplements (docosahexaenoic acid and eicosapentaenoic acid); most of the evidence for these supplements comes from adults with psychiatric disorders. However, one study showed reduced tics in children with Tourette’s – if they can stand the fishy taste. It also can cause belching, nosebleeds, nausea, loose stools, and, at higher doses, decreased blood coagulation.
Peppermint can be used to reduce nausea, coughs, anxiety, and irritable bowel syndrome symptoms, but it needs to be taken as 1-2 enteric capsules, not as tea or another form.
“Chamomile is very helpful for generalized colic and also for those with chronic anxiety,” Dr. Breuner said, and arnica can be used topically for bruising. Ginger also can be used to reduce nausea but can cause heartburn. A combination of peppermint, chamomile, arnica, and ginger may be appropriate to address various chemotherapy symptoms in a child, she said.
Several articles are useful for looking up interactions between herbs and drugs, including Pediatrics. 2017. doi: 10.1542/peds.2010-2720C; J Emerg Med. 2005 Apr;28(3):267-71; and Clin Med (Lond). 2013 Feb;13(1):7-12.
No funding was used for this presentation, and Dr. Breuner reported having no disclosures.
CHICAGO – Nearly one in five people who take prescription medications also take herbal or mineral supplements, so emphasized Cora Breuner, MD, MPH, a professor of pediatrics at the University of Washington in Seattle.
“In chronically ill children, almost 80% to 90% of kids are using supplements, so it’s really almost imperative that this be asked when you’re taking your histories, not in the social history, but when you’re asking about medications,” Dr. Breuner told attendees at the annual meeting of the American Academy of Pediatrics. “Remember to ask it, and remember to ask it every time because it makes the patient actually realize it’s something like a medication, and so you can get the drug-herb interactions.”
Providers also should be familiar with the evidence base for complementary and alternative medicine (CAM). According to the 2012 U.S. National Health Interview Survey, which included 10,218 youths, 11.6% of those aged 4-17 years had taken or used some type of complementary health product within the previous year. Fish oil/omega-3 fatty acid supplements, melatonin, probiotics/prebiotics, and echinacea topped the list.
“For children, complementary approaches were most often used for back or neck pain, other musculoskeletal conditions, head or chest colds, anxiety or stress, attention-deficit hyperactivity disorder [ADHD], and insomnia or trouble sleeping,” Dr. Breuner said.
Regulation of herbal and other supplements
Dietary supplements, including vitamins, minerals, and herbal remedies, are regulated under the Dietary Supplement Health and Education Act of 1994 (DSHEA) – not the Food and Drug Administration. Not only can products enter the market without any testing for efficacy, but companies only have to provide “reasonable assurance” of a product’s safety, not proof.
“Supplements do not have to be manufactured according to any standards,” Dr. Breuner said, although reputable manufacturers support standards. “It’s basically up to the company that manufactures it to make sure the product is not contaminated and that the product is basically consistent. There’s no need whatsoever for the company to make sure it works.”
Yet many patients and parents don’t realize that, she said.
“It’s important for people to be aware that this is not a regulated industry per se by the federal government,” she said. “Patients really do think that it is.”
One voluntary quality indicator is the United States Pharmacopeia Dietary Supplement Verification Program, identified by a USP “dietary supplement verified” logo. ConsumerLab.com also provides an “approved quality” logo, tests samples voluntarily sent by manufacturers, and rates the quality of different brands.
“Supplements may not claim to cure or prevent a disease, but they can say how it affects the body’s structure and function,” she said, and companies do not need FDA approval for packaging or marketing claims. In this low regulatory environment, substantial variations exist in the quality and quantity of biological ingredients in marketed supplements.
Risks from herbal supplements
Dr. Breuner cited a 2011 study finding that 75% of 68 products tested had no key safety messages, including all 12 ginkgo products and all but 1 of the 21 garlic and seven Asian ginseng products tested. Most of the 13 echinacea products also lacked safety messages, but two-thirds of the 12 St John’s wort products did have safety information.
Risks can include contamination, inadequate packaging information, and unknown toxicities and interactions. Adverse reactions should be reported to the Food and Drug Administration’s MedWatch at 800-FDA-1088 (fax: 800-FDA-0178) and to Poison Control at 800-222-1222.
Two popular herbal remedies that are unsafe for children include licorice and ephedra. Although it is used for peptic ulcers, licorice lacks much evidence backing it and also shouldn’t be used (or eaten) during pregnancy. Ephedra (ma huang), an appetite suppressant and decongestant, can cause heart palpitations, heart attacks, and death.
“You can still get ephedra over the Internet, but it’s very, very dangerous,” Dr. Breuner said.
Dr. Breuner listed other herbal products available online but deemed unsafe for children: aconite (also known as bushi), species from the genus Aristolochia, belladonna, blue cohosh, borage, broom, calamus, chaparral, coltsfoot, comfrey, germander, life root, lobelia, pennyroyal, poke root, sassafras, skullcap, tansy ragwort, and wormwood.
Another set of herbs can be dangerous prior to surgery, she said, noting that an estimated 26% of patients scheduled for surgery use herbal products.
“Many, many of the herbs cause platelet aggregation issues,” Dr. Breuner said, so it’s very important to ask about different herbs before surgeries. Patients should discontinue echinacea, ephedra, garlic, ginkgo, ginseng, kava, St. John’s wort, and valerian before surgery. Risks include cardiovascular instability, prolonged sedation, bleeding, electrolyte disturbances, and immunosuppression. Additionally, four supplements also adversely interact with warfarin: garlic, ginger, and feverfew have additive effects (although small dietary amounts of ginger and garlic are fine), and St. John’s wort can decrease warfarin’s effects.
Dr. Breuner urged attendees to use resources like PubMed Dietary Supplement Subset to find out more about supplements; this subset limits results of a PubMed search of citations and abstracts to just those related to dietary supplements. It was created through a partnership between the Office of Dietary Supplements and the National Library of Medicine, both parts of the National Institutes of Health.
Information on specific herbs
Ginkgo. Although commonly used to boost memory and concentration, only limited studies in adults shows some potential benefit from ginkgo at 40 mg three times a day. “There isn’t any evidence to show any reason to use it in children,” Dr. Breuner said. Adverse effects can include gastrointestinal irritation, headache, bleeding, and contact dermatitis.
Echinacea. Although people use echinacea to treat or prevent the common cold or upper respiratory infections, the evidence does not show significant reductions of incidence, duration, or severity of upper respiratory infections and common colds. Anyone immunocompromised with an allergy or autoimmune disease should not take it.
Zinc. Some evidence from a pediatric Cochrane Review, albeit with heterogeneous studies, supports using 75 mg of zinc a day to reduce duration of common cold and sore throat symptoms in healthy people. Adverse effects include a bad taste, nausea, and anosmia.
Valerian. Children can take 400 mg nightly of valerian to help with sleep, although there are some caveats.
“The problem with Valerian is that it takes 2-6 weeks before it has any effect,” Breuner said. “It tastes terrible, and it’s only in a capsule form. It isn’t dosed for age at all, so you have to be careful about this, and it’s not like Ambien,” she added. It does not work instantaneously, and stopping it abruptly can cause withdrawal symptoms, although she would recommend it over melatonin. Despite its use for sleep, it can have adverse effects, such as anxiety, restlessness, and heart palpitations, and it can interfere with barbiturates.
St. John’s wort. No one is quite sure how it works, but research has shown St. John’s wort extracts can treat mild to moderate depression about as well as standard antidepressants. However, the dose is 300 mg three times a day. “There’s no St. John’s XL,” Dr. Breuner joked. It can also interfere with a wide range of prescribed medications, including oral contraception.
Butterbur. Those taking pyrrolizidine alkaloids should avoid butterbur, but it otherwise can help prevent migraine when dosed at 50-75 mg daily divided up into 2-3 for ages 8-9 years and 100-150 mg daily divided up into 2-3 for ages 10-17 years. “Most of the neurologists at my institution are recommending butterbur,” Dr. Breuner said. “It’s not an abortive, but it’s a preventive, with decreased intensity and severity in childhood migraine 6 weeks after using it. This is absolutely something to consider in your patients with chronic headaches.” Adverse effects include diarrhea, stomach upset, belching, and dermal and allergic symptoms, such as itchy eyes, asthma, and rash.
Magnesium. Also recommended by pediatric neurologists at her institution, 300-500 mg daily of magnesium can reduce migraine incidence, but doses should be titrated up at first. “Don’t start with the higher doses,” she said. “You have to be careful about starting at too high of a dose because of diarrhea,” which is its primary adverse effect. Magnesium also can interfere with bisphosphonates, antibiotics, and diuretics; proton pump inhibitors may reduce magnesium levels.
Melatonin. Unlike most supplements that are herbal or mineral, melatonin is a synthetic hormone, but Dr. Breuner said many patients don’t realize that. “Because it’s a hormone, I’m very, very careful about it,” she said, never recommending more than 0.5 to 5 mg a night for help falling asleep. “I’m really not a fan of melatonin,” she said. “You develop a tolerance to it, and this is not something parents or children should be taking chronically because we do not know long-term outcomes at all. It’s not benign even though you can just toss it into your grocery basket.”
She briefly wrapped up with mentions of omega-3 fatty acid supplements (docosahexaenoic acid and eicosapentaenoic acid); most of the evidence for these supplements comes from adults with psychiatric disorders. However, one study showed reduced tics in children with Tourette’s – if they can stand the fishy taste. It also can cause belching, nosebleeds, nausea, loose stools, and, at higher doses, decreased blood coagulation.
Peppermint can be used to reduce nausea, coughs, anxiety, and irritable bowel syndrome symptoms, but it needs to be taken as 1-2 enteric capsules, not as tea or another form.
“Chamomile is very helpful for generalized colic and also for those with chronic anxiety,” Dr. Breuner said, and arnica can be used topically for bruising. Ginger also can be used to reduce nausea but can cause heartburn. A combination of peppermint, chamomile, arnica, and ginger may be appropriate to address various chemotherapy symptoms in a child, she said.
Several articles are useful for looking up interactions between herbs and drugs, including Pediatrics. 2017. doi: 10.1542/peds.2010-2720C; J Emerg Med. 2005 Apr;28(3):267-71; and Clin Med (Lond). 2013 Feb;13(1):7-12.
No funding was used for this presentation, and Dr. Breuner reported having no disclosures.
CHICAGO – Nearly one in five people who take prescription medications also take herbal or mineral supplements, so emphasized Cora Breuner, MD, MPH, a professor of pediatrics at the University of Washington in Seattle.
“In chronically ill children, almost 80% to 90% of kids are using supplements, so it’s really almost imperative that this be asked when you’re taking your histories, not in the social history, but when you’re asking about medications,” Dr. Breuner told attendees at the annual meeting of the American Academy of Pediatrics. “Remember to ask it, and remember to ask it every time because it makes the patient actually realize it’s something like a medication, and so you can get the drug-herb interactions.”
Providers also should be familiar with the evidence base for complementary and alternative medicine (CAM). According to the 2012 U.S. National Health Interview Survey, which included 10,218 youths, 11.6% of those aged 4-17 years had taken or used some type of complementary health product within the previous year. Fish oil/omega-3 fatty acid supplements, melatonin, probiotics/prebiotics, and echinacea topped the list.
“For children, complementary approaches were most often used for back or neck pain, other musculoskeletal conditions, head or chest colds, anxiety or stress, attention-deficit hyperactivity disorder [ADHD], and insomnia or trouble sleeping,” Dr. Breuner said.
Regulation of herbal and other supplements
Dietary supplements, including vitamins, minerals, and herbal remedies, are regulated under the Dietary Supplement Health and Education Act of 1994 (DSHEA) – not the Food and Drug Administration. Not only can products enter the market without any testing for efficacy, but companies only have to provide “reasonable assurance” of a product’s safety, not proof.
“Supplements do not have to be manufactured according to any standards,” Dr. Breuner said, although reputable manufacturers support standards. “It’s basically up to the company that manufactures it to make sure the product is not contaminated and that the product is basically consistent. There’s no need whatsoever for the company to make sure it works.”
Yet many patients and parents don’t realize that, she said.
“It’s important for people to be aware that this is not a regulated industry per se by the federal government,” she said. “Patients really do think that it is.”
One voluntary quality indicator is the United States Pharmacopeia Dietary Supplement Verification Program, identified by a USP “dietary supplement verified” logo. ConsumerLab.com also provides an “approved quality” logo, tests samples voluntarily sent by manufacturers, and rates the quality of different brands.
“Supplements may not claim to cure or prevent a disease, but they can say how it affects the body’s structure and function,” she said, and companies do not need FDA approval for packaging or marketing claims. In this low regulatory environment, substantial variations exist in the quality and quantity of biological ingredients in marketed supplements.
Risks from herbal supplements
Dr. Breuner cited a 2011 study finding that 75% of 68 products tested had no key safety messages, including all 12 ginkgo products and all but 1 of the 21 garlic and seven Asian ginseng products tested. Most of the 13 echinacea products also lacked safety messages, but two-thirds of the 12 St John’s wort products did have safety information.
Risks can include contamination, inadequate packaging information, and unknown toxicities and interactions. Adverse reactions should be reported to the Food and Drug Administration’s MedWatch at 800-FDA-1088 (fax: 800-FDA-0178) and to Poison Control at 800-222-1222.
Two popular herbal remedies that are unsafe for children include licorice and ephedra. Although it is used for peptic ulcers, licorice lacks much evidence backing it and also shouldn’t be used (or eaten) during pregnancy. Ephedra (ma huang), an appetite suppressant and decongestant, can cause heart palpitations, heart attacks, and death.
“You can still get ephedra over the Internet, but it’s very, very dangerous,” Dr. Breuner said.
Dr. Breuner listed other herbal products available online but deemed unsafe for children: aconite (also known as bushi), species from the genus Aristolochia, belladonna, blue cohosh, borage, broom, calamus, chaparral, coltsfoot, comfrey, germander, life root, lobelia, pennyroyal, poke root, sassafras, skullcap, tansy ragwort, and wormwood.
Another set of herbs can be dangerous prior to surgery, she said, noting that an estimated 26% of patients scheduled for surgery use herbal products.
“Many, many of the herbs cause platelet aggregation issues,” Dr. Breuner said, so it’s very important to ask about different herbs before surgeries. Patients should discontinue echinacea, ephedra, garlic, ginkgo, ginseng, kava, St. John’s wort, and valerian before surgery. Risks include cardiovascular instability, prolonged sedation, bleeding, electrolyte disturbances, and immunosuppression. Additionally, four supplements also adversely interact with warfarin: garlic, ginger, and feverfew have additive effects (although small dietary amounts of ginger and garlic are fine), and St. John’s wort can decrease warfarin’s effects.
Dr. Breuner urged attendees to use resources like PubMed Dietary Supplement Subset to find out more about supplements; this subset limits results of a PubMed search of citations and abstracts to just those related to dietary supplements. It was created through a partnership between the Office of Dietary Supplements and the National Library of Medicine, both parts of the National Institutes of Health.
Information on specific herbs
Ginkgo. Although commonly used to boost memory and concentration, only limited studies in adults shows some potential benefit from ginkgo at 40 mg three times a day. “There isn’t any evidence to show any reason to use it in children,” Dr. Breuner said. Adverse effects can include gastrointestinal irritation, headache, bleeding, and contact dermatitis.
Echinacea. Although people use echinacea to treat or prevent the common cold or upper respiratory infections, the evidence does not show significant reductions of incidence, duration, or severity of upper respiratory infections and common colds. Anyone immunocompromised with an allergy or autoimmune disease should not take it.
Zinc. Some evidence from a pediatric Cochrane Review, albeit with heterogeneous studies, supports using 75 mg of zinc a day to reduce duration of common cold and sore throat symptoms in healthy people. Adverse effects include a bad taste, nausea, and anosmia.
Valerian. Children can take 400 mg nightly of valerian to help with sleep, although there are some caveats.
“The problem with Valerian is that it takes 2-6 weeks before it has any effect,” Breuner said. “It tastes terrible, and it’s only in a capsule form. It isn’t dosed for age at all, so you have to be careful about this, and it’s not like Ambien,” she added. It does not work instantaneously, and stopping it abruptly can cause withdrawal symptoms, although she would recommend it over melatonin. Despite its use for sleep, it can have adverse effects, such as anxiety, restlessness, and heart palpitations, and it can interfere with barbiturates.
St. John’s wort. No one is quite sure how it works, but research has shown St. John’s wort extracts can treat mild to moderate depression about as well as standard antidepressants. However, the dose is 300 mg three times a day. “There’s no St. John’s XL,” Dr. Breuner joked. It can also interfere with a wide range of prescribed medications, including oral contraception.
Butterbur. Those taking pyrrolizidine alkaloids should avoid butterbur, but it otherwise can help prevent migraine when dosed at 50-75 mg daily divided up into 2-3 for ages 8-9 years and 100-150 mg daily divided up into 2-3 for ages 10-17 years. “Most of the neurologists at my institution are recommending butterbur,” Dr. Breuner said. “It’s not an abortive, but it’s a preventive, with decreased intensity and severity in childhood migraine 6 weeks after using it. This is absolutely something to consider in your patients with chronic headaches.” Adverse effects include diarrhea, stomach upset, belching, and dermal and allergic symptoms, such as itchy eyes, asthma, and rash.
Magnesium. Also recommended by pediatric neurologists at her institution, 300-500 mg daily of magnesium can reduce migraine incidence, but doses should be titrated up at first. “Don’t start with the higher doses,” she said. “You have to be careful about starting at too high of a dose because of diarrhea,” which is its primary adverse effect. Magnesium also can interfere with bisphosphonates, antibiotics, and diuretics; proton pump inhibitors may reduce magnesium levels.
Melatonin. Unlike most supplements that are herbal or mineral, melatonin is a synthetic hormone, but Dr. Breuner said many patients don’t realize that. “Because it’s a hormone, I’m very, very careful about it,” she said, never recommending more than 0.5 to 5 mg a night for help falling asleep. “I’m really not a fan of melatonin,” she said. “You develop a tolerance to it, and this is not something parents or children should be taking chronically because we do not know long-term outcomes at all. It’s not benign even though you can just toss it into your grocery basket.”
She briefly wrapped up with mentions of omega-3 fatty acid supplements (docosahexaenoic acid and eicosapentaenoic acid); most of the evidence for these supplements comes from adults with psychiatric disorders. However, one study showed reduced tics in children with Tourette’s – if they can stand the fishy taste. It also can cause belching, nosebleeds, nausea, loose stools, and, at higher doses, decreased blood coagulation.
Peppermint can be used to reduce nausea, coughs, anxiety, and irritable bowel syndrome symptoms, but it needs to be taken as 1-2 enteric capsules, not as tea or another form.
“Chamomile is very helpful for generalized colic and also for those with chronic anxiety,” Dr. Breuner said, and arnica can be used topically for bruising. Ginger also can be used to reduce nausea but can cause heartburn. A combination of peppermint, chamomile, arnica, and ginger may be appropriate to address various chemotherapy symptoms in a child, she said.
Several articles are useful for looking up interactions between herbs and drugs, including Pediatrics. 2017. doi: 10.1542/peds.2010-2720C; J Emerg Med. 2005 Apr;28(3):267-71; and Clin Med (Lond). 2013 Feb;13(1):7-12.
No funding was used for this presentation, and Dr. Breuner reported having no disclosures.
EXPERT ANALYSIS FROM AAP 2017
Teach your adolescent patients about normal menses, so they know when it’s abnormal
CHICAGO – , according to S. Paige Hertweck, MD, chief of gynecology at Norton Children’s Hospital in Louisville, Ky.
“Remember to use the menstrual cycle as a vital sign,” Dr. Hertweck told attendees at the American Academy of Pediatrics annual meeting. “Even within the first year of menarche, most girls have a period at least every 90 days, so work up those who don’t.”
The median age of menarche is 12.4 years, typically beginning within 2-3 years of breast budding at Tanner Stage 4 breast development, she said. By 15 years of age, 98% of girls have begun menstruation.
Girls’ cycles typically last 21-45 days, an average of 32.2 days during their first year of menstruation, with flow for 7 days or less, requiring an average of 3-6 pads and/or tampons per day. Dr. Hertweck recommends you write down these features of normal menstruation so that your patients can tell you when their cycle is abnormal or menses doesn’t return.
“Cycle length is more variable for teens versus women 20-40 years old,” she said. However, “it’s not true that ‘anything goes’ for cycle length” in teens, she added. “Cycles that are consistently outside the range of 21-45 days are statistically uncommon.” Hence the need to evaluate causes of amenorrhea in girls whose cycles exceed 90 days.
Possible causes of amenorrhea include pregnancy, polycystic ovary syndrome, thyroid abnormalities, hyperprolactinemia, primary ovarian insufficiency, or hypogonadal amenorrhea, typically stimulated by the first instance of anorexia, Crohn’s disease, celiac disease, or a gluten intolerance.
Primary amenorrhea
Dr. Hertweck listed five benchmarks that indicate primary amenorrhea requiring evaluation. Those indicators include girls who have no menarche by age 15 years or within 3 years of breast budding, no breast development by age 13 years, or no menses by age 14 years with hirsutism or with a history of excessive exercise or of an eating disorder.
You can start by examining what normal menstruation relies on: an intact central nervous system with a functioning pituitary, an ovarian response, and a normal uterus, cervix, and vagina. You should check the patient’s follicle-stimulating hormone, thyroid-stimulating hormone, and prolactin levels to assess CNS functioning, and estradiol levels to assess ovarian response. A genital exam with a pelvic ultrasound can reveal any possible defects in the uterus, cervix, or vagina.
The presence of breasts without a uterus indicates normal estrogen production, so the missing uterus could be a congenital defect or result from androgen insensitivity, Dr. Hertweck explained. In those without breasts, gonadal dysgenesis or gonadal enzymatic deficiency may explain no estrogen production. If the patient has both breasts and a uterus, you should rule out pregnancy first and then track CNS changes via FSH, TSH, and prolactin levels.
Premature ovarian insufficiency
Approximately 1% of females experience premature ovarian insufficiency, which can be diagnosed as early as age 14 years and should be suspected in a patient with a uterus but without breasts who has low estradiol levels, CNS failure identified by a high FSH level, and gonadal failure.
Formal diagnosis requires two separate instances of FSH elevation, and chromosomal testing should be done to rule out gonadal dysgenesis. You also should test the serum anti-Müllerian hormone biomarker (readings above 8 are concerning) and look for two possible causes. The FMR1 (Fragile X) premutation carrier status could be a cause, or presence of 21-hydroxylase and/or adrenal antibodies indicate autoimmune polyglandular syndrome.
Catching premature ovarian insufficiency early enough may allow patients to preserve some fertility if they still have oocytes present. Aside from this, girls will need hormone replacement therapy to fulfill developmental emotional and physical needs, such as bone growth and overall health. Despite a history of treating teens with premature ovarian insufficiency like adults, you should follow the practice guidelines specific to adolescents by the American College of Obstetricians and Gynecologists committee opinion statement (Obstet Gynecol. 2014;123:193-7).
Menorrhagia: heavy menstrual bleeding
Even though average blood loss is estimated at 30 mL per period, that number means little in clinical practice because patients cannot measure the actual amount of menses. Better indicators of abnormally greater flow include flow lasting longer than 7 days, finding clots larger than a quarter, changing menstrual products every 1-2 hours, leaking onto clothing such that patients need to take extra clothes to school, and any heavy periods that occur with easy bruising or with a family history of bleeding disorders.
First-line treatment for heavy menstrual bleeding in teens is hormonal contraception, either combination oral contraceptive pills, the transdermal patch, or the intravaginal ring, which can be combined with other therapies.
An alternative for those under age 18 (per Food and Drug Administration labeling) is oral tranexamic acid, found in a crossover trial with an oral contraceptive pill to be just as effective at reducing average blood loss and improving quality of life, but with fewer side effects and better compliance. Before prescribing anything for heavy menstrual bleeding, however, you must consider possible causes and rule some out that require different management.
Aside from pregnancy, one potential cause of menorrhagia is infection such as chlamydia or gonorrhea, which should be considered even in those with a negative sexual history, Dr. Hertweck said. Other possible causes include an immature hypothalamic-pituitary-ovarian axis, polycystic ovary syndrome (even with low hemoglobin), malignancy with a hormone-producing tumor, hypothalamic dysfunction (often stimulated by eating disorders, obesity, rapid weight loss, or gluten intolerance), or coagulopathy.
“Teens with menorrhagia may need to be screened for a bleeding disorder,” Dr. Hertweck said. At a minimum, she recommends checking complete blood count, ferritin, and TSH. “The most common bleeding disorders associated with heavy menstrual bleeding include platelet function disorders and von Willebrand.”
Up to half of teen girls with menorrhagia who visit a hematologist or multidisciplinary clinic receive a diagnosis of a bleeding disorder, Dr. Hertweck said. And up to half of those with menorrhagia at menarche may have von Willebrand, as do one in six adolescents who go to the emergency department because of heavy menstrual bleeding.
Von Willebrand syndrome
Von Willebrand syndrome is a deficiency or dysfunction of von Willebrand factor (vWF), a protein with binding sites for platelets, collagen, and factor VIII that “serves as a bridge between platelets and injury sites in vessel walls” and “protects factor VIII from rapid proteolytic degradation,” Dr. Hertweck said. Von Willebrand syndrome is the most common inherited congenital bleeding disorder. Although acquired von Willebrand syndrome is rare, it has grown in incidence among those with complex cardiovascular, hematologic, or immunologic disorders.
“Correct diagnosis is complex and not always straightforward,” Dr. Hertweck said, but “a positive response to questions in four categories is highly sensitive.” They are as follows:
• Menses lasting at least 7 days and interfering with a person’s daily activities.
• “History of treatment for anemia.
• Family history of a diagnosed bleeding disorder.
• History of excessive bleeding after tooth extraction, delivery, miscarriage, or surgery.
Diagnostic assays include platelet concentration of vWF antigen, an activity test of vWF-platelet binding, and factor VIII activity. However, you often need to repeat diagnostic testing because vWF antigens vary according to race, blood type, age, acute phase response, and menstrual cycle timing, Dr. Hertweck said.
“Remember to draw von Willebrand testing only during the first 3 days of the menstrual cycle when estrogen levels are at the nadir,” she said.
Because estrogen increases vWF, treatment for von Willebrand syndrome should be progestin only, either oral pills, medroxyprogesterone acetate (MPA, or Depo-Provera injections), or an etonogestrel implant.
Dr. Hertweck presented several cases of abnormal menstruation and extreme conditions such as severe menorrhagia. Outside of von Willebrand in such patients, possible platelet disorders could include Glanzmann thrombasthenia (a platelet function disorder that is caused by an abnormality in the genes for glycoproteins IIb/IIIa) and platelet storage pool disorder, both of which should be diagnosed by a hematologist.
Dr. Hertweck reported having a research grant from Merck related to contraceptive implants in adolescents.
CHICAGO – , according to S. Paige Hertweck, MD, chief of gynecology at Norton Children’s Hospital in Louisville, Ky.
“Remember to use the menstrual cycle as a vital sign,” Dr. Hertweck told attendees at the American Academy of Pediatrics annual meeting. “Even within the first year of menarche, most girls have a period at least every 90 days, so work up those who don’t.”
The median age of menarche is 12.4 years, typically beginning within 2-3 years of breast budding at Tanner Stage 4 breast development, she said. By 15 years of age, 98% of girls have begun menstruation.
Girls’ cycles typically last 21-45 days, an average of 32.2 days during their first year of menstruation, with flow for 7 days or less, requiring an average of 3-6 pads and/or tampons per day. Dr. Hertweck recommends you write down these features of normal menstruation so that your patients can tell you when their cycle is abnormal or menses doesn’t return.
“Cycle length is more variable for teens versus women 20-40 years old,” she said. However, “it’s not true that ‘anything goes’ for cycle length” in teens, she added. “Cycles that are consistently outside the range of 21-45 days are statistically uncommon.” Hence the need to evaluate causes of amenorrhea in girls whose cycles exceed 90 days.
Possible causes of amenorrhea include pregnancy, polycystic ovary syndrome, thyroid abnormalities, hyperprolactinemia, primary ovarian insufficiency, or hypogonadal amenorrhea, typically stimulated by the first instance of anorexia, Crohn’s disease, celiac disease, or a gluten intolerance.
Primary amenorrhea
Dr. Hertweck listed five benchmarks that indicate primary amenorrhea requiring evaluation. Those indicators include girls who have no menarche by age 15 years or within 3 years of breast budding, no breast development by age 13 years, or no menses by age 14 years with hirsutism or with a history of excessive exercise or of an eating disorder.
You can start by examining what normal menstruation relies on: an intact central nervous system with a functioning pituitary, an ovarian response, and a normal uterus, cervix, and vagina. You should check the patient’s follicle-stimulating hormone, thyroid-stimulating hormone, and prolactin levels to assess CNS functioning, and estradiol levels to assess ovarian response. A genital exam with a pelvic ultrasound can reveal any possible defects in the uterus, cervix, or vagina.
The presence of breasts without a uterus indicates normal estrogen production, so the missing uterus could be a congenital defect or result from androgen insensitivity, Dr. Hertweck explained. In those without breasts, gonadal dysgenesis or gonadal enzymatic deficiency may explain no estrogen production. If the patient has both breasts and a uterus, you should rule out pregnancy first and then track CNS changes via FSH, TSH, and prolactin levels.
Premature ovarian insufficiency
Approximately 1% of females experience premature ovarian insufficiency, which can be diagnosed as early as age 14 years and should be suspected in a patient with a uterus but without breasts who has low estradiol levels, CNS failure identified by a high FSH level, and gonadal failure.
Formal diagnosis requires two separate instances of FSH elevation, and chromosomal testing should be done to rule out gonadal dysgenesis. You also should test the serum anti-Müllerian hormone biomarker (readings above 8 are concerning) and look for two possible causes. The FMR1 (Fragile X) premutation carrier status could be a cause, or presence of 21-hydroxylase and/or adrenal antibodies indicate autoimmune polyglandular syndrome.
Catching premature ovarian insufficiency early enough may allow patients to preserve some fertility if they still have oocytes present. Aside from this, girls will need hormone replacement therapy to fulfill developmental emotional and physical needs, such as bone growth and overall health. Despite a history of treating teens with premature ovarian insufficiency like adults, you should follow the practice guidelines specific to adolescents by the American College of Obstetricians and Gynecologists committee opinion statement (Obstet Gynecol. 2014;123:193-7).
Menorrhagia: heavy menstrual bleeding
Even though average blood loss is estimated at 30 mL per period, that number means little in clinical practice because patients cannot measure the actual amount of menses. Better indicators of abnormally greater flow include flow lasting longer than 7 days, finding clots larger than a quarter, changing menstrual products every 1-2 hours, leaking onto clothing such that patients need to take extra clothes to school, and any heavy periods that occur with easy bruising or with a family history of bleeding disorders.
First-line treatment for heavy menstrual bleeding in teens is hormonal contraception, either combination oral contraceptive pills, the transdermal patch, or the intravaginal ring, which can be combined with other therapies.
An alternative for those under age 18 (per Food and Drug Administration labeling) is oral tranexamic acid, found in a crossover trial with an oral contraceptive pill to be just as effective at reducing average blood loss and improving quality of life, but with fewer side effects and better compliance. Before prescribing anything for heavy menstrual bleeding, however, you must consider possible causes and rule some out that require different management.
Aside from pregnancy, one potential cause of menorrhagia is infection such as chlamydia or gonorrhea, which should be considered even in those with a negative sexual history, Dr. Hertweck said. Other possible causes include an immature hypothalamic-pituitary-ovarian axis, polycystic ovary syndrome (even with low hemoglobin), malignancy with a hormone-producing tumor, hypothalamic dysfunction (often stimulated by eating disorders, obesity, rapid weight loss, or gluten intolerance), or coagulopathy.
“Teens with menorrhagia may need to be screened for a bleeding disorder,” Dr. Hertweck said. At a minimum, she recommends checking complete blood count, ferritin, and TSH. “The most common bleeding disorders associated with heavy menstrual bleeding include platelet function disorders and von Willebrand.”
Up to half of teen girls with menorrhagia who visit a hematologist or multidisciplinary clinic receive a diagnosis of a bleeding disorder, Dr. Hertweck said. And up to half of those with menorrhagia at menarche may have von Willebrand, as do one in six adolescents who go to the emergency department because of heavy menstrual bleeding.
Von Willebrand syndrome
Von Willebrand syndrome is a deficiency or dysfunction of von Willebrand factor (vWF), a protein with binding sites for platelets, collagen, and factor VIII that “serves as a bridge between platelets and injury sites in vessel walls” and “protects factor VIII from rapid proteolytic degradation,” Dr. Hertweck said. Von Willebrand syndrome is the most common inherited congenital bleeding disorder. Although acquired von Willebrand syndrome is rare, it has grown in incidence among those with complex cardiovascular, hematologic, or immunologic disorders.
“Correct diagnosis is complex and not always straightforward,” Dr. Hertweck said, but “a positive response to questions in four categories is highly sensitive.” They are as follows:
• Menses lasting at least 7 days and interfering with a person’s daily activities.
• “History of treatment for anemia.
• Family history of a diagnosed bleeding disorder.
• History of excessive bleeding after tooth extraction, delivery, miscarriage, or surgery.
Diagnostic assays include platelet concentration of vWF antigen, an activity test of vWF-platelet binding, and factor VIII activity. However, you often need to repeat diagnostic testing because vWF antigens vary according to race, blood type, age, acute phase response, and menstrual cycle timing, Dr. Hertweck said.
“Remember to draw von Willebrand testing only during the first 3 days of the menstrual cycle when estrogen levels are at the nadir,” she said.
Because estrogen increases vWF, treatment for von Willebrand syndrome should be progestin only, either oral pills, medroxyprogesterone acetate (MPA, or Depo-Provera injections), or an etonogestrel implant.
Dr. Hertweck presented several cases of abnormal menstruation and extreme conditions such as severe menorrhagia. Outside of von Willebrand in such patients, possible platelet disorders could include Glanzmann thrombasthenia (a platelet function disorder that is caused by an abnormality in the genes for glycoproteins IIb/IIIa) and platelet storage pool disorder, both of which should be diagnosed by a hematologist.
Dr. Hertweck reported having a research grant from Merck related to contraceptive implants in adolescents.
CHICAGO – , according to S. Paige Hertweck, MD, chief of gynecology at Norton Children’s Hospital in Louisville, Ky.
“Remember to use the menstrual cycle as a vital sign,” Dr. Hertweck told attendees at the American Academy of Pediatrics annual meeting. “Even within the first year of menarche, most girls have a period at least every 90 days, so work up those who don’t.”
The median age of menarche is 12.4 years, typically beginning within 2-3 years of breast budding at Tanner Stage 4 breast development, she said. By 15 years of age, 98% of girls have begun menstruation.
Girls’ cycles typically last 21-45 days, an average of 32.2 days during their first year of menstruation, with flow for 7 days or less, requiring an average of 3-6 pads and/or tampons per day. Dr. Hertweck recommends you write down these features of normal menstruation so that your patients can tell you when their cycle is abnormal or menses doesn’t return.
“Cycle length is more variable for teens versus women 20-40 years old,” she said. However, “it’s not true that ‘anything goes’ for cycle length” in teens, she added. “Cycles that are consistently outside the range of 21-45 days are statistically uncommon.” Hence the need to evaluate causes of amenorrhea in girls whose cycles exceed 90 days.
Possible causes of amenorrhea include pregnancy, polycystic ovary syndrome, thyroid abnormalities, hyperprolactinemia, primary ovarian insufficiency, or hypogonadal amenorrhea, typically stimulated by the first instance of anorexia, Crohn’s disease, celiac disease, or a gluten intolerance.
Primary amenorrhea
Dr. Hertweck listed five benchmarks that indicate primary amenorrhea requiring evaluation. Those indicators include girls who have no menarche by age 15 years or within 3 years of breast budding, no breast development by age 13 years, or no menses by age 14 years with hirsutism or with a history of excessive exercise or of an eating disorder.
You can start by examining what normal menstruation relies on: an intact central nervous system with a functioning pituitary, an ovarian response, and a normal uterus, cervix, and vagina. You should check the patient’s follicle-stimulating hormone, thyroid-stimulating hormone, and prolactin levels to assess CNS functioning, and estradiol levels to assess ovarian response. A genital exam with a pelvic ultrasound can reveal any possible defects in the uterus, cervix, or vagina.
The presence of breasts without a uterus indicates normal estrogen production, so the missing uterus could be a congenital defect or result from androgen insensitivity, Dr. Hertweck explained. In those without breasts, gonadal dysgenesis or gonadal enzymatic deficiency may explain no estrogen production. If the patient has both breasts and a uterus, you should rule out pregnancy first and then track CNS changes via FSH, TSH, and prolactin levels.
Premature ovarian insufficiency
Approximately 1% of females experience premature ovarian insufficiency, which can be diagnosed as early as age 14 years and should be suspected in a patient with a uterus but without breasts who has low estradiol levels, CNS failure identified by a high FSH level, and gonadal failure.
Formal diagnosis requires two separate instances of FSH elevation, and chromosomal testing should be done to rule out gonadal dysgenesis. You also should test the serum anti-Müllerian hormone biomarker (readings above 8 are concerning) and look for two possible causes. The FMR1 (Fragile X) premutation carrier status could be a cause, or presence of 21-hydroxylase and/or adrenal antibodies indicate autoimmune polyglandular syndrome.
Catching premature ovarian insufficiency early enough may allow patients to preserve some fertility if they still have oocytes present. Aside from this, girls will need hormone replacement therapy to fulfill developmental emotional and physical needs, such as bone growth and overall health. Despite a history of treating teens with premature ovarian insufficiency like adults, you should follow the practice guidelines specific to adolescents by the American College of Obstetricians and Gynecologists committee opinion statement (Obstet Gynecol. 2014;123:193-7).
Menorrhagia: heavy menstrual bleeding
Even though average blood loss is estimated at 30 mL per period, that number means little in clinical practice because patients cannot measure the actual amount of menses. Better indicators of abnormally greater flow include flow lasting longer than 7 days, finding clots larger than a quarter, changing menstrual products every 1-2 hours, leaking onto clothing such that patients need to take extra clothes to school, and any heavy periods that occur with easy bruising or with a family history of bleeding disorders.
First-line treatment for heavy menstrual bleeding in teens is hormonal contraception, either combination oral contraceptive pills, the transdermal patch, or the intravaginal ring, which can be combined with other therapies.
An alternative for those under age 18 (per Food and Drug Administration labeling) is oral tranexamic acid, found in a crossover trial with an oral contraceptive pill to be just as effective at reducing average blood loss and improving quality of life, but with fewer side effects and better compliance. Before prescribing anything for heavy menstrual bleeding, however, you must consider possible causes and rule some out that require different management.
Aside from pregnancy, one potential cause of menorrhagia is infection such as chlamydia or gonorrhea, which should be considered even in those with a negative sexual history, Dr. Hertweck said. Other possible causes include an immature hypothalamic-pituitary-ovarian axis, polycystic ovary syndrome (even with low hemoglobin), malignancy with a hormone-producing tumor, hypothalamic dysfunction (often stimulated by eating disorders, obesity, rapid weight loss, or gluten intolerance), or coagulopathy.
“Teens with menorrhagia may need to be screened for a bleeding disorder,” Dr. Hertweck said. At a minimum, she recommends checking complete blood count, ferritin, and TSH. “The most common bleeding disorders associated with heavy menstrual bleeding include platelet function disorders and von Willebrand.”
Up to half of teen girls with menorrhagia who visit a hematologist or multidisciplinary clinic receive a diagnosis of a bleeding disorder, Dr. Hertweck said. And up to half of those with menorrhagia at menarche may have von Willebrand, as do one in six adolescents who go to the emergency department because of heavy menstrual bleeding.
Von Willebrand syndrome
Von Willebrand syndrome is a deficiency or dysfunction of von Willebrand factor (vWF), a protein with binding sites for platelets, collagen, and factor VIII that “serves as a bridge between platelets and injury sites in vessel walls” and “protects factor VIII from rapid proteolytic degradation,” Dr. Hertweck said. Von Willebrand syndrome is the most common inherited congenital bleeding disorder. Although acquired von Willebrand syndrome is rare, it has grown in incidence among those with complex cardiovascular, hematologic, or immunologic disorders.
“Correct diagnosis is complex and not always straightforward,” Dr. Hertweck said, but “a positive response to questions in four categories is highly sensitive.” They are as follows:
• Menses lasting at least 7 days and interfering with a person’s daily activities.
• “History of treatment for anemia.
• Family history of a diagnosed bleeding disorder.
• History of excessive bleeding after tooth extraction, delivery, miscarriage, or surgery.
Diagnostic assays include platelet concentration of vWF antigen, an activity test of vWF-platelet binding, and factor VIII activity. However, you often need to repeat diagnostic testing because vWF antigens vary according to race, blood type, age, acute phase response, and menstrual cycle timing, Dr. Hertweck said.
“Remember to draw von Willebrand testing only during the first 3 days of the menstrual cycle when estrogen levels are at the nadir,” she said.
Because estrogen increases vWF, treatment for von Willebrand syndrome should be progestin only, either oral pills, medroxyprogesterone acetate (MPA, or Depo-Provera injections), or an etonogestrel implant.
Dr. Hertweck presented several cases of abnormal menstruation and extreme conditions such as severe menorrhagia. Outside of von Willebrand in such patients, possible platelet disorders could include Glanzmann thrombasthenia (a platelet function disorder that is caused by an abnormality in the genes for glycoproteins IIb/IIIa) and platelet storage pool disorder, both of which should be diagnosed by a hematologist.
Dr. Hertweck reported having a research grant from Merck related to contraceptive implants in adolescents.
EXPERT ANALYSIS FROM AAP 2017
LARCs remain best contraception for teens
CHICAGO – The steady drop in teen pregnancy rates over the past 25 years – more than a 75% decline – is directly attributed to more effective use of contraception, but it only will continue if teens use the most effective forms of contraception, explained Rachael Phelps, MD, medical director of Planned Parenthood of Central and Western New York.
Teen birth rates in the United States already remain much higher than those in other high-income countries. In fact, the 2015 U.S. rate of 22 births per 1,000 teens ages 15-19 years is barely below that of India and Rwanda – and more than triple the rates in France, Germany, Italy, and other Western European countries.
“A lot of what you’re doing for adolescents in primary care is transitioning them from being a child to being an adult,” Dr. Phelps said. “Once they’re in their 20s, they may not see a primary care doctor, so you have the opportunity to give them the skills and the knowledge they need with contraception to protect themselves not only through their teens, but through their 20s.”
Contraceptive methods’ effectiveness
The most effective forms of birth control, with a less than 1% chance of pregnancy, are long-acting reversible contraceptives (LARCs), including the implant (Nexplanon) and an intrauterine device (IUD), such as Skyla, Mirena, Liletta, and Kyleena, and the hormone-free Paragard. Sterilization also is highly effective, but is permanent and rarely an ideal option for the average teen.
Other hormonal options are second best, with 94%-99% effectiveness, but require more frequent replacement. Whereas the implant lasts 3 years and the IUDs last anywhere from 3 to 12 years depending on the type, the pill must be taken daily. The patch is replaced each week, the ring is replaced each month, and Depo-Provera shots are required every 3 months.
The least effective methods of birth control include withdrawal, natural family planning (fertility planning), and barrier methods such as condoms and diaphragms. Depending on the method, 12-24 women out of 100 will get pregnant each year using these methods, although that’s better than the 90% or more of women who get pregnant each year when using no contraception.
“The problem is, if you try pills first and see how that goes, the way you’re going to find out it didn’t go so well is she’s going to be pregnant,” Dr. Phelps said. “When you think about an IUD or an implant being invasive, you need to think about the alternative, which is pregnancy.”
Just over half of teens using contraception use oral contraceptives (54%), according to the Centers for Disease Control and Prevention, yet research shows only a third of women remember to take their pill every day in their first month. By their third month, just one in five women have remembered the pill every day, and more than half (51%) have forgotten three or more pills (Fam Plann Perspect. 1996 Jul-Aug;28[4]:154-8).
“When we talk about risk, we often think about the risk of the method versus not using the method,” Dr. Phelps said. “But what we should be thinking about is the risk of the method versus the risk of pregnancy. That’s the true comparison because they’re not going to stop having sex.”
After oral contraception, condoms are most popular (23%), followed by 9% using Depo-Provera, and the remaining 10% split across withdrawal, the ring, and the patch, she said.
LARCs preferred by teens and organizations
The AAP, the American College of Obstetricians and Gynecologists (ACOG), and the American Academy of Family Physicians (AAFP) all recommend LARCs as first-line contraceptive choices.
Teens also prefer LARCs to the short-term, less effective methods as well, found the Contraceptive Choice Project study. Given a choice of any birth control method without cost or other access barriers, 72% of teens would choose a LARC, compared with 28% of teens who would choose a short-acting method, Dr. Phelps said.
Satisfaction rates with LARCs, ranging from 78% with the implant to 86% with a hormonal IUD, also far exceeded satisfaction with other hormonal contraception, ranging from 42% for the patch to 54% for Depo-Provera and oral contraceptives, the study found. And LARCs are among the safest contraceptive choices because they contain no estrogen and have few contraindications.
Understanding LARC and hormonal options
The two types of IUDs are an levonorgestrel IUD and a copper-T IUD. The levonorgestrel IUD contains progestin only, released at 20 mcg per day, and is effective up to 3-7 years. Most patients have light spotting initially, lasting 6 months in about 25% of patients and up to a year in 10%. By 6 months, 44% don’t have periods, which increases to 50% by 1 year (“Contraceptive Technology,” 19ed. [London: Ardent Media, 2007]).
The copper-T IUD contains copper ions but no hormones and is effective up to 12 years, starting immediately. Women have regular periods, but they may be heavier, longer, or with more cramps for the first 6 months.
Both IUDs and implants are safe in nulliparous, postpartum, and breastfeeding teens as well as those with obesity, cervical intraepithelial neoplasia, diabetes, HIV, depression, stroke/myocardial infarction/deep vein thrombosis/pulmonary embolism, pelvic inflammatory disease, and sexually transmitted infections.
Dr. Phelps reviewed insertion for both IUDs and the implant, but also said providers can refer teens for LARCs using http://larc.arhp.org to find someone. She also recommended the Managing Contraception pocket-sized book, available at www.managingcontraception.com and free for medical students and residents. Further, the U.S. Medical Eligibility Criteria provides all necessary information on contraindications and is available as a mobile app.
All the hormonal options, including the levonorgestrel IUD, become effective 1 week after starting. The implant, costing $300-$600, contains only progesterone, is effective up to 4 years and works by inhibiting ovulation. Just over one in five girls (22%) have no period, 34% have infrequent light bleeding, and 11% discontinue it because of frequent bleeding.
Depo-Provera contains progestin only and involves an injection every 12-14 weeks; irregular bleeding is initially common, after which most patients experience amenorrhea.
Patients using the patch, containing both estrogen and progestin, should change it once a week for 3 weeks and then take 1 week off for their period. Providers should advise teens to stick the patch directly on clean, dry skin of the arm, torso, buttocks, or stomach, but not to their breasts.
The ring similarly contains estrogen and progestin and has 1 off week after 3 weeks of use, but it is changed out monthly. Patients pinch the ring and place it into the vagina in any location, going deeper if it is uncomfortable.
Emergency contraception
Of the two emergency contraception options, ulipristal acetate – prescription only as 30 mg used up to 120 hours after unprotected sex – is always more effective than levonorgestrel – over-the-counter as 1.5 mg used up to 72 hours after unprotected sex. Both, however, are less effective in those with obesity (ulipristal acetate if BMI great than 30 and levonorgestrel if BMI greater than 25), Dr. Phelps said. If the patient had unprotected sex 3-5 days earlier and/or has a higher BMI, ulipristal acetate is preferred. Ideally, teens should be provided emergency contraception ahead of time, thereby increasing earlier use and use overall when it’s needed without increasing risk-taking behavior.
Common misconceptions
Dr. Phelps also reviewed some of the key myths that providers and teens often believe about LARCs and other contraceptive methods.
“When providers or patients hold misperceptions about the risks associated with contraception, teens’ choices are unnecessarily limited,” she said.
Key facts to know about IUDs are that even nulliparous teens can use them, teens can tolerate IUD placement, and IUDs do not increase the risk of pelvic inflammatory disease or infertility. Even teens with multiple partners and/or a history of sexually transmitted infections, pelvic inflammatory disease, or ectopic pregnancy can use IUDs, Dr. Phelps emphasized.
Although Depo-Provera can lead to 3%-5% bone loss, similar to pregnancy and breastfeeding, in the first 1-2 years, the loss is temporary and reversible. No research has shown Depo-Provera to increase risk of fracture or other negative clinical outcomes, no limits to its duration of use exist, and measuring bone mass density is not recommended.
Although Depo-Provera does cause excessive weight gain in 25% of users – an average 15 pounds over 3 years – the risk of increase is evident at 6 months. All other hormonal options – IUDs, the implant, pill, patch, or ring – do not cause weight gain. Finally, obesity does not decrease the effectiveness of IUDs, the implant, patch, pill, or ring.
No funding was used for this presentation. Dr. Phelps reported having done clinical training and speaking for Merck.
CHICAGO – The steady drop in teen pregnancy rates over the past 25 years – more than a 75% decline – is directly attributed to more effective use of contraception, but it only will continue if teens use the most effective forms of contraception, explained Rachael Phelps, MD, medical director of Planned Parenthood of Central and Western New York.
Teen birth rates in the United States already remain much higher than those in other high-income countries. In fact, the 2015 U.S. rate of 22 births per 1,000 teens ages 15-19 years is barely below that of India and Rwanda – and more than triple the rates in France, Germany, Italy, and other Western European countries.
“A lot of what you’re doing for adolescents in primary care is transitioning them from being a child to being an adult,” Dr. Phelps said. “Once they’re in their 20s, they may not see a primary care doctor, so you have the opportunity to give them the skills and the knowledge they need with contraception to protect themselves not only through their teens, but through their 20s.”
Contraceptive methods’ effectiveness
The most effective forms of birth control, with a less than 1% chance of pregnancy, are long-acting reversible contraceptives (LARCs), including the implant (Nexplanon) and an intrauterine device (IUD), such as Skyla, Mirena, Liletta, and Kyleena, and the hormone-free Paragard. Sterilization also is highly effective, but is permanent and rarely an ideal option for the average teen.
Other hormonal options are second best, with 94%-99% effectiveness, but require more frequent replacement. Whereas the implant lasts 3 years and the IUDs last anywhere from 3 to 12 years depending on the type, the pill must be taken daily. The patch is replaced each week, the ring is replaced each month, and Depo-Provera shots are required every 3 months.
The least effective methods of birth control include withdrawal, natural family planning (fertility planning), and barrier methods such as condoms and diaphragms. Depending on the method, 12-24 women out of 100 will get pregnant each year using these methods, although that’s better than the 90% or more of women who get pregnant each year when using no contraception.
“The problem is, if you try pills first and see how that goes, the way you’re going to find out it didn’t go so well is she’s going to be pregnant,” Dr. Phelps said. “When you think about an IUD or an implant being invasive, you need to think about the alternative, which is pregnancy.”
Just over half of teens using contraception use oral contraceptives (54%), according to the Centers for Disease Control and Prevention, yet research shows only a third of women remember to take their pill every day in their first month. By their third month, just one in five women have remembered the pill every day, and more than half (51%) have forgotten three or more pills (Fam Plann Perspect. 1996 Jul-Aug;28[4]:154-8).
“When we talk about risk, we often think about the risk of the method versus not using the method,” Dr. Phelps said. “But what we should be thinking about is the risk of the method versus the risk of pregnancy. That’s the true comparison because they’re not going to stop having sex.”
After oral contraception, condoms are most popular (23%), followed by 9% using Depo-Provera, and the remaining 10% split across withdrawal, the ring, and the patch, she said.
LARCs preferred by teens and organizations
The AAP, the American College of Obstetricians and Gynecologists (ACOG), and the American Academy of Family Physicians (AAFP) all recommend LARCs as first-line contraceptive choices.
Teens also prefer LARCs to the short-term, less effective methods as well, found the Contraceptive Choice Project study. Given a choice of any birth control method without cost or other access barriers, 72% of teens would choose a LARC, compared with 28% of teens who would choose a short-acting method, Dr. Phelps said.
Satisfaction rates with LARCs, ranging from 78% with the implant to 86% with a hormonal IUD, also far exceeded satisfaction with other hormonal contraception, ranging from 42% for the patch to 54% for Depo-Provera and oral contraceptives, the study found. And LARCs are among the safest contraceptive choices because they contain no estrogen and have few contraindications.
Understanding LARC and hormonal options
The two types of IUDs are an levonorgestrel IUD and a copper-T IUD. The levonorgestrel IUD contains progestin only, released at 20 mcg per day, and is effective up to 3-7 years. Most patients have light spotting initially, lasting 6 months in about 25% of patients and up to a year in 10%. By 6 months, 44% don’t have periods, which increases to 50% by 1 year (“Contraceptive Technology,” 19ed. [London: Ardent Media, 2007]).
The copper-T IUD contains copper ions but no hormones and is effective up to 12 years, starting immediately. Women have regular periods, but they may be heavier, longer, or with more cramps for the first 6 months.
Both IUDs and implants are safe in nulliparous, postpartum, and breastfeeding teens as well as those with obesity, cervical intraepithelial neoplasia, diabetes, HIV, depression, stroke/myocardial infarction/deep vein thrombosis/pulmonary embolism, pelvic inflammatory disease, and sexually transmitted infections.
Dr. Phelps reviewed insertion for both IUDs and the implant, but also said providers can refer teens for LARCs using http://larc.arhp.org to find someone. She also recommended the Managing Contraception pocket-sized book, available at www.managingcontraception.com and free for medical students and residents. Further, the U.S. Medical Eligibility Criteria provides all necessary information on contraindications and is available as a mobile app.
All the hormonal options, including the levonorgestrel IUD, become effective 1 week after starting. The implant, costing $300-$600, contains only progesterone, is effective up to 4 years and works by inhibiting ovulation. Just over one in five girls (22%) have no period, 34% have infrequent light bleeding, and 11% discontinue it because of frequent bleeding.
Depo-Provera contains progestin only and involves an injection every 12-14 weeks; irregular bleeding is initially common, after which most patients experience amenorrhea.
Patients using the patch, containing both estrogen and progestin, should change it once a week for 3 weeks and then take 1 week off for their period. Providers should advise teens to stick the patch directly on clean, dry skin of the arm, torso, buttocks, or stomach, but not to their breasts.
The ring similarly contains estrogen and progestin and has 1 off week after 3 weeks of use, but it is changed out monthly. Patients pinch the ring and place it into the vagina in any location, going deeper if it is uncomfortable.
Emergency contraception
Of the two emergency contraception options, ulipristal acetate – prescription only as 30 mg used up to 120 hours after unprotected sex – is always more effective than levonorgestrel – over-the-counter as 1.5 mg used up to 72 hours after unprotected sex. Both, however, are less effective in those with obesity (ulipristal acetate if BMI great than 30 and levonorgestrel if BMI greater than 25), Dr. Phelps said. If the patient had unprotected sex 3-5 days earlier and/or has a higher BMI, ulipristal acetate is preferred. Ideally, teens should be provided emergency contraception ahead of time, thereby increasing earlier use and use overall when it’s needed without increasing risk-taking behavior.
Common misconceptions
Dr. Phelps also reviewed some of the key myths that providers and teens often believe about LARCs and other contraceptive methods.
“When providers or patients hold misperceptions about the risks associated with contraception, teens’ choices are unnecessarily limited,” she said.
Key facts to know about IUDs are that even nulliparous teens can use them, teens can tolerate IUD placement, and IUDs do not increase the risk of pelvic inflammatory disease or infertility. Even teens with multiple partners and/or a history of sexually transmitted infections, pelvic inflammatory disease, or ectopic pregnancy can use IUDs, Dr. Phelps emphasized.
Although Depo-Provera can lead to 3%-5% bone loss, similar to pregnancy and breastfeeding, in the first 1-2 years, the loss is temporary and reversible. No research has shown Depo-Provera to increase risk of fracture or other negative clinical outcomes, no limits to its duration of use exist, and measuring bone mass density is not recommended.
Although Depo-Provera does cause excessive weight gain in 25% of users – an average 15 pounds over 3 years – the risk of increase is evident at 6 months. All other hormonal options – IUDs, the implant, pill, patch, or ring – do not cause weight gain. Finally, obesity does not decrease the effectiveness of IUDs, the implant, patch, pill, or ring.
No funding was used for this presentation. Dr. Phelps reported having done clinical training and speaking for Merck.
CHICAGO – The steady drop in teen pregnancy rates over the past 25 years – more than a 75% decline – is directly attributed to more effective use of contraception, but it only will continue if teens use the most effective forms of contraception, explained Rachael Phelps, MD, medical director of Planned Parenthood of Central and Western New York.
Teen birth rates in the United States already remain much higher than those in other high-income countries. In fact, the 2015 U.S. rate of 22 births per 1,000 teens ages 15-19 years is barely below that of India and Rwanda – and more than triple the rates in France, Germany, Italy, and other Western European countries.
“A lot of what you’re doing for adolescents in primary care is transitioning them from being a child to being an adult,” Dr. Phelps said. “Once they’re in their 20s, they may not see a primary care doctor, so you have the opportunity to give them the skills and the knowledge they need with contraception to protect themselves not only through their teens, but through their 20s.”
Contraceptive methods’ effectiveness
The most effective forms of birth control, with a less than 1% chance of pregnancy, are long-acting reversible contraceptives (LARCs), including the implant (Nexplanon) and an intrauterine device (IUD), such as Skyla, Mirena, Liletta, and Kyleena, and the hormone-free Paragard. Sterilization also is highly effective, but is permanent and rarely an ideal option for the average teen.
Other hormonal options are second best, with 94%-99% effectiveness, but require more frequent replacement. Whereas the implant lasts 3 years and the IUDs last anywhere from 3 to 12 years depending on the type, the pill must be taken daily. The patch is replaced each week, the ring is replaced each month, and Depo-Provera shots are required every 3 months.
The least effective methods of birth control include withdrawal, natural family planning (fertility planning), and barrier methods such as condoms and diaphragms. Depending on the method, 12-24 women out of 100 will get pregnant each year using these methods, although that’s better than the 90% or more of women who get pregnant each year when using no contraception.
“The problem is, if you try pills first and see how that goes, the way you’re going to find out it didn’t go so well is she’s going to be pregnant,” Dr. Phelps said. “When you think about an IUD or an implant being invasive, you need to think about the alternative, which is pregnancy.”
Just over half of teens using contraception use oral contraceptives (54%), according to the Centers for Disease Control and Prevention, yet research shows only a third of women remember to take their pill every day in their first month. By their third month, just one in five women have remembered the pill every day, and more than half (51%) have forgotten three or more pills (Fam Plann Perspect. 1996 Jul-Aug;28[4]:154-8).
“When we talk about risk, we often think about the risk of the method versus not using the method,” Dr. Phelps said. “But what we should be thinking about is the risk of the method versus the risk of pregnancy. That’s the true comparison because they’re not going to stop having sex.”
After oral contraception, condoms are most popular (23%), followed by 9% using Depo-Provera, and the remaining 10% split across withdrawal, the ring, and the patch, she said.
LARCs preferred by teens and organizations
The AAP, the American College of Obstetricians and Gynecologists (ACOG), and the American Academy of Family Physicians (AAFP) all recommend LARCs as first-line contraceptive choices.
Teens also prefer LARCs to the short-term, less effective methods as well, found the Contraceptive Choice Project study. Given a choice of any birth control method without cost or other access barriers, 72% of teens would choose a LARC, compared with 28% of teens who would choose a short-acting method, Dr. Phelps said.
Satisfaction rates with LARCs, ranging from 78% with the implant to 86% with a hormonal IUD, also far exceeded satisfaction with other hormonal contraception, ranging from 42% for the patch to 54% for Depo-Provera and oral contraceptives, the study found. And LARCs are among the safest contraceptive choices because they contain no estrogen and have few contraindications.
Understanding LARC and hormonal options
The two types of IUDs are an levonorgestrel IUD and a copper-T IUD. The levonorgestrel IUD contains progestin only, released at 20 mcg per day, and is effective up to 3-7 years. Most patients have light spotting initially, lasting 6 months in about 25% of patients and up to a year in 10%. By 6 months, 44% don’t have periods, which increases to 50% by 1 year (“Contraceptive Technology,” 19ed. [London: Ardent Media, 2007]).
The copper-T IUD contains copper ions but no hormones and is effective up to 12 years, starting immediately. Women have regular periods, but they may be heavier, longer, or with more cramps for the first 6 months.
Both IUDs and implants are safe in nulliparous, postpartum, and breastfeeding teens as well as those with obesity, cervical intraepithelial neoplasia, diabetes, HIV, depression, stroke/myocardial infarction/deep vein thrombosis/pulmonary embolism, pelvic inflammatory disease, and sexually transmitted infections.
Dr. Phelps reviewed insertion for both IUDs and the implant, but also said providers can refer teens for LARCs using http://larc.arhp.org to find someone. She also recommended the Managing Contraception pocket-sized book, available at www.managingcontraception.com and free for medical students and residents. Further, the U.S. Medical Eligibility Criteria provides all necessary information on contraindications and is available as a mobile app.
All the hormonal options, including the levonorgestrel IUD, become effective 1 week after starting. The implant, costing $300-$600, contains only progesterone, is effective up to 4 years and works by inhibiting ovulation. Just over one in five girls (22%) have no period, 34% have infrequent light bleeding, and 11% discontinue it because of frequent bleeding.
Depo-Provera contains progestin only and involves an injection every 12-14 weeks; irregular bleeding is initially common, after which most patients experience amenorrhea.
Patients using the patch, containing both estrogen and progestin, should change it once a week for 3 weeks and then take 1 week off for their period. Providers should advise teens to stick the patch directly on clean, dry skin of the arm, torso, buttocks, or stomach, but not to their breasts.
The ring similarly contains estrogen and progestin and has 1 off week after 3 weeks of use, but it is changed out monthly. Patients pinch the ring and place it into the vagina in any location, going deeper if it is uncomfortable.
Emergency contraception
Of the two emergency contraception options, ulipristal acetate – prescription only as 30 mg used up to 120 hours after unprotected sex – is always more effective than levonorgestrel – over-the-counter as 1.5 mg used up to 72 hours after unprotected sex. Both, however, are less effective in those with obesity (ulipristal acetate if BMI great than 30 and levonorgestrel if BMI greater than 25), Dr. Phelps said. If the patient had unprotected sex 3-5 days earlier and/or has a higher BMI, ulipristal acetate is preferred. Ideally, teens should be provided emergency contraception ahead of time, thereby increasing earlier use and use overall when it’s needed without increasing risk-taking behavior.
Common misconceptions
Dr. Phelps also reviewed some of the key myths that providers and teens often believe about LARCs and other contraceptive methods.
“When providers or patients hold misperceptions about the risks associated with contraception, teens’ choices are unnecessarily limited,” she said.
Key facts to know about IUDs are that even nulliparous teens can use them, teens can tolerate IUD placement, and IUDs do not increase the risk of pelvic inflammatory disease or infertility. Even teens with multiple partners and/or a history of sexually transmitted infections, pelvic inflammatory disease, or ectopic pregnancy can use IUDs, Dr. Phelps emphasized.
Although Depo-Provera can lead to 3%-5% bone loss, similar to pregnancy and breastfeeding, in the first 1-2 years, the loss is temporary and reversible. No research has shown Depo-Provera to increase risk of fracture or other negative clinical outcomes, no limits to its duration of use exist, and measuring bone mass density is not recommended.
Although Depo-Provera does cause excessive weight gain in 25% of users – an average 15 pounds over 3 years – the risk of increase is evident at 6 months. All other hormonal options – IUDs, the implant, pill, patch, or ring – do not cause weight gain. Finally, obesity does not decrease the effectiveness of IUDs, the implant, patch, pill, or ring.
No funding was used for this presentation. Dr. Phelps reported having done clinical training and speaking for Merck.
EXPERT ANALYSIS FROM AAP 2017