Damian McNamara

Some stressful childhood emotional experiences are associated with an increased likelihood of adult obesity and, therefore, a greater risk for type 2 diabetes, according to findings of a British population-based study of more than 9,000 participants.

Claudia Thomas, Ph.D., and her associates studied 9,310 participants of a 1958 British birth cohort followed longitudinally up to age 45 years. They were asked about emotional and physical neglect, household dysfunction, and abuse at different evaluations during the longitudinal study. The investigators looked for associations with midlife body mass index (BMI), central obesity, and glucose control (Pediatrics 2008;121:e1240-9 [doi:10.1542/peds.2007-2403]).

“We found that several different experiences, ranging from severe adversities, such as physical abuse, to other experiences, such as less severe forms of emotional neglect, increased the risk for obesity and, in doing so, increased the risk for poor glucose control,” wrote Dr. Thomas and her associates from the Centre for Paediatric Epidemiology and Biostatistics, Institute of Child Health, University College London.

The investigators found some significant correlations, some nonsignificant trends, and even an inverse relationship (between parental depression and later adverse health outcomes measured).

Of the adversities measured during childhood, low parental aspirations and little paternal or maternal interest in education were significantly associated with increased BMI, central obesity, and a glycosylated hemoglobin (HbA_1c) of 6% or greater at 45 years. Children who reported that they hardly ever took outings with their father had significantly higher midlife BMI and central obesity rates, but a nonsignificant increased risk of an HbA_1c of 6% or greater.

In contrast, children who reported that their mother hardly ever read to them or they did not “get on with either parent” were not at an increased risk. Likewise, those who appeared scruffy or dirty (at 7 and 11 years, according to teachers), experienced domestic tension and/or parental alcoholism or were placed in local or voluntary care before age 16 years were not more likely to have a higher adiposity or worse glucose control.

Dr. Thomas and her associates also adjusted for possible confounders. When they did, only a few correlations remained significant. All children who reported their mother had little interest in their education had significantly increased BMI and likelihood of HbA_1c of 6% or greater. Girls in this group also had a significantly increased likelihood of later central obesity. Socioeconomic position at birth, type of accommodation (owned vs. rented), number of persons per room in household, and whether any child received free school meals at age 11 or 16 years were the possible confounders.

Dr. Thomas and her associates also retrospectively asked participants at age 45 about childhood adversity. They found a strict upbringing significantly related to increased BMI, central obesity, and an HbA_1c of 6% or greater. Reported physical abuse also was significantly associated with increases in adiposity.

Previous studies have linked abusive and neglectful experiences early in life with increased risks of obesity, cardiovascular disease, diabetes, and liver disease. Associations between lower childhood socioeconomic status and increased risk of insulin resistance and type 2 diabetes also are proposed in several studies.

Some stressful childhood emotional experiences are associated with an increased likelihood of adult obesity and, therefore, a greater risk for type 2 diabetes, according to findings of a British population-based study of more than 9,000 participants.

Claudia Thomas, Ph.D., and her associates studied 9,310 participants of a 1958 British birth cohort followed longitudinally up to age 45 years. They were asked about emotional and physical neglect, household dysfunction, and abuse at different evaluations during the longitudinal study. The investigators looked for associations with midlife body mass index (BMI), central obesity, and glucose control (Pediatrics 2008;121:e1240-9 [doi:10.1542/peds.2007-2403]).

“We found that several different experiences, ranging from severe adversities, such as physical abuse, to other experiences, such as less severe forms of emotional neglect, increased the risk for obesity and, in doing so, increased the risk for poor glucose control,” wrote Dr. Thomas and her associates from the Centre for Paediatric Epidemiology and Biostatistics, Institute of Child Health, University College London.

The investigators found some significant correlations, some nonsignificant trends, and even an inverse relationship (between parental depression and later adverse health outcomes measured).

Of the adversities measured during childhood, low parental aspirations and little paternal or maternal interest in education were significantly associated with increased BMI, central obesity, and a glycosylated hemoglobin (HbA_1c) of 6% or greater at 45 years. Children who reported that they hardly ever took outings with their father had significantly higher midlife BMI and central obesity rates, but a nonsignificant increased risk of an HbA_1c of 6% or greater.

In contrast, children who reported that their mother hardly ever read to them or they did not “get on with either parent” were not at an increased risk. Likewise, those who appeared scruffy or dirty (at 7 and 11 years, according to teachers), experienced domestic tension and/or parental alcoholism or were placed in local or voluntary care before age 16 years were not more likely to have a higher adiposity or worse glucose control.

Dr. Thomas and her associates also adjusted for possible confounders. When they did, only a few correlations remained significant. All children who reported their mother had little interest in their education had significantly increased BMI and likelihood of HbA_1c of 6% or greater. Girls in this group also had a significantly increased likelihood of later central obesity. Socioeconomic position at birth, type of accommodation (owned vs. rented), number of persons per room in household, and whether any child received free school meals at age 11 or 16 years were the possible confounders.

Dr. Thomas and her associates also retrospectively asked participants at age 45 about childhood adversity. They found a strict upbringing significantly related to increased BMI, central obesity, and an HbA_1c of 6% or greater. Reported physical abuse also was significantly associated with increases in adiposity.

Previous studies have linked abusive and neglectful experiences early in life with increased risks of obesity, cardiovascular disease, diabetes, and liver disease. Associations between lower childhood socioeconomic status and increased risk of insulin resistance and type 2 diabetes also are proposed in several studies.

Some stressful childhood emotional experiences are associated with an increased likelihood of adult obesity and, therefore, a greater risk for type 2 diabetes, according to findings of a British population-based study of more than 9,000 participants.

Claudia Thomas, Ph.D., and her associates studied 9,310 participants of a 1958 British birth cohort followed longitudinally up to age 45 years. They were asked about emotional and physical neglect, household dysfunction, and abuse at different evaluations during the longitudinal study. The investigators looked for associations with midlife body mass index (BMI), central obesity, and glucose control (Pediatrics 2008;121:e1240-9 [doi:10.1542/peds.2007-2403]).

“We found that several different experiences, ranging from severe adversities, such as physical abuse, to other experiences, such as less severe forms of emotional neglect, increased the risk for obesity and, in doing so, increased the risk for poor glucose control,” wrote Dr. Thomas and her associates from the Centre for Paediatric Epidemiology and Biostatistics, Institute of Child Health, University College London.

The investigators found some significant correlations, some nonsignificant trends, and even an inverse relationship (between parental depression and later adverse health outcomes measured).

Of the adversities measured during childhood, low parental aspirations and little paternal or maternal interest in education were significantly associated with increased BMI, central obesity, and a glycosylated hemoglobin (HbA_1c) of 6% or greater at 45 years. Children who reported that they hardly ever took outings with their father had significantly higher midlife BMI and central obesity rates, but a nonsignificant increased risk of an HbA_1c of 6% or greater.

In contrast, children who reported that their mother hardly ever read to them or they did not “get on with either parent” were not at an increased risk. Likewise, those who appeared scruffy or dirty (at 7 and 11 years, according to teachers), experienced domestic tension and/or parental alcoholism or were placed in local or voluntary care before age 16 years were not more likely to have a higher adiposity or worse glucose control.

Dr. Thomas and her associates also adjusted for possible confounders. When they did, only a few correlations remained significant. All children who reported their mother had little interest in their education had significantly increased BMI and likelihood of HbA_1c of 6% or greater. Girls in this group also had a significantly increased likelihood of later central obesity. Socioeconomic position at birth, type of accommodation (owned vs. rented), number of persons per room in household, and whether any child received free school meals at age 11 or 16 years were the possible confounders.

Dr. Thomas and her associates also retrospectively asked participants at age 45 about childhood adversity. They found a strict upbringing significantly related to increased BMI, central obesity, and an HbA_1c of 6% or greater. Reported physical abuse also was significantly associated with increases in adiposity.

Previous studies have linked abusive and neglectful experiences early in life with increased risks of obesity, cardiovascular disease, diabetes, and liver disease. Associations between lower childhood socioeconomic status and increased risk of insulin resistance and type 2 diabetes also are proposed in several studies.

MIAMI BEACH – To avoid mistakes in the management of a child with attention-deficit/hyperactivity disorder, consider the patient's receptive language age, comorbidities such as depression, and medication to protect a young child when a parent is very intolerant of the child's behavior, Dr. David O. Childers recommended.

Attention-deficit/hyperactivity disorder (ADHD) is complex and not a stand-alone diagnosis, said Dr. Childers, a neurodevelopmental pediatrician. Look for a grouping of social, behavioral, and attention issues, as well as immaturity of fine and gross motor skills, judgment, and/or learning.

Errors in stimulant dosing, untreated insomnia, and missing ADHD inattentive type in an adolescent are other pitfalls to avoid, Dr. Childers said at the annual Masters of Pediatrics conference sponsored by the University of Miami.

Begin with assessment of receptive language age. “Our receptive language defines our behavior. We all have conversations in our heads. If the conversation in your head is at the 3-year-old level, your behavior will be like a 3-year-old,” said Dr. Childers, who serves as chief of the section of developmental pediatrics, University of Florida College of Medicine in Jacksonville.

Medications make a difference, he said, “But they are a Band-Aid approach–they do not make the problem go away.”

Dr. Childers outlined the following possible mistakes in management of ADHD:

▸ Mistake 1: Automatic prescription of stimulants for a hyperactive 3-year-old. A physician might want to dose “the hyperactive child who is jumping off the chair and up on the exam table … but is it the right thing to do?” Dr. Childers asked. The medication will allow the young child to focus their attention where they want to, and “a 3-year-old is nothing but a walking 'id.' They want it, they want it, they want it now,” he said, whether it's a toy or their own personal needs met.

▸ Mistake 2: Not dosing a young child for protection. A possible exception to the first mistake is the scenario of a “really, really hyperactive 3-year-old with a really intolerant parent. There is a subset of children who have a desperate need for protection,” he said. “Sometimes the stimulant is important at this age” in such cases.

▸ Mistake 3: Inappropriate initial dosing. There can be, for example, a 5-year-old who is extremely emotional, a zombie, or absolutely intolerable after starting a particular medication. “I get a lot of these referrals,” Dr. Childers said.

A prescription of 5 mg of methylphenidate is 2.5 mg of the L isomer and 2.5 mg D isomer, or 2.5 mg total of active isomer.

“Part of the problem is we start frequently with the mixed amphetamine salts 5 mg,” he said. This is 5 mg of active isomer. “So starting them on mixed salts is double the dose [we give with methylphenidate]. This is not the ideal [starting] dose for the average 4- to 6-year-old. I'm not saying you're not going to get there, anyway, but do you want to start there?”

▸ Mistake 4: Confusing the first effective dose with an ideal dose. “We find a dose that is effective, and we leave it there. We make the mistake of settling for lowest effective dose, not the best dose,” Dr. Childers said. Parents in this situation might say, “He tried the medicine–it didn't work” or “The medicine worked for a little while, but then his body got used to it.”

▸ Mistake 5: Neglecting comorbidities. “This is where some people start to make mistakes,” he noted. ADHD might be primary, and it might be secondary. Learning disabilities, oppositional defiant disorder, conduct disorder, anxiety, depression, encopresis/enuresis, and poor self-esteem are among possible comorbidities.

Parents will ask, “What did you do to my kid? He is crying all day, upset all the time since starting the medication.”

“Many times I diagnose childhood depression,” Dr. Childers said. “Childhood depression can look like ADHD in many cases.” ADHD incidence is 6%–10%, childhood depression incidence is 10%, and they can be comorbid. “You think it's hard to talk to a parent about putting a child on a stimulant, try to talk to them about putting a child on Prozac.”

▸ Mistake 6: Not detecting drug diversion. “ADHD is inherited. It is one of the most heritable conditions we know of,” Dr. Childers said. “You find a child with ADHD, the likelihood you'll find a parent with ADHD is 0.8.”

He added that there are exceptions, but sometimes “my goal is to see how fast I can make the diagnosis in the parent.”

Keep in mind that maybe the child is not the only one who sees the value of the medication. “Parents can divert.” A drug-seeking parent might say, “I need to change my child from the long-acting to the short-acting.” Long-acting agents, in general, have much less abuse potential. In contrast, short-acting stimulants can be divided, and there can be enough to get a child through school and a parent through work.

▸ Mistake 7: Confusing ADHD with an undiagnosed learning disability. Learning disabilities are more common, with an incidence of 15%–20%, compared with 6%–10% for ADHD, he said.

The physician might, for example, see a young boy who got all As and Bs in school, and, then all of sudden, starts getting Ds in third grade. It could be a learning disability arising at a time when children have to read to learn. Or it could manifest later, such as an inattentive 13- or 14-year-old girl who sits quietly in the back of class and just makes passing grades.

“Be careful of what you call it before you diagnose it,” Dr. Childers said. “Once you label the kid as 'ADHD,' the school will not be looking for anything else.”

One person attending the meeting said sometimes a school asks the physician to treat the child for ADHD on a trial basis. “Parents have told me that the child is not allowed back in school without a prescription for Ritalin,” Dr. Childers said. “I write a letter to school saying they need to make the diagnosis of a learning disability first. It's a war, and difficult if you don't have access to testing.”

The Federal Individuals with Disability Education Act (IDEA) requires schools to test for a learning disability at the parent's request, he added.

▸ Mistake 8: Undiagnosed ADHD in an adolescent. Sometimes it is easy to miss the adolescent with ADHD, inattentive subtype, Dr. Childers said. “We get so programmatic in our approach that the differential list of problems in adolescence doesn't place ADHD high on the index of suspicion.” He added, “Just because ADHD was not diagnosed in childhood doesn't mean it is not there.”

▸ Mistake 9: Insufficient dosing. “Rebound and insomnia is not subtle,” Dr. Childers said. “I use a booster dose. The problem isn't the medicine; the problem is the medicine wearing off.” If a stimulant wears off at 4 p.m. and bedtime is at 8 p.m., a small dose in the evening “can make a huge difference. Kids will be more stable and be able to fall asleep.”

It is important to note whether the insomnia predated the stimulant use. Get a basal sleep history, Dr. Childers advised. Also recommend proper sleep hygiene. “My first question is: Is there a TV in the bedroom? The answer is always yes, and I ask them “Why?” They can't answer it.” Remove the television forever, and give the child a bath and warm milk before bedtime, he said. “That is enough for most kids.”

▸ Mistake 10: Overdiagnosis of bipolar disorder. More and more parents are coming in and saying, “My teacher, aunt, therapist, neighbor, etc. said my child has 'bipolar disorder,'” Dr. Childers remarked.

The adult prevalence of bipolar disorder is 1%–1.6%, according to a National Alliance of Mental Illness Fact Sheet, January 2004. “It's not a curable illness. Bipolar is a lifelong diagnosis. So how can 7% of children have bipolar disorder?”

A much more common diagnosis is a combination of ADHD and oppositional defiant disorder (ODD) versus bipolar disorder, Dr. Childers said. “The one big difference I always look for is a trigger to the behavior. If a parent says, 'Every time I tell him no, he has a tantrum,' it is unlikely it's bipolar disorder, and more often it's ODD.”

Dr. Childers said he tells parents that they should have three goals for their child that appropriate management of ADHD can help to achieve: a happy childhood, a successful academic experience, and out the door and independent by age 18.

Dr. Childers had no relevant financial disclosures.

MIAMI BEACH – To avoid mistakes in the management of a child with attention-deficit/hyperactivity disorder, consider the patient's receptive language age, comorbidities such as depression, and medication to protect a young child when a parent is very intolerant of the child's behavior, Dr. David O. Childers recommended.

Attention-deficit/hyperactivity disorder (ADHD) is complex and not a stand-alone diagnosis, said Dr. Childers, a neurodevelopmental pediatrician. Look for a grouping of social, behavioral, and attention issues, as well as immaturity of fine and gross motor skills, judgment, and/or learning.

Errors in stimulant dosing, untreated insomnia, and missing ADHD inattentive type in an adolescent are other pitfalls to avoid, Dr. Childers said at the annual Masters of Pediatrics conference sponsored by the University of Miami.

Begin with assessment of receptive language age. “Our receptive language defines our behavior. We all have conversations in our heads. If the conversation in your head is at the 3-year-old level, your behavior will be like a 3-year-old,” said Dr. Childers, who serves as chief of the section of developmental pediatrics, University of Florida College of Medicine in Jacksonville.

Medications make a difference, he said, “But they are a Band-Aid approach–they do not make the problem go away.”

Dr. Childers outlined the following possible mistakes in management of ADHD:

▸ Mistake 1: Automatic prescription of stimulants for a hyperactive 3-year-old. A physician might want to dose “the hyperactive child who is jumping off the chair and up on the exam table … but is it the right thing to do?” Dr. Childers asked. The medication will allow the young child to focus their attention where they want to, and “a 3-year-old is nothing but a walking 'id.' They want it, they want it, they want it now,” he said, whether it's a toy or their own personal needs met.

▸ Mistake 2: Not dosing a young child for protection. A possible exception to the first mistake is the scenario of a “really, really hyperactive 3-year-old with a really intolerant parent. There is a subset of children who have a desperate need for protection,” he said. “Sometimes the stimulant is important at this age” in such cases.

▸ Mistake 3: Inappropriate initial dosing. There can be, for example, a 5-year-old who is extremely emotional, a zombie, or absolutely intolerable after starting a particular medication. “I get a lot of these referrals,” Dr. Childers said.

A prescription of 5 mg of methylphenidate is 2.5 mg of the L isomer and 2.5 mg D isomer, or 2.5 mg total of active isomer.

“Part of the problem is we start frequently with the mixed amphetamine salts 5 mg,” he said. This is 5 mg of active isomer. “So starting them on mixed salts is double the dose [we give with methylphenidate]. This is not the ideal [starting] dose for the average 4- to 6-year-old. I'm not saying you're not going to get there, anyway, but do you want to start there?”

▸ Mistake 4: Confusing the first effective dose with an ideal dose. “We find a dose that is effective, and we leave it there. We make the mistake of settling for lowest effective dose, not the best dose,” Dr. Childers said. Parents in this situation might say, “He tried the medicine–it didn't work” or “The medicine worked for a little while, but then his body got used to it.”

▸ Mistake 5: Neglecting comorbidities. “This is where some people start to make mistakes,” he noted. ADHD might be primary, and it might be secondary. Learning disabilities, oppositional defiant disorder, conduct disorder, anxiety, depression, encopresis/enuresis, and poor self-esteem are among possible comorbidities.

Parents will ask, “What did you do to my kid? He is crying all day, upset all the time since starting the medication.”

“Many times I diagnose childhood depression,” Dr. Childers said. “Childhood depression can look like ADHD in many cases.” ADHD incidence is 6%–10%, childhood depression incidence is 10%, and they can be comorbid. “You think it's hard to talk to a parent about putting a child on a stimulant, try to talk to them about putting a child on Prozac.”

▸ Mistake 6: Not detecting drug diversion. “ADHD is inherited. It is one of the most heritable conditions we know of,” Dr. Childers said. “You find a child with ADHD, the likelihood you'll find a parent with ADHD is 0.8.”

He added that there are exceptions, but sometimes “my goal is to see how fast I can make the diagnosis in the parent.”

Keep in mind that maybe the child is not the only one who sees the value of the medication. “Parents can divert.” A drug-seeking parent might say, “I need to change my child from the long-acting to the short-acting.” Long-acting agents, in general, have much less abuse potential. In contrast, short-acting stimulants can be divided, and there can be enough to get a child through school and a parent through work.

▸ Mistake 7: Confusing ADHD with an undiagnosed learning disability. Learning disabilities are more common, with an incidence of 15%–20%, compared with 6%–10% for ADHD, he said.

The physician might, for example, see a young boy who got all As and Bs in school, and, then all of sudden, starts getting Ds in third grade. It could be a learning disability arising at a time when children have to read to learn. Or it could manifest later, such as an inattentive 13- or 14-year-old girl who sits quietly in the back of class and just makes passing grades.

“Be careful of what you call it before you diagnose it,” Dr. Childers said. “Once you label the kid as 'ADHD,' the school will not be looking for anything else.”

One person attending the meeting said sometimes a school asks the physician to treat the child for ADHD on a trial basis. “Parents have told me that the child is not allowed back in school without a prescription for Ritalin,” Dr. Childers said. “I write a letter to school saying they need to make the diagnosis of a learning disability first. It's a war, and difficult if you don't have access to testing.”

The Federal Individuals with Disability Education Act (IDEA) requires schools to test for a learning disability at the parent's request, he added.

▸ Mistake 8: Undiagnosed ADHD in an adolescent. Sometimes it is easy to miss the adolescent with ADHD, inattentive subtype, Dr. Childers said. “We get so programmatic in our approach that the differential list of problems in adolescence doesn't place ADHD high on the index of suspicion.” He added, “Just because ADHD was not diagnosed in childhood doesn't mean it is not there.”

▸ Mistake 9: Insufficient dosing. “Rebound and insomnia is not subtle,” Dr. Childers said. “I use a booster dose. The problem isn't the medicine; the problem is the medicine wearing off.” If a stimulant wears off at 4 p.m. and bedtime is at 8 p.m., a small dose in the evening “can make a huge difference. Kids will be more stable and be able to fall asleep.”

It is important to note whether the insomnia predated the stimulant use. Get a basal sleep history, Dr. Childers advised. Also recommend proper sleep hygiene. “My first question is: Is there a TV in the bedroom? The answer is always yes, and I ask them “Why?” They can't answer it.” Remove the television forever, and give the child a bath and warm milk before bedtime, he said. “That is enough for most kids.”

▸ Mistake 10: Overdiagnosis of bipolar disorder. More and more parents are coming in and saying, “My teacher, aunt, therapist, neighbor, etc. said my child has 'bipolar disorder,'” Dr. Childers remarked.

The adult prevalence of bipolar disorder is 1%–1.6%, according to a National Alliance of Mental Illness Fact Sheet, January 2004. “It's not a curable illness. Bipolar is a lifelong diagnosis. So how can 7% of children have bipolar disorder?”

A much more common diagnosis is a combination of ADHD and oppositional defiant disorder (ODD) versus bipolar disorder, Dr. Childers said. “The one big difference I always look for is a trigger to the behavior. If a parent says, 'Every time I tell him no, he has a tantrum,' it is unlikely it's bipolar disorder, and more often it's ODD.”

Dr. Childers said he tells parents that they should have three goals for their child that appropriate management of ADHD can help to achieve: a happy childhood, a successful academic experience, and out the door and independent by age 18.

Dr. Childers had no relevant financial disclosures.

MIAMI BEACH – To avoid mistakes in the management of a child with attention-deficit/hyperactivity disorder, consider the patient's receptive language age, comorbidities such as depression, and medication to protect a young child when a parent is very intolerant of the child's behavior, Dr. David O. Childers recommended.

Attention-deficit/hyperactivity disorder (ADHD) is complex and not a stand-alone diagnosis, said Dr. Childers, a neurodevelopmental pediatrician. Look for a grouping of social, behavioral, and attention issues, as well as immaturity of fine and gross motor skills, judgment, and/or learning.

Errors in stimulant dosing, untreated insomnia, and missing ADHD inattentive type in an adolescent are other pitfalls to avoid, Dr. Childers said at the annual Masters of Pediatrics conference sponsored by the University of Miami.

Begin with assessment of receptive language age. “Our receptive language defines our behavior. We all have conversations in our heads. If the conversation in your head is at the 3-year-old level, your behavior will be like a 3-year-old,” said Dr. Childers, who serves as chief of the section of developmental pediatrics, University of Florida College of Medicine in Jacksonville.

Medications make a difference, he said, “But they are a Band-Aid approach–they do not make the problem go away.”

Dr. Childers outlined the following possible mistakes in management of ADHD:

▸ Mistake 1: Automatic prescription of stimulants for a hyperactive 3-year-old. A physician might want to dose “the hyperactive child who is jumping off the chair and up on the exam table … but is it the right thing to do?” Dr. Childers asked. The medication will allow the young child to focus their attention where they want to, and “a 3-year-old is nothing but a walking 'id.' They want it, they want it, they want it now,” he said, whether it's a toy or their own personal needs met.

▸ Mistake 2: Not dosing a young child for protection. A possible exception to the first mistake is the scenario of a “really, really hyperactive 3-year-old with a really intolerant parent. There is a subset of children who have a desperate need for protection,” he said. “Sometimes the stimulant is important at this age” in such cases.

▸ Mistake 3: Inappropriate initial dosing. There can be, for example, a 5-year-old who is extremely emotional, a zombie, or absolutely intolerable after starting a particular medication. “I get a lot of these referrals,” Dr. Childers said.

A prescription of 5 mg of methylphenidate is 2.5 mg of the L isomer and 2.5 mg D isomer, or 2.5 mg total of active isomer.

“Part of the problem is we start frequently with the mixed amphetamine salts 5 mg,” he said. This is 5 mg of active isomer. “So starting them on mixed salts is double the dose [we give with methylphenidate]. This is not the ideal [starting] dose for the average 4- to 6-year-old. I'm not saying you're not going to get there, anyway, but do you want to start there?”

▸ Mistake 4: Confusing the first effective dose with an ideal dose. “We find a dose that is effective, and we leave it there. We make the mistake of settling for lowest effective dose, not the best dose,” Dr. Childers said. Parents in this situation might say, “He tried the medicine–it didn't work” or “The medicine worked for a little while, but then his body got used to it.”

▸ Mistake 5: Neglecting comorbidities. “This is where some people start to make mistakes,” he noted. ADHD might be primary, and it might be secondary. Learning disabilities, oppositional defiant disorder, conduct disorder, anxiety, depression, encopresis/enuresis, and poor self-esteem are among possible comorbidities.

Parents will ask, “What did you do to my kid? He is crying all day, upset all the time since starting the medication.”

“Many times I diagnose childhood depression,” Dr. Childers said. “Childhood depression can look like ADHD in many cases.” ADHD incidence is 6%–10%, childhood depression incidence is 10%, and they can be comorbid. “You think it's hard to talk to a parent about putting a child on a stimulant, try to talk to them about putting a child on Prozac.”

▸ Mistake 6: Not detecting drug diversion. “ADHD is inherited. It is one of the most heritable conditions we know of,” Dr. Childers said. “You find a child with ADHD, the likelihood you'll find a parent with ADHD is 0.8.”

He added that there are exceptions, but sometimes “my goal is to see how fast I can make the diagnosis in the parent.”

Keep in mind that maybe the child is not the only one who sees the value of the medication. “Parents can divert.” A drug-seeking parent might say, “I need to change my child from the long-acting to the short-acting.” Long-acting agents, in general, have much less abuse potential. In contrast, short-acting stimulants can be divided, and there can be enough to get a child through school and a parent through work.

▸ Mistake 7: Confusing ADHD with an undiagnosed learning disability. Learning disabilities are more common, with an incidence of 15%–20%, compared with 6%–10% for ADHD, he said.

The physician might, for example, see a young boy who got all As and Bs in school, and, then all of sudden, starts getting Ds in third grade. It could be a learning disability arising at a time when children have to read to learn. Or it could manifest later, such as an inattentive 13- or 14-year-old girl who sits quietly in the back of class and just makes passing grades.

“Be careful of what you call it before you diagnose it,” Dr. Childers said. “Once you label the kid as 'ADHD,' the school will not be looking for anything else.”

One person attending the meeting said sometimes a school asks the physician to treat the child for ADHD on a trial basis. “Parents have told me that the child is not allowed back in school without a prescription for Ritalin,” Dr. Childers said. “I write a letter to school saying they need to make the diagnosis of a learning disability first. It's a war, and difficult if you don't have access to testing.”

The Federal Individuals with Disability Education Act (IDEA) requires schools to test for a learning disability at the parent's request, he added.

▸ Mistake 8: Undiagnosed ADHD in an adolescent. Sometimes it is easy to miss the adolescent with ADHD, inattentive subtype, Dr. Childers said. “We get so programmatic in our approach that the differential list of problems in adolescence doesn't place ADHD high on the index of suspicion.” He added, “Just because ADHD was not diagnosed in childhood doesn't mean it is not there.”

▸ Mistake 9: Insufficient dosing. “Rebound and insomnia is not subtle,” Dr. Childers said. “I use a booster dose. The problem isn't the medicine; the problem is the medicine wearing off.” If a stimulant wears off at 4 p.m. and bedtime is at 8 p.m., a small dose in the evening “can make a huge difference. Kids will be more stable and be able to fall asleep.”

It is important to note whether the insomnia predated the stimulant use. Get a basal sleep history, Dr. Childers advised. Also recommend proper sleep hygiene. “My first question is: Is there a TV in the bedroom? The answer is always yes, and I ask them “Why?” They can't answer it.” Remove the television forever, and give the child a bath and warm milk before bedtime, he said. “That is enough for most kids.”

▸ Mistake 10: Overdiagnosis of bipolar disorder. More and more parents are coming in and saying, “My teacher, aunt, therapist, neighbor, etc. said my child has 'bipolar disorder,'” Dr. Childers remarked.

The adult prevalence of bipolar disorder is 1%–1.6%, according to a National Alliance of Mental Illness Fact Sheet, January 2004. “It's not a curable illness. Bipolar is a lifelong diagnosis. So how can 7% of children have bipolar disorder?”

A much more common diagnosis is a combination of ADHD and oppositional defiant disorder (ODD) versus bipolar disorder, Dr. Childers said. “The one big difference I always look for is a trigger to the behavior. If a parent says, 'Every time I tell him no, he has a tantrum,' it is unlikely it's bipolar disorder, and more often it's ODD.”

Dr. Childers said he tells parents that they should have three goals for their child that appropriate management of ADHD can help to achieve: a happy childhood, a successful academic experience, and out the door and independent by age 18.

Dr. Childers had no relevant financial disclosures.

The CDC's “Protect Yourself from Mosquito Bites and Dengue” patient brochure can be downloaded free at www.cdc.gov/ncidod/dvbid/dengue

MIAMI — From 1977 to 2004, there were 3,806 suspected cases of dengue imported to the United States, according to the Centers for Disease Control and Prevention.

“Many more cases probably go unreported each year because surveillance in the United States is passive and relies on physicians to recognize the disease, inquire about the patient's travel history, obtain proper diagnostic samples, and report the case,” according to the CDC.

“We are starting to see more and more cases of dengue fever,” Dr. Christian C. Patrick said at a pediatric update sponsored by Miami Children's Hospital, “particularly in south Texas.”

Following a case report of a woman in Brownsville, Tex., infected with dengue without traveling in July 2005 and an outbreak of 1,251 reported cases in Tamaulipas, Mexico, an investigation identified 24 additional cases in Texas, including 2 more infections not associated with travel (MMWR 2007;56:785–9). A review of hospitalization records revealed that 16 of 25 (64%) eventual infections in Texas developed the more serious dengue hemorrhagic fever, compared with 34 of 104 cases (33%) identified in Mexico.

Results of another study suggest dengue is endemic along the southern Texas-Mexico border (Emerg. Infect. Dis. 2007;13:1477–83). Investigators found 2% of Brownsville residents had serologic evidence of recent dengue infection, compared with 7.3% of residents in the bordering city of Matamoros in Tamaulipas in 2004. The cross-sectional survey with 600 participants also showed that 40% of Brownsville residents and 78% of Matamoros residents had a past dengue infection. Relevant mosquito larvae were found in 30% of households in both cities, they reported.

The Aedes aegypti mosquito that spreads this disease is now found throughout central and southern United States, he said.

Dr. David Morens and Dr. Anthony Fauci also described dengue and hemorrhagic fever as a potential public health threat to residents of the continental United States in a commentary in JAMA (2008; 299:214–6). Dr. Fauci is the director of the National Institute of Allergy and Infectious Diseases, where Dr. Morens is the dengue program officer.

“The range of Aedes albopictus ('Asian tiger mosquito'), a secondary dengue vector related to the classical vector, Aedes aegypti, has been expanding globally at an alarming rate. Since its introduction into the United States in 1985, Aedes albopictus has spread to 36 states,” they wrote. “Worldwide, dengue is among the most important reemerging infectious diseases with an estimated 50 million to 100 million annual cases and, by WHO [World Health Organization] estimates, 22,000 deaths, mostly in children.”

“We don't talk much about [dengue] in the United States, but we have it in our differential,” said Dr. Patrick, chief medical officer and senior vice president for medical and academic affairs, Miami Children's Hospital.

In 1997–1998, there were 18 cases of confirmed imported dengue reported in Florida, higher than the previously reported 10-year mean of 1.3 cases per year (MMWR 1999;48:1150–2).

The incubation period for dengue fever generally is 4–7 days after a mosquito bite (range, 3–14 days), with a characteristic high fever. “Temperature and the virus go hand in hand,” Dr. Patrick said.

Infected patients also typically experience abrupt headaches, retrobulbar eye pain, marked muscle and joint pain, and a variety of rashes, both macular and maculopapular. Respiratory symptoms include cough, sore throat, and congestion; each is observed in approximately one-third of patients, he said.

A meeting attendee asked how Dr. Patrick would decide which patients to test. “There are a lot of patients who do not have dengue fever. But the retrobulbar pain is pretty distinctive.” Epidemiology also is helpful, he said, and recommended testing any patient with a febrile illness who has traveled to a high-risk region within 2 weeks of presentation.

The differential diagnosis includes influenza, typhoid fever, malaria, measles, and rubella.

Diagnosis of dengue is mainly serology based. An IgM immunoassay is recommended, although the timing can be tricky. Most people present while acutely febrile, a time when the IgM serology usually is negative, Dr. Patrick said.

Leucopenia and thrombocytopenia also indicate dengue infection, as does transaminase values 2–5 times the upper limit of normal.

Dengue fever is the most common mosquito-borne viral disease. The A. aegypti mosquito is a daytime biter that resides near domestic areas. A secondary vector, the A. albopictus mosquito, is a more aggressive biter and is better adapted to colder environments. This characteristic may portend a shift in the epidemiology of dengue northward, Dr. Patrick said.

Vaccines to prevent dengue infection are in preclinical trials. Although an immunized person could have lifelong protection, dengue is an RNA virus with four distinct subtypes.

The CDC's “Protect Yourself from Mosquito Bites and Dengue” patient brochure can be downloaded free at www.cdc.gov/ncidod/dvbid/dengue

MIAMI — From 1977 to 2004, there were 3,806 suspected cases of dengue imported to the United States, according to the Centers for Disease Control and Prevention.

“Many more cases probably go unreported each year because surveillance in the United States is passive and relies on physicians to recognize the disease, inquire about the patient's travel history, obtain proper diagnostic samples, and report the case,” according to the CDC.

“We are starting to see more and more cases of dengue fever,” Dr. Christian C. Patrick said at a pediatric update sponsored by Miami Children's Hospital, “particularly in south Texas.”

Following a case report of a woman in Brownsville, Tex., infected with dengue without traveling in July 2005 and an outbreak of 1,251 reported cases in Tamaulipas, Mexico, an investigation identified 24 additional cases in Texas, including 2 more infections not associated with travel (MMWR 2007;56:785–9). A review of hospitalization records revealed that 16 of 25 (64%) eventual infections in Texas developed the more serious dengue hemorrhagic fever, compared with 34 of 104 cases (33%) identified in Mexico.

Results of another study suggest dengue is endemic along the southern Texas-Mexico border (Emerg. Infect. Dis. 2007;13:1477–83). Investigators found 2% of Brownsville residents had serologic evidence of recent dengue infection, compared with 7.3% of residents in the bordering city of Matamoros in Tamaulipas in 2004. The cross-sectional survey with 600 participants also showed that 40% of Brownsville residents and 78% of Matamoros residents had a past dengue infection. Relevant mosquito larvae were found in 30% of households in both cities, they reported.

The Aedes aegypti mosquito that spreads this disease is now found throughout central and southern United States, he said.

Dr. David Morens and Dr. Anthony Fauci also described dengue and hemorrhagic fever as a potential public health threat to residents of the continental United States in a commentary in JAMA (2008; 299:214–6). Dr. Fauci is the director of the National Institute of Allergy and Infectious Diseases, where Dr. Morens is the dengue program officer.

“The range of Aedes albopictus ('Asian tiger mosquito'), a secondary dengue vector related to the classical vector, Aedes aegypti, has been expanding globally at an alarming rate. Since its introduction into the United States in 1985, Aedes albopictus has spread to 36 states,” they wrote. “Worldwide, dengue is among the most important reemerging infectious diseases with an estimated 50 million to 100 million annual cases and, by WHO [World Health Organization] estimates, 22,000 deaths, mostly in children.”

“We don't talk much about [dengue] in the United States, but we have it in our differential,” said Dr. Patrick, chief medical officer and senior vice president for medical and academic affairs, Miami Children's Hospital.

In 1997–1998, there were 18 cases of confirmed imported dengue reported in Florida, higher than the previously reported 10-year mean of 1.3 cases per year (MMWR 1999;48:1150–2).

The incubation period for dengue fever generally is 4–7 days after a mosquito bite (range, 3–14 days), with a characteristic high fever. “Temperature and the virus go hand in hand,” Dr. Patrick said.

Infected patients also typically experience abrupt headaches, retrobulbar eye pain, marked muscle and joint pain, and a variety of rashes, both macular and maculopapular. Respiratory symptoms include cough, sore throat, and congestion; each is observed in approximately one-third of patients, he said.

A meeting attendee asked how Dr. Patrick would decide which patients to test. “There are a lot of patients who do not have dengue fever. But the retrobulbar pain is pretty distinctive.” Epidemiology also is helpful, he said, and recommended testing any patient with a febrile illness who has traveled to a high-risk region within 2 weeks of presentation.

The differential diagnosis includes influenza, typhoid fever, malaria, measles, and rubella.

Diagnosis of dengue is mainly serology based. An IgM immunoassay is recommended, although the timing can be tricky. Most people present while acutely febrile, a time when the IgM serology usually is negative, Dr. Patrick said.

Leucopenia and thrombocytopenia also indicate dengue infection, as does transaminase values 2–5 times the upper limit of normal.

Dengue fever is the most common mosquito-borne viral disease. The A. aegypti mosquito is a daytime biter that resides near domestic areas. A secondary vector, the A. albopictus mosquito, is a more aggressive biter and is better adapted to colder environments. This characteristic may portend a shift in the epidemiology of dengue northward, Dr. Patrick said.

Vaccines to prevent dengue infection are in preclinical trials. Although an immunized person could have lifelong protection, dengue is an RNA virus with four distinct subtypes.

The CDC's “Protect Yourself from Mosquito Bites and Dengue” patient brochure can be downloaded free at www.cdc.gov/ncidod/dvbid/dengue

MIAMI — From 1977 to 2004, there were 3,806 suspected cases of dengue imported to the United States, according to the Centers for Disease Control and Prevention.

“Many more cases probably go unreported each year because surveillance in the United States is passive and relies on physicians to recognize the disease, inquire about the patient's travel history, obtain proper diagnostic samples, and report the case,” according to the CDC.

“We are starting to see more and more cases of dengue fever,” Dr. Christian C. Patrick said at a pediatric update sponsored by Miami Children's Hospital, “particularly in south Texas.”

Following a case report of a woman in Brownsville, Tex., infected with dengue without traveling in July 2005 and an outbreak of 1,251 reported cases in Tamaulipas, Mexico, an investigation identified 24 additional cases in Texas, including 2 more infections not associated with travel (MMWR 2007;56:785–9). A review of hospitalization records revealed that 16 of 25 (64%) eventual infections in Texas developed the more serious dengue hemorrhagic fever, compared with 34 of 104 cases (33%) identified in Mexico.

Results of another study suggest dengue is endemic along the southern Texas-Mexico border (Emerg. Infect. Dis. 2007;13:1477–83). Investigators found 2% of Brownsville residents had serologic evidence of recent dengue infection, compared with 7.3% of residents in the bordering city of Matamoros in Tamaulipas in 2004. The cross-sectional survey with 600 participants also showed that 40% of Brownsville residents and 78% of Matamoros residents had a past dengue infection. Relevant mosquito larvae were found in 30% of households in both cities, they reported.

The Aedes aegypti mosquito that spreads this disease is now found throughout central and southern United States, he said.

Dr. David Morens and Dr. Anthony Fauci also described dengue and hemorrhagic fever as a potential public health threat to residents of the continental United States in a commentary in JAMA (2008; 299:214–6). Dr. Fauci is the director of the National Institute of Allergy and Infectious Diseases, where Dr. Morens is the dengue program officer.

“The range of Aedes albopictus ('Asian tiger mosquito'), a secondary dengue vector related to the classical vector, Aedes aegypti, has been expanding globally at an alarming rate. Since its introduction into the United States in 1985, Aedes albopictus has spread to 36 states,” they wrote. “Worldwide, dengue is among the most important reemerging infectious diseases with an estimated 50 million to 100 million annual cases and, by WHO [World Health Organization] estimates, 22,000 deaths, mostly in children.”

“We don't talk much about [dengue] in the United States, but we have it in our differential,” said Dr. Patrick, chief medical officer and senior vice president for medical and academic affairs, Miami Children's Hospital.

In 1997–1998, there were 18 cases of confirmed imported dengue reported in Florida, higher than the previously reported 10-year mean of 1.3 cases per year (MMWR 1999;48:1150–2).

The incubation period for dengue fever generally is 4–7 days after a mosquito bite (range, 3–14 days), with a characteristic high fever. “Temperature and the virus go hand in hand,” Dr. Patrick said.

Infected patients also typically experience abrupt headaches, retrobulbar eye pain, marked muscle and joint pain, and a variety of rashes, both macular and maculopapular. Respiratory symptoms include cough, sore throat, and congestion; each is observed in approximately one-third of patients, he said.

A meeting attendee asked how Dr. Patrick would decide which patients to test. “There are a lot of patients who do not have dengue fever. But the retrobulbar pain is pretty distinctive.” Epidemiology also is helpful, he said, and recommended testing any patient with a febrile illness who has traveled to a high-risk region within 2 weeks of presentation.

The differential diagnosis includes influenza, typhoid fever, malaria, measles, and rubella.

Diagnosis of dengue is mainly serology based. An IgM immunoassay is recommended, although the timing can be tricky. Most people present while acutely febrile, a time when the IgM serology usually is negative, Dr. Patrick said.

Leucopenia and thrombocytopenia also indicate dengue infection, as does transaminase values 2–5 times the upper limit of normal.

Dengue fever is the most common mosquito-borne viral disease. The A. aegypti mosquito is a daytime biter that resides near domestic areas. A secondary vector, the A. albopictus mosquito, is a more aggressive biter and is better adapted to colder environments. This characteristic may portend a shift in the epidemiology of dengue northward, Dr. Patrick said.

Vaccines to prevent dengue infection are in preclinical trials. Although an immunized person could have lifelong protection, dengue is an RNA virus with four distinct subtypes.

MIAMI — A "progressive discipline" system of warnings and suggestions for improvement before firing an underperforming employee maximizes chances of winning a wrongful termination lawsuit, according to a labor and employee attorney.

In addition, perform regular and honest performance evaluations and keep all employee documents under lock and key. "I suggest to my clients that they do not fire someone until there is enough of a paper trail," said Chad K. Lang, a labor and employee attorney practicing in Miami.

"Progressive discipline … is about fairness. The No. 1 reason employees file lawsuits is they believe they were not treated fairly, regardless of how many warnings you gave them. They truly believe they are right," Mr. Lang said. There is no legal requirement for progressive discipline, but it will look "very fair to a jury." It will be perceived as, "We gave them benefit of the doubt, they chose not to listen, and we had to let them go."

Avoid oral warnings about performance, Mr. Lang said. But if an initial warning is spoken, document it in writing afterward. Write, for example, I met with him on this date, we discussed this, and this is what I asked him to improve. E-mail is acceptable. For example, send an e-mail stating, "Thank you for meeting with me today. This is what we discussed."

Subsequent warnings are more formal and always should be in writing, Mr. Lang said at a pediatric update sponsored by Miami Children's Hospital.

Have a witness in the room when presenting an employee with a written performance warning, Mr. Lang suggested. "A lot of people do these in a closed-door situation." The presence of a manager or supervisor is recommended, preferably one of the same gender as the employee in question to avoid allegations of sexual harassment before termination.

Link the written warning to prior oral discussions and require the employee to sign and date it. "A lot of times, people remember the signature but forget to date it," Mr. Lang said. "They might countersue and say they signed it at different time." If an employee refuses to sign the written warning, note this, sign and date it, and have witness do the same. "The witness does not need to say a word. They are observers, so if it comes down to it, it does not become a 'he said, she said' situation."

Employees also should sign an employee handbook acknowledgment form, Mr. Lang said. "An employee will most likely lie and say [she] never received it."

A written company policy should state that these progressive steps are a guideline and, in some instances, there will be immediate termination, Mr. Lang said. The employee handbook should include an "at-will" employee policy. This implies there is no contract for you to keep them.

Honest, written performance evaluations for all employees are another protection against a future lawsuit, Mr. Lang said. "A lukewarm evaluation will not help if you fire them for doing a poor job. If you are going to take the time to do these, tell the truth and be accurate."

Many employers tie evaluation scores to salary and bonus pay. It will look inconsistent to a judge or jury, however, if an underperformer gets the same raise as another employee doing well. "If it goes to disposition, they will ask why you gave an underperformer a raise in the first place, and then why was it equal to someone you did not fire," Mr. Lang said.

Praise and criticism are not mutually exclusive. Recognize tasks they are doing well in their performance evaluations, Mr. Lang said. Use objective criteria and standards when possible, and include an improvement plan for underperformers. It can state, for example, that within 30 days or 60 days they have 'X' and 'Y' to do. "Improvement plans are good and they are objective."

In addition, "I highly recommend you keep the documents under lock and key," Mr. Lang said. Often, employees know when their firing is coming, and, a day or 2 beforehand their personnel files miraculously disappear.

A final piece of advice is to have a specific document retention strategy in your office policies, Mr. Lang said. "This is where lawsuits are won and lost nowadays." It is advantageous, for example, to state that all e-mail messages are automatically deleted after 6 months or 1 year. Otherwise, a judge or jury can deem failure to preserve electronic records "willful spoliation." "Adverse jury inference instructs the jury to assume the spoliation of documents presumes they were harmful to the defendant's case."

MIAMI — A "progressive discipline" system of warnings and suggestions for improvement before firing an underperforming employee maximizes chances of winning a wrongful termination lawsuit, according to a labor and employee attorney.

In addition, perform regular and honest performance evaluations and keep all employee documents under lock and key. "I suggest to my clients that they do not fire someone until there is enough of a paper trail," said Chad K. Lang, a labor and employee attorney practicing in Miami.

"Progressive discipline … is about fairness. The No. 1 reason employees file lawsuits is they believe they were not treated fairly, regardless of how many warnings you gave them. They truly believe they are right," Mr. Lang said. There is no legal requirement for progressive discipline, but it will look "very fair to a jury." It will be perceived as, "We gave them benefit of the doubt, they chose not to listen, and we had to let them go."

Avoid oral warnings about performance, Mr. Lang said. But if an initial warning is spoken, document it in writing afterward. Write, for example, I met with him on this date, we discussed this, and this is what I asked him to improve. E-mail is acceptable. For example, send an e-mail stating, "Thank you for meeting with me today. This is what we discussed."

Subsequent warnings are more formal and always should be in writing, Mr. Lang said at a pediatric update sponsored by Miami Children's Hospital.

Have a witness in the room when presenting an employee with a written performance warning, Mr. Lang suggested. "A lot of people do these in a closed-door situation." The presence of a manager or supervisor is recommended, preferably one of the same gender as the employee in question to avoid allegations of sexual harassment before termination.

Link the written warning to prior oral discussions and require the employee to sign and date it. "A lot of times, people remember the signature but forget to date it," Mr. Lang said. "They might countersue and say they signed it at different time." If an employee refuses to sign the written warning, note this, sign and date it, and have witness do the same. "The witness does not need to say a word. They are observers, so if it comes down to it, it does not become a 'he said, she said' situation."

Employees also should sign an employee handbook acknowledgment form, Mr. Lang said. "An employee will most likely lie and say [she] never received it."

A written company policy should state that these progressive steps are a guideline and, in some instances, there will be immediate termination, Mr. Lang said. The employee handbook should include an "at-will" employee policy. This implies there is no contract for you to keep them.

Honest, written performance evaluations for all employees are another protection against a future lawsuit, Mr. Lang said. "A lukewarm evaluation will not help if you fire them for doing a poor job. If you are going to take the time to do these, tell the truth and be accurate."

Many employers tie evaluation scores to salary and bonus pay. It will look inconsistent to a judge or jury, however, if an underperformer gets the same raise as another employee doing well. "If it goes to disposition, they will ask why you gave an underperformer a raise in the first place, and then why was it equal to someone you did not fire," Mr. Lang said.

Praise and criticism are not mutually exclusive. Recognize tasks they are doing well in their performance evaluations, Mr. Lang said. Use objective criteria and standards when possible, and include an improvement plan for underperformers. It can state, for example, that within 30 days or 60 days they have 'X' and 'Y' to do. "Improvement plans are good and they are objective."

In addition, "I highly recommend you keep the documents under lock and key," Mr. Lang said. Often, employees know when their firing is coming, and, a day or 2 beforehand their personnel files miraculously disappear.

A final piece of advice is to have a specific document retention strategy in your office policies, Mr. Lang said. "This is where lawsuits are won and lost nowadays." It is advantageous, for example, to state that all e-mail messages are automatically deleted after 6 months or 1 year. Otherwise, a judge or jury can deem failure to preserve electronic records "willful spoliation." "Adverse jury inference instructs the jury to assume the spoliation of documents presumes they were harmful to the defendant's case."

MIAMI — A "progressive discipline" system of warnings and suggestions for improvement before firing an underperforming employee maximizes chances of winning a wrongful termination lawsuit, according to a labor and employee attorney.

In addition, perform regular and honest performance evaluations and keep all employee documents under lock and key. "I suggest to my clients that they do not fire someone until there is enough of a paper trail," said Chad K. Lang, a labor and employee attorney practicing in Miami.

"Progressive discipline … is about fairness. The No. 1 reason employees file lawsuits is they believe they were not treated fairly, regardless of how many warnings you gave them. They truly believe they are right," Mr. Lang said. There is no legal requirement for progressive discipline, but it will look "very fair to a jury." It will be perceived as, "We gave them benefit of the doubt, they chose not to listen, and we had to let them go."

Avoid oral warnings about performance, Mr. Lang said. But if an initial warning is spoken, document it in writing afterward. Write, for example, I met with him on this date, we discussed this, and this is what I asked him to improve. E-mail is acceptable. For example, send an e-mail stating, "Thank you for meeting with me today. This is what we discussed."

Subsequent warnings are more formal and always should be in writing, Mr. Lang said at a pediatric update sponsored by Miami Children's Hospital.

Have a witness in the room when presenting an employee with a written performance warning, Mr. Lang suggested. "A lot of people do these in a closed-door situation." The presence of a manager or supervisor is recommended, preferably one of the same gender as the employee in question to avoid allegations of sexual harassment before termination.

Link the written warning to prior oral discussions and require the employee to sign and date it. "A lot of times, people remember the signature but forget to date it," Mr. Lang said. "They might countersue and say they signed it at different time." If an employee refuses to sign the written warning, note this, sign and date it, and have witness do the same. "The witness does not need to say a word. They are observers, so if it comes down to it, it does not become a 'he said, she said' situation."

Employees also should sign an employee handbook acknowledgment form, Mr. Lang said. "An employee will most likely lie and say [she] never received it."

A written company policy should state that these progressive steps are a guideline and, in some instances, there will be immediate termination, Mr. Lang said. The employee handbook should include an "at-will" employee policy. This implies there is no contract for you to keep them.

Honest, written performance evaluations for all employees are another protection against a future lawsuit, Mr. Lang said. "A lukewarm evaluation will not help if you fire them for doing a poor job. If you are going to take the time to do these, tell the truth and be accurate."

Many employers tie evaluation scores to salary and bonus pay. It will look inconsistent to a judge or jury, however, if an underperformer gets the same raise as another employee doing well. "If it goes to disposition, they will ask why you gave an underperformer a raise in the first place, and then why was it equal to someone you did not fire," Mr. Lang said.

Praise and criticism are not mutually exclusive. Recognize tasks they are doing well in their performance evaluations, Mr. Lang said. Use objective criteria and standards when possible, and include an improvement plan for underperformers. It can state, for example, that within 30 days or 60 days they have 'X' and 'Y' to do. "Improvement plans are good and they are objective."

In addition, "I highly recommend you keep the documents under lock and key," Mr. Lang said. Often, employees know when their firing is coming, and, a day or 2 beforehand their personnel files miraculously disappear.

A final piece of advice is to have a specific document retention strategy in your office policies, Mr. Lang said. "This is where lawsuits are won and lost nowadays." It is advantageous, for example, to state that all e-mail messages are automatically deleted after 6 months or 1 year. Otherwise, a judge or jury can deem failure to preserve electronic records "willful spoliation." "Adverse jury inference instructs the jury to assume the spoliation of documents presumes they were harmful to the defendant's case."

MIAMI — Minimizing exposure to employee lawsuits—including sexual harassment and discrimination claims—begins with hiring the right employee for your office, according to Chad K. Lang.

Fairness and consistency are important. Always treat one office assistant to the same raises, benefits, and time off as another. "Doctors' offices are small, and there are no secrets," said Mr. Lang, a labor and employee attorney practicing in Miami.

"I am here to help you deal with a commodity you deal with every day—your employees," Mr. Lang said at a pediatric update sponsored by Miami Children's Hospital. "They can be your greatest asset or your greatest nightmare."

Laws concerning labor and employment are about much more than worker's compensation. The only law that may not apply to a small practitioner is the Family and Medical Leave Act, which only applies to staff with a minimum of 50 employees. Although federal law generally applies to firms or practices with 15 or more employees, discrimination law applies to those with only 5.

Prevention is the best strategy. Mr. Lang recommends that you look under a microscope at every employment decision you make. He estimated that about 90% of all employee disputes are caused by 10% of employees.

Avoid general employment application forms; customize one with questions relevant to work in a medical practice, he said. Also, train interviewers to spot facial expressions that indicate lying or shading of the truth. "What if you find out 6 months later someone you hired was jailed for embezzlement? You need to know enough about employment law so you can recognize a red flag and know [when] to call someone to help."

Fairness, documentation, and consistency—"those three words can win a lawsuit," Mr. Lang continued.

There cannot be discrimination if a physician treats all employees the same. "But if you give one person a $10,000 raise and the other a $5,000 raise … everyone will know about it. When that person leaves, whether [they leave] voluntarily or not, they sue," Mr. Lang said. "And most attorneys work on a contingency fee, so there is no cost to the employee."

Wage-hour audits are another fairness issue. "You need to have someone figure out if you are treating your employees correctly. Are they truly exempt from overtime?" Mr. Lang said. "Let's say you pay someone $60,000 per year. Are they entitled to overtime? It depends on their job description."

Wage-hour audits are the No. 1 legal issue that companies face in the United States, Mr. Lang said. Beginning in 2001, the number of wage-hour class action lawsuits surpassed the number of class actions for race, sex, national origin, color, religion, and age in federal courts—combined.

Mr. Lang also addressed the perils of dating in the workplace. "I have three sexual harassment cases now based solely on a supervisor dating a subordinate," he said. "What do you think a subordinate employee will do if they are fired? They will sue, and most likely they will win."

Some employers have policies that address dating in the workplace. "What has recently become a trend that I cannot believe is a 'love contract,'" Mr. Lang said. Some companies allow workers to date but they have to inform the employer when a relationship develops. Also, they are required to sign a contract stating that they are not being coerced.

Once a year, hire an expert to train your office managers about harassment and discrimination, Mr. Lang suggested. "Why? It's an insurance policy," he said.

An employee handbook with a specific process for making sexual harassment complaints is recommended. Complaints should be made to at least two people—one of each gender—listed in the handbook by job title instead of name. This will ensure that an employee has someone to talk with besides the person doing the alleged harassment.

A meeting attendee asked Mr. Lang about his fees. "I charge about $2,000-$2,500 to develop a new handbook or revise one. A 3-hour training once a year costs about $1,000," Mr. Lang said. His rates as a law firm partner range from $250/hour to $350/hour. He also has trained associates who charge less per hour for consultation.

Another element of legal protection is, not surprisingly, "documentation, documentation, documentation," Mr. Lang said. "But do not write down anything you do not want someone to read. This sounds like something your grandmother would tell you."

Never assume your e-mail, text message, or instant message (IM) is not going to be exhibit No. 1 in a lawsuit, Mr. Lang said. "Good employment lawyers have great experts that will get e-mails and IMs. Do not assume they are gone after you delete them."

Mr. Lang's last piece of advice was "know a good employment lawyer."

MIAMI — Minimizing exposure to employee lawsuits—including sexual harassment and discrimination claims—begins with hiring the right employee for your office, according to Chad K. Lang.

Fairness and consistency are important. Always treat one office assistant to the same raises, benefits, and time off as another. "Doctors' offices are small, and there are no secrets," said Mr. Lang, a labor and employee attorney practicing in Miami.

"I am here to help you deal with a commodity you deal with every day—your employees," Mr. Lang said at a pediatric update sponsored by Miami Children's Hospital. "They can be your greatest asset or your greatest nightmare."

Laws concerning labor and employment are about much more than worker's compensation. The only law that may not apply to a small practitioner is the Family and Medical Leave Act, which only applies to staff with a minimum of 50 employees. Although federal law generally applies to firms or practices with 15 or more employees, discrimination law applies to those with only 5.

Prevention is the best strategy. Mr. Lang recommends that you look under a microscope at every employment decision you make. He estimated that about 90% of all employee disputes are caused by 10% of employees.

Avoid general employment application forms; customize one with questions relevant to work in a medical practice, he said. Also, train interviewers to spot facial expressions that indicate lying or shading of the truth. "What if you find out 6 months later someone you hired was jailed for embezzlement? You need to know enough about employment law so you can recognize a red flag and know [when] to call someone to help."

Fairness, documentation, and consistency—"those three words can win a lawsuit," Mr. Lang continued.

There cannot be discrimination if a physician treats all employees the same. "But if you give one person a $10,000 raise and the other a $5,000 raise … everyone will know about it. When that person leaves, whether [they leave] voluntarily or not, they sue," Mr. Lang said. "And most attorneys work on a contingency fee, so there is no cost to the employee."

Wage-hour audits are another fairness issue. "You need to have someone figure out if you are treating your employees correctly. Are they truly exempt from overtime?" Mr. Lang said. "Let's say you pay someone $60,000 per year. Are they entitled to overtime? It depends on their job description."

Wage-hour audits are the No. 1 legal issue that companies face in the United States, Mr. Lang said. Beginning in 2001, the number of wage-hour class action lawsuits surpassed the number of class actions for race, sex, national origin, color, religion, and age in federal courts—combined.

Mr. Lang also addressed the perils of dating in the workplace. "I have three sexual harassment cases now based solely on a supervisor dating a subordinate," he said. "What do you think a subordinate employee will do if they are fired? They will sue, and most likely they will win."

Some employers have policies that address dating in the workplace. "What has recently become a trend that I cannot believe is a 'love contract,'" Mr. Lang said. Some companies allow workers to date but they have to inform the employer when a relationship develops. Also, they are required to sign a contract stating that they are not being coerced.

Once a year, hire an expert to train your office managers about harassment and discrimination, Mr. Lang suggested. "Why? It's an insurance policy," he said.

An employee handbook with a specific process for making sexual harassment complaints is recommended. Complaints should be made to at least two people—one of each gender—listed in the handbook by job title instead of name. This will ensure that an employee has someone to talk with besides the person doing the alleged harassment.

A meeting attendee asked Mr. Lang about his fees. "I charge about $2,000-$2,500 to develop a new handbook or revise one. A 3-hour training once a year costs about $1,000," Mr. Lang said. His rates as a law firm partner range from $250/hour to $350/hour. He also has trained associates who charge less per hour for consultation.

Another element of legal protection is, not surprisingly, "documentation, documentation, documentation," Mr. Lang said. "But do not write down anything you do not want someone to read. This sounds like something your grandmother would tell you."

Never assume your e-mail, text message, or instant message (IM) is not going to be exhibit No. 1 in a lawsuit, Mr. Lang said. "Good employment lawyers have great experts that will get e-mails and IMs. Do not assume they are gone after you delete them."

Mr. Lang's last piece of advice was "know a good employment lawyer."

MIAMI — Minimizing exposure to employee lawsuits—including sexual harassment and discrimination claims—begins with hiring the right employee for your office, according to Chad K. Lang.

Fairness and consistency are important. Always treat one office assistant to the same raises, benefits, and time off as another. "Doctors' offices are small, and there are no secrets," said Mr. Lang, a labor and employee attorney practicing in Miami.

"I am here to help you deal with a commodity you deal with every day—your employees," Mr. Lang said at a pediatric update sponsored by Miami Children's Hospital. "They can be your greatest asset or your greatest nightmare."

Laws concerning labor and employment are about much more than worker's compensation. The only law that may not apply to a small practitioner is the Family and Medical Leave Act, which only applies to staff with a minimum of 50 employees. Although federal law generally applies to firms or practices with 15 or more employees, discrimination law applies to those with only 5.

Prevention is the best strategy. Mr. Lang recommends that you look under a microscope at every employment decision you make. He estimated that about 90% of all employee disputes are caused by 10% of employees.

Avoid general employment application forms; customize one with questions relevant to work in a medical practice, he said. Also, train interviewers to spot facial expressions that indicate lying or shading of the truth. "What if you find out 6 months later someone you hired was jailed for embezzlement? You need to know enough about employment law so you can recognize a red flag and know [when] to call someone to help."

Fairness, documentation, and consistency—"those three words can win a lawsuit," Mr. Lang continued.

There cannot be discrimination if a physician treats all employees the same. "But if you give one person a $10,000 raise and the other a $5,000 raise … everyone will know about it. When that person leaves, whether [they leave] voluntarily or not, they sue," Mr. Lang said. "And most attorneys work on a contingency fee, so there is no cost to the employee."

Wage-hour audits are another fairness issue. "You need to have someone figure out if you are treating your employees correctly. Are they truly exempt from overtime?" Mr. Lang said. "Let's say you pay someone $60,000 per year. Are they entitled to overtime? It depends on their job description."

Wage-hour audits are the No. 1 legal issue that companies face in the United States, Mr. Lang said. Beginning in 2001, the number of wage-hour class action lawsuits surpassed the number of class actions for race, sex, national origin, color, religion, and age in federal courts—combined.

Mr. Lang also addressed the perils of dating in the workplace. "I have three sexual harassment cases now based solely on a supervisor dating a subordinate," he said. "What do you think a subordinate employee will do if they are fired? They will sue, and most likely they will win."

Some employers have policies that address dating in the workplace. "What has recently become a trend that I cannot believe is a 'love contract,'" Mr. Lang said. Some companies allow workers to date but they have to inform the employer when a relationship develops. Also, they are required to sign a contract stating that they are not being coerced.

Once a year, hire an expert to train your office managers about harassment and discrimination, Mr. Lang suggested. "Why? It's an insurance policy," he said.

An employee handbook with a specific process for making sexual harassment complaints is recommended. Complaints should be made to at least two people—one of each gender—listed in the handbook by job title instead of name. This will ensure that an employee has someone to talk with besides the person doing the alleged harassment.

A meeting attendee asked Mr. Lang about his fees. "I charge about $2,000-$2,500 to develop a new handbook or revise one. A 3-hour training once a year costs about $1,000," Mr. Lang said. His rates as a law firm partner range from $250/hour to $350/hour. He also has trained associates who charge less per hour for consultation.

Another element of legal protection is, not surprisingly, "documentation, documentation, documentation," Mr. Lang said. "But do not write down anything you do not want someone to read. This sounds like something your grandmother would tell you."

Never assume your e-mail, text message, or instant message (IM) is not going to be exhibit No. 1 in a lawsuit, Mr. Lang said. "Good employment lawyers have great experts that will get e-mails and IMs. Do not assume they are gone after you delete them."

Mr. Lang's last piece of advice was "know a good employment lawyer."

MIAMI BEACH — An unbelievable or inconsistent explanation for bruises, fractures, head trauma, or burns in a child is among the red flags that raise suspicion of physical abuse, said Dr. Joseph A. Zenel.

Bruises left by abuse can appear on the soft tissue of the face, chest, abdomen, buttocks, ears, neck, genital areas, and inner thighs. Infants not old enough to walk with multiple, uniform soft tissue bruises in particular might be victims of abuse (Arch. Dis. Child. 2005;90:182–9).

Another tip is to look for multiple bruises that appear on more than one plane, said Dr. Zenel, who is on the pediatrics faculty at Oregon Health and Science University, Portland. The majority of accidental bruises appear over bony prominences, he added.

A trauma history that changes over time or is inconsistent, as well as evidence of multiple injuries at various healing stages, are other red flags for abuse, Dr. Zenel said. Estimation of the timing of a bruise based on appearance, especially within the first 24 hours of injury, can be highly inaccurate (Pediatrics 2003;112:804–7).

Clinical suspicion, physical examination, and a variety of imaging modalities contribute to the diagnosis of child abuse. A CT or MRI of the head may be indicated because about 50% of abuse is associated with head trauma, Dr. Zenel said. A depressed skull fracture, a diastatic fracture greater than 3 mm wide, a nonparietal fracture, and any fracture associated with intracranial hemorrhage raise the suspicion of abuse.

In a study of 152 children less than 2 years of age with traumatic brain injuries, 80 (53%) were confirmed abuse cases (Pediatrics 2004;114:633–9). Those with inflicted injury were more likely to present with no external signs of trauma, subdural hematoma, cerebral edema, seizures, and rib, long bone, or metaphyseal fractures than those with accidental injuries.

"Suspect inflicted head trauma in any acute neurologic deterioration in an otherwise healthy infant or child," Dr. Zenel said at the annual Masters of Pediatrics conference sponsored by the University of Miami.

In a study of 81 adults who admitted abuse, 56% were the fathers, 16% were the mothers' boyfriends, 15% were the mothers, 5% were female babysitters, and the remainder were "other" perpetrators (Arch. Pediatr. Adolesc. Med. 2004;158:454–8). The perpetrator may be a person you do not suspect, he said.

A skeletal survey and retinal examination should be considered part of the physical examination depending on the pattern or number of injuries. In addition, a bone scan is warranted in some cases, Dr. Zenel said. Skeletal trauma is the second most common sign of physical child abuse, he said, particularly in infants younger than 18 months of age.

Researchers found that isolated femoral fractures were rarely associated with abuse, accounting for 9% of fractures among 139 children under age 4 years (J. Pediatr. Orthop. 2000:20:475–81). Patient age was the most significant predictor associated with abuse in this report: 10 (42%) of 24 non-walking-age children were abused versus 3 (3%) of 115 walking-age children.

Evaluation of the child by social services should include assessment of other children in the household, Dr. Zenel said. Physicians have an obligation to report suspected child abuse.

Recommended laboratory tests in a suspected abuse case include complete blood count, prothrombin time/partial prothrombin time assay, liver function test, and amylase assay, Dr. Zenel said.

Inflicted burns associated with child abuse are typically a result of discipline or punishment, he said. Clinical presentation is typically deeper burns in a more symmetrical pattern versus accidental burns. A stocking or glove distribution is another sign of a potentially inflicted burn.

While not physical abuse, neglect is the leading form of maltreatment of children, Dr. Zenel said. Neglect accounts for more than half of reports made to child welfare authorities. Delays in health care, failure to thrive, hunger, apathy, inadequate hygiene, homelessness, inadequate clothing, and unmet educational needs are among the leading signs of neglect.

The American Academy of Pediatrics provides additional information on child abuse and neglect for providers and parents. Visit www.aap.org/healthtopics/childabuse.cfm

MIAMI BEACH — An unbelievable or inconsistent explanation for bruises, fractures, head trauma, or burns in a child is among the red flags that raise suspicion of physical abuse, said Dr. Joseph A. Zenel.

Bruises left by abuse can appear on the soft tissue of the face, chest, abdomen, buttocks, ears, neck, genital areas, and inner thighs. Infants not old enough to walk with multiple, uniform soft tissue bruises in particular might be victims of abuse (Arch. Dis. Child. 2005;90:182–9).

Another tip is to look for multiple bruises that appear on more than one plane, said Dr. Zenel, who is on the pediatrics faculty at Oregon Health and Science University, Portland. The majority of accidental bruises appear over bony prominences, he added.

A trauma history that changes over time or is inconsistent, as well as evidence of multiple injuries at various healing stages, are other red flags for abuse, Dr. Zenel said. Estimation of the timing of a bruise based on appearance, especially within the first 24 hours of injury, can be highly inaccurate (Pediatrics 2003;112:804–7).

Clinical suspicion, physical examination, and a variety of imaging modalities contribute to the diagnosis of child abuse. A CT or MRI of the head may be indicated because about 50% of abuse is associated with head trauma, Dr. Zenel said. A depressed skull fracture, a diastatic fracture greater than 3 mm wide, a nonparietal fracture, and any fracture associated with intracranial hemorrhage raise the suspicion of abuse.

In a study of 152 children less than 2 years of age with traumatic brain injuries, 80 (53%) were confirmed abuse cases (Pediatrics 2004;114:633–9). Those with inflicted injury were more likely to present with no external signs of trauma, subdural hematoma, cerebral edema, seizures, and rib, long bone, or metaphyseal fractures than those with accidental injuries.

"Suspect inflicted head trauma in any acute neurologic deterioration in an otherwise healthy infant or child," Dr. Zenel said at the annual Masters of Pediatrics conference sponsored by the University of Miami.

In a study of 81 adults who admitted abuse, 56% were the fathers, 16% were the mothers' boyfriends, 15% were the mothers, 5% were female babysitters, and the remainder were "other" perpetrators (Arch. Pediatr. Adolesc. Med. 2004;158:454–8). The perpetrator may be a person you do not suspect, he said.

A skeletal survey and retinal examination should be considered part of the physical examination depending on the pattern or number of injuries. In addition, a bone scan is warranted in some cases, Dr. Zenel said. Skeletal trauma is the second most common sign of physical child abuse, he said, particularly in infants younger than 18 months of age.

Researchers found that isolated femoral fractures were rarely associated with abuse, accounting for 9% of fractures among 139 children under age 4 years (J. Pediatr. Orthop. 2000:20:475–81). Patient age was the most significant predictor associated with abuse in this report: 10 (42%) of 24 non-walking-age children were abused versus 3 (3%) of 115 walking-age children.

Evaluation of the child by social services should include assessment of other children in the household, Dr. Zenel said. Physicians have an obligation to report suspected child abuse.

Recommended laboratory tests in a suspected abuse case include complete blood count, prothrombin time/partial prothrombin time assay, liver function test, and amylase assay, Dr. Zenel said.

Inflicted burns associated with child abuse are typically a result of discipline or punishment, he said. Clinical presentation is typically deeper burns in a more symmetrical pattern versus accidental burns. A stocking or glove distribution is another sign of a potentially inflicted burn.

While not physical abuse, neglect is the leading form of maltreatment of children, Dr. Zenel said. Neglect accounts for more than half of reports made to child welfare authorities. Delays in health care, failure to thrive, hunger, apathy, inadequate hygiene, homelessness, inadequate clothing, and unmet educational needs are among the leading signs of neglect.

The American Academy of Pediatrics provides additional information on child abuse and neglect for providers and parents. Visit www.aap.org/healthtopics/childabuse.cfm

MIAMI BEACH — An unbelievable or inconsistent explanation for bruises, fractures, head trauma, or burns in a child is among the red flags that raise suspicion of physical abuse, said Dr. Joseph A. Zenel.

Bruises left by abuse can appear on the soft tissue of the face, chest, abdomen, buttocks, ears, neck, genital areas, and inner thighs. Infants not old enough to walk with multiple, uniform soft tissue bruises in particular might be victims of abuse (Arch. Dis. Child. 2005;90:182–9).

Another tip is to look for multiple bruises that appear on more than one plane, said Dr. Zenel, who is on the pediatrics faculty at Oregon Health and Science University, Portland. The majority of accidental bruises appear over bony prominences, he added.

A trauma history that changes over time or is inconsistent, as well as evidence of multiple injuries at various healing stages, are other red flags for abuse, Dr. Zenel said. Estimation of the timing of a bruise based on appearance, especially within the first 24 hours of injury, can be highly inaccurate (Pediatrics 2003;112:804–7).

Clinical suspicion, physical examination, and a variety of imaging modalities contribute to the diagnosis of child abuse. A CT or MRI of the head may be indicated because about 50% of abuse is associated with head trauma, Dr. Zenel said. A depressed skull fracture, a diastatic fracture greater than 3 mm wide, a nonparietal fracture, and any fracture associated with intracranial hemorrhage raise the suspicion of abuse.

In a study of 152 children less than 2 years of age with traumatic brain injuries, 80 (53%) were confirmed abuse cases (Pediatrics 2004;114:633–9). Those with inflicted injury were more likely to present with no external signs of trauma, subdural hematoma, cerebral edema, seizures, and rib, long bone, or metaphyseal fractures than those with accidental injuries.

"Suspect inflicted head trauma in any acute neurologic deterioration in an otherwise healthy infant or child," Dr. Zenel said at the annual Masters of Pediatrics conference sponsored by the University of Miami.

In a study of 81 adults who admitted abuse, 56% were the fathers, 16% were the mothers' boyfriends, 15% were the mothers, 5% were female babysitters, and the remainder were "other" perpetrators (Arch. Pediatr. Adolesc. Med. 2004;158:454–8). The perpetrator may be a person you do not suspect, he said.

A skeletal survey and retinal examination should be considered part of the physical examination depending on the pattern or number of injuries. In addition, a bone scan is warranted in some cases, Dr. Zenel said. Skeletal trauma is the second most common sign of physical child abuse, he said, particularly in infants younger than 18 months of age.

Researchers found that isolated femoral fractures were rarely associated with abuse, accounting for 9% of fractures among 139 children under age 4 years (J. Pediatr. Orthop. 2000:20:475–81). Patient age was the most significant predictor associated with abuse in this report: 10 (42%) of 24 non-walking-age children were abused versus 3 (3%) of 115 walking-age children.

Evaluation of the child by social services should include assessment of other children in the household, Dr. Zenel said. Physicians have an obligation to report suspected child abuse.

Recommended laboratory tests in a suspected abuse case include complete blood count, prothrombin time/partial prothrombin time assay, liver function test, and amylase assay, Dr. Zenel said.

Inflicted burns associated with child abuse are typically a result of discipline or punishment, he said. Clinical presentation is typically deeper burns in a more symmetrical pattern versus accidental burns. A stocking or glove distribution is another sign of a potentially inflicted burn.

While not physical abuse, neglect is the leading form of maltreatment of children, Dr. Zenel said. Neglect accounts for more than half of reports made to child welfare authorities. Delays in health care, failure to thrive, hunger, apathy, inadequate hygiene, homelessness, inadequate clothing, and unmet educational needs are among the leading signs of neglect.

The American Academy of Pediatrics provides additional information on child abuse and neglect for providers and parents. Visit www.aap.org/healthtopics/childabuse.cfm

FORT LAUDERDALE, FLA. — Ask patients in an open-minded way about their use of unconventional therapies related to asthma, allergies, and other pulmonary conditions.

“The take-home message is 'beware of being unaware,'” Dr. Cheryl Doyle said at a pediatric pulmonology meeting sponsored by the American College of Chest Physicians. Otherwise, drug or disease interactions, unnecessary testing or changes in therapy, and therapeutic failures can result.

“It's a tremendous act of faith and [cooperation] to integrate complementary and conventional [therapies], when not contraindicated,” said Dr. Doyle, a pediatric pulmonologist in private practice in Brooklyn, N.Y. She had no relevant financial disclosures.

The term “complementary medicine” has evolved into “integrative holistic medicine,” because “complementary” assigns an adjunctive role to nonconventional medicine, she said. “Healing addresses the body, mind, and spirit, and we as healers—not providers—are part of that system.”

Integrative holistic medicine includes six systems: biomolecular therapies; botanical therapies; ethnic/cultural therapies; homeopathic remedies; manual therapies such as massage, yoga, and chiropractic treatment; and energy therapies such as reflexology, the laying-on of hands, and manipulation of people's auras.

Different cultures have different nonconventional therapies. In traditional Chinese medicine, asthma therapies include ma huang, ginkgo biloba, ginseng, magnolia, Minor Blue Dragon, Scutellaria, cinnamon, and licorice. Ma huang, for example, is an acrid herb believed to open pores, facilitate lung qi (energy), and control wheezing, Dr. Doyle said, adding that it controls wheezing because “about 80%-90% [of the herb] is L-ephedrine, a ?-agonist that relaxes smooth muscle.” It also contains D-pseudoephedrine, L-methylephedrine, L-norepinephrine, and D-N-methyl pseudoephedrine.

Albuterol, for instance, could attenuate the ma huang side effects, which include increased heart rate, increased blood pressure, palpitations, nervousness, headache, insomnia, and dizziness.

Ginkgo biloba is commonly used in Europe for asthma, Dr. Doyle said. It is an expectorant and bronchodilator, and a treatment for coughing and wheezing when combined with Ephedra, apricot seed, and Morus alba root. The leaf extract contains ginkgetin, which inhibits histamine-induced bronchoconstriction.

Panax ginseng, also known as Korean ginseng, “tonifies the lungs” and is said to enhance qi; it is used to treat wheezing, shortness of breath, and dyspnea on exertion, Dr. Doyle said. The root is used for cough, and the leaves are used as emetics and expectorants. Animal studies show ginseng is an anti-inflammatory that decreases IgE serum levels.

Although Hispanic people come from different countries and backgrounds, they share some common medical beliefs. Religion, faith, and spiritual healing are an integral part of their health and well-being, Dr. Doyle said. Opposing properties of illness and treatment are another common tenet so that a “cold” disease, such as asthma, is treated with “hot” remedies, she said.

Unconventional Hispanic treatments are sometimes administered in combination as “zumas” or syrup mixtures. For example, the Siete Jarabes (Seven Syrups) contain honey syrup, sweet almond oil, castor oil, wild cherry, licorice, honey, and cocillana (a bark used for bronchitis). Because of the honey components, Dr. Doyle asked, “Wouldn't you want to know if a 3-year-old is getting sick on this?”

African/Caribbean therapies include the consumption of raw onion to treat asthma, chest colds, and persistent cough. Onion, or Allium cepa, contains quercetin, an anti-inflammatory used for allergic rhinitis.

The understanding and acceptance of nonconventional therapies can go a long way to help patients. “It would be nice for us to return to our mission as physicians,” Dr. Doyle said, quoting Dr. Harold S. Jenkins: “The truly competent physician is the one who sits down, senses the 'mystery' of another human being, and offers with an open hand the simple gifts of personal interest and understanding” (JAMA 2002;287:161-2).

FORT LAUDERDALE, FLA. — Ask patients in an open-minded way about their use of unconventional therapies related to asthma, allergies, and other pulmonary conditions.

“The take-home message is 'beware of being unaware,'” Dr. Cheryl Doyle said at a pediatric pulmonology meeting sponsored by the American College of Chest Physicians. Otherwise, drug or disease interactions, unnecessary testing or changes in therapy, and therapeutic failures can result.

“It's a tremendous act of faith and [cooperation] to integrate complementary and conventional [therapies], when not contraindicated,” said Dr. Doyle, a pediatric pulmonologist in private practice in Brooklyn, N.Y. She had no relevant financial disclosures.

The term “complementary medicine” has evolved into “integrative holistic medicine,” because “complementary” assigns an adjunctive role to nonconventional medicine, she said. “Healing addresses the body, mind, and spirit, and we as healers—not providers—are part of that system.”

Integrative holistic medicine includes six systems: biomolecular therapies; botanical therapies; ethnic/cultural therapies; homeopathic remedies; manual therapies such as massage, yoga, and chiropractic treatment; and energy therapies such as reflexology, the laying-on of hands, and manipulation of people's auras.

Different cultures have different nonconventional therapies. In traditional Chinese medicine, asthma therapies include ma huang, ginkgo biloba, ginseng, magnolia, Minor Blue Dragon, Scutellaria, cinnamon, and licorice. Ma huang, for example, is an acrid herb believed to open pores, facilitate lung qi (energy), and control wheezing, Dr. Doyle said, adding that it controls wheezing because “about 80%-90% [of the herb] is L-ephedrine, a ?-agonist that relaxes smooth muscle.” It also contains D-pseudoephedrine, L-methylephedrine, L-norepinephrine, and D-N-methyl pseudoephedrine.

Albuterol, for instance, could attenuate the ma huang side effects, which include increased heart rate, increased blood pressure, palpitations, nervousness, headache, insomnia, and dizziness.

Ginkgo biloba is commonly used in Europe for asthma, Dr. Doyle said. It is an expectorant and bronchodilator, and a treatment for coughing and wheezing when combined with Ephedra, apricot seed, and Morus alba root. The leaf extract contains ginkgetin, which inhibits histamine-induced bronchoconstriction.

Panax ginseng, also known as Korean ginseng, “tonifies the lungs” and is said to enhance qi; it is used to treat wheezing, shortness of breath, and dyspnea on exertion, Dr. Doyle said. The root is used for cough, and the leaves are used as emetics and expectorants. Animal studies show ginseng is an anti-inflammatory that decreases IgE serum levels.

Although Hispanic people come from different countries and backgrounds, they share some common medical beliefs. Religion, faith, and spiritual healing are an integral part of their health and well-being, Dr. Doyle said. Opposing properties of illness and treatment are another common tenet so that a “cold” disease, such as asthma, is treated with “hot” remedies, she said.

Unconventional Hispanic treatments are sometimes administered in combination as “zumas” or syrup mixtures. For example, the Siete Jarabes (Seven Syrups) contain honey syrup, sweet almond oil, castor oil, wild cherry, licorice, honey, and cocillana (a bark used for bronchitis). Because of the honey components, Dr. Doyle asked, “Wouldn't you want to know if a 3-year-old is getting sick on this?”

African/Caribbean therapies include the consumption of raw onion to treat asthma, chest colds, and persistent cough. Onion, or Allium cepa, contains quercetin, an anti-inflammatory used for allergic rhinitis.

The understanding and acceptance of nonconventional therapies can go a long way to help patients. “It would be nice for us to return to our mission as physicians,” Dr. Doyle said, quoting Dr. Harold S. Jenkins: “The truly competent physician is the one who sits down, senses the 'mystery' of another human being, and offers with an open hand the simple gifts of personal interest and understanding” (JAMA 2002;287:161-2).

FORT LAUDERDALE, FLA. — Ask patients in an open-minded way about their use of unconventional therapies related to asthma, allergies, and other pulmonary conditions.

“The take-home message is 'beware of being unaware,'” Dr. Cheryl Doyle said at a pediatric pulmonology meeting sponsored by the American College of Chest Physicians. Otherwise, drug or disease interactions, unnecessary testing or changes in therapy, and therapeutic failures can result.

“It's a tremendous act of faith and [cooperation] to integrate complementary and conventional [therapies], when not contraindicated,” said Dr. Doyle, a pediatric pulmonologist in private practice in Brooklyn, N.Y. She had no relevant financial disclosures.

The term “complementary medicine” has evolved into “integrative holistic medicine,” because “complementary” assigns an adjunctive role to nonconventional medicine, she said. “Healing addresses the body, mind, and spirit, and we as healers—not providers—are part of that system.”

Integrative holistic medicine includes six systems: biomolecular therapies; botanical therapies; ethnic/cultural therapies; homeopathic remedies; manual therapies such as massage, yoga, and chiropractic treatment; and energy therapies such as reflexology, the laying-on of hands, and manipulation of people's auras.

Different cultures have different nonconventional therapies. In traditional Chinese medicine, asthma therapies include ma huang, ginkgo biloba, ginseng, magnolia, Minor Blue Dragon, Scutellaria, cinnamon, and licorice. Ma huang, for example, is an acrid herb believed to open pores, facilitate lung qi (energy), and control wheezing, Dr. Doyle said, adding that it controls wheezing because “about 80%-90% [of the herb] is L-ephedrine, a ?-agonist that relaxes smooth muscle.” It also contains D-pseudoephedrine, L-methylephedrine, L-norepinephrine, and D-N-methyl pseudoephedrine.

Albuterol, for instance, could attenuate the ma huang side effects, which include increased heart rate, increased blood pressure, palpitations, nervousness, headache, insomnia, and dizziness.

Ginkgo biloba is commonly used in Europe for asthma, Dr. Doyle said. It is an expectorant and bronchodilator, and a treatment for coughing and wheezing when combined with Ephedra, apricot seed, and Morus alba root. The leaf extract contains ginkgetin, which inhibits histamine-induced bronchoconstriction.

Panax ginseng, also known as Korean ginseng, “tonifies the lungs” and is said to enhance qi; it is used to treat wheezing, shortness of breath, and dyspnea on exertion, Dr. Doyle said. The root is used for cough, and the leaves are used as emetics and expectorants. Animal studies show ginseng is an anti-inflammatory that decreases IgE serum levels.

Although Hispanic people come from different countries and backgrounds, they share some common medical beliefs. Religion, faith, and spiritual healing are an integral part of their health and well-being, Dr. Doyle said. Opposing properties of illness and treatment are another common tenet so that a “cold” disease, such as asthma, is treated with “hot” remedies, she said.

Unconventional Hispanic treatments are sometimes administered in combination as “zumas” or syrup mixtures. For example, the Siete Jarabes (Seven Syrups) contain honey syrup, sweet almond oil, castor oil, wild cherry, licorice, honey, and cocillana (a bark used for bronchitis). Because of the honey components, Dr. Doyle asked, “Wouldn't you want to know if a 3-year-old is getting sick on this?”

African/Caribbean therapies include the consumption of raw onion to treat asthma, chest colds, and persistent cough. Onion, or Allium cepa, contains quercetin, an anti-inflammatory used for allergic rhinitis.

The understanding and acceptance of nonconventional therapies can go a long way to help patients. “It would be nice for us to return to our mission as physicians,” Dr. Doyle said, quoting Dr. Harold S. Jenkins: “The truly competent physician is the one who sits down, senses the 'mystery' of another human being, and offers with an open hand the simple gifts of personal interest and understanding” (JAMA 2002;287:161-2).

FORT LAUDERDALE, FLA. — More children with pneumonia are developing necrotizing pneumonia from an increasing variety of infectious agents, including methicillin-resistant Staphylococcus aureus, according to a retrospective, 15-year study.

“Necrotizing pneumonia is real,” Dr. Andrew Colin said, noting that if a child has a persistent fever that does not respond to treatment for 3 or more weeks, along with pleural effusions suggesting community-acquired pneumonia, consider coexisting necrotizing pneumonia.

Multiple organisms are playing a role, “including a lot of necrotizing pneumonias [in which] we do not know the organism. These could be mycoplasma,” said Dr. Colin, director of the division of pediatric pulmonology, Holtz Children's Hospital at the University of Miami/Jackson Memorial Medical Center in Florida.

Of 80 patients, 38 (48%) had positive cultures. Streptococcus pneumoniae was the predominant organism, although more recently there was a variety of organisms responsible, most notably methicillin-resistant Staphylococcus aureus (MRSA), Dr. Colin said at a pediatric pulmonology meeting sponsored by the American College of Chest Physicians.

Dr. Colin and his associates found an increasing incidence of necrotizing pneumonia from January 1990 to February 2005 at Children's Hospital Boston (Eur. Respir. J. 2008 Jan. 23 [Epub ahead of print]). Of 80 cases identified, there was 1 case during 1993-1994; 11 each during 1995-1996 and 1997-1998; 17 cases during 1999-2000; and 12 cases during 2001-2002. “By the end of the study, years 2003-2004, we had 28 cases in one hospital, which is quite significant,” he said.

A meeting attendee asked if children at greater risk for necrotizing pneumonia can be identified. “We don't have large enough numbers to predict who will develop necrotizing pneumonia,” answered Dr. Colin, who is also professor of pediatrics at the University of Miami.

Necrotizing pneumonia presents with coexisting effusion in a majority of patients. In the study, 69 children (86%) had pleural effusion with a low pH (mean 7.08). It is clinically challenging to differentiate the signs and symptoms of necrotizing pneumonia from the effusion, Dr. Colin said.

Computed tomography with contrast is the best way to diagnosis necrotizing pneumonia. The imaging detects the characteristic features, the liquefaction and cavitation of lung tissue. Look for demarcation between lung and liquid lung, he suggested.

Another attendee asked how to differentiate a lung abscess from liquid in the lung on the imaging. “The differential diagnosis is absolutely critical,” Dr. Colin said. On the CT scan, abscesses appear with thick walls, whereas necrotizing lungs have thin walls and will collapse in a couple of days, he replied. Also, “if you tap the two, the abscess will be positive in culture, the necrotizing lung will be negative.” Although the lungs are often sterile with necrotizing pneumonia, “there are some bad bugs, so everyone gives antibiotics just in case.”

Dr. Colin advocated a conservative approach to prolonged chest tube drainage in patients who develop necrotizing pneumonia. The longer drainage continues, the greater the risk of puncturing a lung. A bronchopleural fistula is a serious complication that can substantially lengthen a hospital stay and recovery time, he added.

“Despite the serious morbidity, massive parenchymal damage, and prolonged hospitalizations, long-term outcome following necrotizing pneumonia is excellent,” wrote the authors.

In fact, all patients in the study had a complete clinical resolution within 2 months, he added. “The good news is you do not have to resect damaged lungs—these young patients have a remarkable ability to recover.”

FORT LAUDERDALE, FLA. — More children with pneumonia are developing necrotizing pneumonia from an increasing variety of infectious agents, including methicillin-resistant Staphylococcus aureus, according to a retrospective, 15-year study.

“Necrotizing pneumonia is real,” Dr. Andrew Colin said, noting that if a child has a persistent fever that does not respond to treatment for 3 or more weeks, along with pleural effusions suggesting community-acquired pneumonia, consider coexisting necrotizing pneumonia.

Multiple organisms are playing a role, “including a lot of necrotizing pneumonias [in which] we do not know the organism. These could be mycoplasma,” said Dr. Colin, director of the division of pediatric pulmonology, Holtz Children's Hospital at the University of Miami/Jackson Memorial Medical Center in Florida.

Of 80 patients, 38 (48%) had positive cultures. Streptococcus pneumoniae was the predominant organism, although more recently there was a variety of organisms responsible, most notably methicillin-resistant Staphylococcus aureus (MRSA), Dr. Colin said at a pediatric pulmonology meeting sponsored by the American College of Chest Physicians.

Dr. Colin and his associates found an increasing incidence of necrotizing pneumonia from January 1990 to February 2005 at Children's Hospital Boston (Eur. Respir. J. 2008 Jan. 23 [Epub ahead of print]). Of 80 cases identified, there was 1 case during 1993-1994; 11 each during 1995-1996 and 1997-1998; 17 cases during 1999-2000; and 12 cases during 2001-2002. “By the end of the study, years 2003-2004, we had 28 cases in one hospital, which is quite significant,” he said.

A meeting attendee asked if children at greater risk for necrotizing pneumonia can be identified. “We don't have large enough numbers to predict who will develop necrotizing pneumonia,” answered Dr. Colin, who is also professor of pediatrics at the University of Miami.

Necrotizing pneumonia presents with coexisting effusion in a majority of patients. In the study, 69 children (86%) had pleural effusion with a low pH (mean 7.08). It is clinically challenging to differentiate the signs and symptoms of necrotizing pneumonia from the effusion, Dr. Colin said.

Computed tomography with contrast is the best way to diagnosis necrotizing pneumonia. The imaging detects the characteristic features, the liquefaction and cavitation of lung tissue. Look for demarcation between lung and liquid lung, he suggested.

Another attendee asked how to differentiate a lung abscess from liquid in the lung on the imaging. “The differential diagnosis is absolutely critical,” Dr. Colin said. On the CT scan, abscesses appear with thick walls, whereas necrotizing lungs have thin walls and will collapse in a couple of days, he replied. Also, “if you tap the two, the abscess will be positive in culture, the necrotizing lung will be negative.” Although the lungs are often sterile with necrotizing pneumonia, “there are some bad bugs, so everyone gives antibiotics just in case.”

Dr. Colin advocated a conservative approach to prolonged chest tube drainage in patients who develop necrotizing pneumonia. The longer drainage continues, the greater the risk of puncturing a lung. A bronchopleural fistula is a serious complication that can substantially lengthen a hospital stay and recovery time, he added.

“Despite the serious morbidity, massive parenchymal damage, and prolonged hospitalizations, long-term outcome following necrotizing pneumonia is excellent,” wrote the authors.

In fact, all patients in the study had a complete clinical resolution within 2 months, he added. “The good news is you do not have to resect damaged lungs—these young patients have a remarkable ability to recover.”

FORT LAUDERDALE, FLA. — More children with pneumonia are developing necrotizing pneumonia from an increasing variety of infectious agents, including methicillin-resistant Staphylococcus aureus, according to a retrospective, 15-year study.

“Necrotizing pneumonia is real,” Dr. Andrew Colin said, noting that if a child has a persistent fever that does not respond to treatment for 3 or more weeks, along with pleural effusions suggesting community-acquired pneumonia, consider coexisting necrotizing pneumonia.

Multiple organisms are playing a role, “including a lot of necrotizing pneumonias [in which] we do not know the organism. These could be mycoplasma,” said Dr. Colin, director of the division of pediatric pulmonology, Holtz Children's Hospital at the University of Miami/Jackson Memorial Medical Center in Florida.

Of 80 patients, 38 (48%) had positive cultures. Streptococcus pneumoniae was the predominant organism, although more recently there was a variety of organisms responsible, most notably methicillin-resistant Staphylococcus aureus (MRSA), Dr. Colin said at a pediatric pulmonology meeting sponsored by the American College of Chest Physicians.

Dr. Colin and his associates found an increasing incidence of necrotizing pneumonia from January 1990 to February 2005 at Children's Hospital Boston (Eur. Respir. J. 2008 Jan. 23 [Epub ahead of print]). Of 80 cases identified, there was 1 case during 1993-1994; 11 each during 1995-1996 and 1997-1998; 17 cases during 1999-2000; and 12 cases during 2001-2002. “By the end of the study, years 2003-2004, we had 28 cases in one hospital, which is quite significant,” he said.

A meeting attendee asked if children at greater risk for necrotizing pneumonia can be identified. “We don't have large enough numbers to predict who will develop necrotizing pneumonia,” answered Dr. Colin, who is also professor of pediatrics at the University of Miami.

Necrotizing pneumonia presents with coexisting effusion in a majority of patients. In the study, 69 children (86%) had pleural effusion with a low pH (mean 7.08). It is clinically challenging to differentiate the signs and symptoms of necrotizing pneumonia from the effusion, Dr. Colin said.

Computed tomography with contrast is the best way to diagnosis necrotizing pneumonia. The imaging detects the characteristic features, the liquefaction and cavitation of lung tissue. Look for demarcation between lung and liquid lung, he suggested.

Another attendee asked how to differentiate a lung abscess from liquid in the lung on the imaging. “The differential diagnosis is absolutely critical,” Dr. Colin said. On the CT scan, abscesses appear with thick walls, whereas necrotizing lungs have thin walls and will collapse in a couple of days, he replied. Also, “if you tap the two, the abscess will be positive in culture, the necrotizing lung will be negative.” Although the lungs are often sterile with necrotizing pneumonia, “there are some bad bugs, so everyone gives antibiotics just in case.”

Dr. Colin advocated a conservative approach to prolonged chest tube drainage in patients who develop necrotizing pneumonia. The longer drainage continues, the greater the risk of puncturing a lung. A bronchopleural fistula is a serious complication that can substantially lengthen a hospital stay and recovery time, he added.

“Despite the serious morbidity, massive parenchymal damage, and prolonged hospitalizations, long-term outcome following necrotizing pneumonia is excellent,” wrote the authors.

In fact, all patients in the study had a complete clinical resolution within 2 months, he added. “The good news is you do not have to resect damaged lungs—these young patients have a remarkable ability to recover.”

MIAMI — Two recent outbreaks of measles in the United States highlight the need for vaccination and vigilance for infections imported from overseas, including Europe.

“We need to be aware of the importations from Europe,” said Dr. Carol J. Baker. “Most people do not think of MMR as a travel vaccine. There is a lot of measles in Europe now.”

The Centers for Disease Control and Prevention reported both outbreaks in February 2008.

In one instance, 11 cases in San Diego County in January and February of this year were linked to a 7-year-old unvaccinated boy who was infected during a family trip to Switzerland (MMWR 2008;57:203-6).

None of the eight children he subsequently infected was vaccinated, including two siblings, two playmates from school, and four children exposed in a pediatrician's office (three were infants younger than the immunization age). Another three students at the school were secondarily infected.

About 10% of the children at his school, including those infected, were vaccine personal belief exemptors.

“If you have more and more vaccine exemptors, you will be, as a community, more susceptible to measles,” Dr. Baker said during a pediatric update sponsored by Miami Children's Hospital.

No vaccinated child exposed to the San Diego index case became infected.

Suspect measles infection for all patients who have traveled overseas and present with a fever and rash, Dr. Baker advised. In addition, “separate a suspected case from the waiting room…clean the room very well and wait a few hours [before reentering].”

An earlier outbreak of measles in August and September 2007 also was imported and associated with an unvaccinated youth. The index case was a 12-year-old boy from Japan who attended an International Youth event in Pennsylvania (MMWR 2008;57:169-73).

A multistate investigation identified seven additional measles infections in Pennsylvania, Michigan, and Texas, including six confirmed from the index case using genetic sequencing.

Estimated attendance at the event was 265,000 and included teams from Canada, Chinese Taipei, Curaçao, the Netherlands, Venezuela, Mexico, Saudi Arabia, and Japan. The coaches and boys, who were aged 10-13 years, were housed in the same compound during the event, according to the CDC report.

“If you hear one of your patients is going to one of these events, make sure they are vaccinated,” said Dr. Baker, professor of pediatrics and molecular neurology and microbiology at Baylor College of Medicine, Houston.

“This outbreak highlights the need to maintain the highest possible vaccination coverage in the United States, along with disease surveillance and outbreak-containment capabilities,” the CDC investigators wrote.

At press time, the CDC reported that from January through April 25, 2008, 64 reports of confirmed measles cases were received from nine states, in which outbreaks were ongoing in four (Arizona, Michigan, New York, and Wisconsin).

A total of 59 cases occurred in U.S. residents, and 54 were associated with the importation of measles from other countries. In all but one case, patients were unvaccinated or had unknown vaccination status. In all, 43 (67%) of the patients were less than 19 years of age and 32 (50%) were less than 4 years old.

'Most people do not think of MMR as a travel vaccine. There is a lot of measles in Europe right now.' DR. BAKER

MIAMI — Two recent outbreaks of measles in the United States highlight the need for vaccination and vigilance for infections imported from overseas, including Europe.

“We need to be aware of the importations from Europe,” said Dr. Carol J. Baker. “Most people do not think of MMR as a travel vaccine. There is a lot of measles in Europe now.”

The Centers for Disease Control and Prevention reported both outbreaks in February 2008.

In one instance, 11 cases in San Diego County in January and February of this year were linked to a 7-year-old unvaccinated boy who was infected during a family trip to Switzerland (MMWR 2008;57:203-6).

None of the eight children he subsequently infected was vaccinated, including two siblings, two playmates from school, and four children exposed in a pediatrician's office (three were infants younger than the immunization age). Another three students at the school were secondarily infected.

About 10% of the children at his school, including those infected, were vaccine personal belief exemptors.

“If you have more and more vaccine exemptors, you will be, as a community, more susceptible to measles,” Dr. Baker said during a pediatric update sponsored by Miami Children's Hospital.

No vaccinated child exposed to the San Diego index case became infected.

Suspect measles infection for all patients who have traveled overseas and present with a fever and rash, Dr. Baker advised. In addition, “separate a suspected case from the waiting room…clean the room very well and wait a few hours [before reentering].”

An earlier outbreak of measles in August and September 2007 also was imported and associated with an unvaccinated youth. The index case was a 12-year-old boy from Japan who attended an International Youth event in Pennsylvania (MMWR 2008;57:169-73).

A multistate investigation identified seven additional measles infections in Pennsylvania, Michigan, and Texas, including six confirmed from the index case using genetic sequencing.

Estimated attendance at the event was 265,000 and included teams from Canada, Chinese Taipei, Curaçao, the Netherlands, Venezuela, Mexico, Saudi Arabia, and Japan. The coaches and boys, who were aged 10-13 years, were housed in the same compound during the event, according to the CDC report.

“If you hear one of your patients is going to one of these events, make sure they are vaccinated,” said Dr. Baker, professor of pediatrics and molecular neurology and microbiology at Baylor College of Medicine, Houston.

“This outbreak highlights the need to maintain the highest possible vaccination coverage in the United States, along with disease surveillance and outbreak-containment capabilities,” the CDC investigators wrote.

At press time, the CDC reported that from January through April 25, 2008, 64 reports of confirmed measles cases were received from nine states, in which outbreaks were ongoing in four (Arizona, Michigan, New York, and Wisconsin).

A total of 59 cases occurred in U.S. residents, and 54 were associated with the importation of measles from other countries. In all but one case, patients were unvaccinated or had unknown vaccination status. In all, 43 (67%) of the patients were less than 19 years of age and 32 (50%) were less than 4 years old.

'Most people do not think of MMR as a travel vaccine. There is a lot of measles in Europe right now.' DR. BAKER

MIAMI — Two recent outbreaks of measles in the United States highlight the need for vaccination and vigilance for infections imported from overseas, including Europe.

“We need to be aware of the importations from Europe,” said Dr. Carol J. Baker. “Most people do not think of MMR as a travel vaccine. There is a lot of measles in Europe now.”

The Centers for Disease Control and Prevention reported both outbreaks in February 2008.

In one instance, 11 cases in San Diego County in January and February of this year were linked to a 7-year-old unvaccinated boy who was infected during a family trip to Switzerland (MMWR 2008;57:203-6).

None of the eight children he subsequently infected was vaccinated, including two siblings, two playmates from school, and four children exposed in a pediatrician's office (three were infants younger than the immunization age). Another three students at the school were secondarily infected.

About 10% of the children at his school, including those infected, were vaccine personal belief exemptors.

“If you have more and more vaccine exemptors, you will be, as a community, more susceptible to measles,” Dr. Baker said during a pediatric update sponsored by Miami Children's Hospital.

No vaccinated child exposed to the San Diego index case became infected.

Suspect measles infection for all patients who have traveled overseas and present with a fever and rash, Dr. Baker advised. In addition, “separate a suspected case from the waiting room…clean the room very well and wait a few hours [before reentering].”

An earlier outbreak of measles in August and September 2007 also was imported and associated with an unvaccinated youth. The index case was a 12-year-old boy from Japan who attended an International Youth event in Pennsylvania (MMWR 2008;57:169-73).

A multistate investigation identified seven additional measles infections in Pennsylvania, Michigan, and Texas, including six confirmed from the index case using genetic sequencing.

Estimated attendance at the event was 265,000 and included teams from Canada, Chinese Taipei, Curaçao, the Netherlands, Venezuela, Mexico, Saudi Arabia, and Japan. The coaches and boys, who were aged 10-13 years, were housed in the same compound during the event, according to the CDC report.

“If you hear one of your patients is going to one of these events, make sure they are vaccinated,” said Dr. Baker, professor of pediatrics and molecular neurology and microbiology at Baylor College of Medicine, Houston.

“This outbreak highlights the need to maintain the highest possible vaccination coverage in the United States, along with disease surveillance and outbreak-containment capabilities,” the CDC investigators wrote.

At press time, the CDC reported that from January through April 25, 2008, 64 reports of confirmed measles cases were received from nine states, in which outbreaks were ongoing in four (Arizona, Michigan, New York, and Wisconsin).

A total of 59 cases occurred in U.S. residents, and 54 were associated with the importation of measles from other countries. In all but one case, patients were unvaccinated or had unknown vaccination status. In all, 43 (67%) of the patients were less than 19 years of age and 32 (50%) were less than 4 years old.

'Most people do not think of MMR as a travel vaccine. There is a lot of measles in Europe right now.' DR. BAKER

MIAMI — Absence epilepsy seizures can be differentiated from daydreaming or ADHD with an office procedure involving nothing more than a piece of paper.

“Hyperventilate the child by having them blow on a paper or on their own, and you will see loss of consciousness [if they have absence epilepsy],” said Dr. Michael S. Duchowny. “It's a very easy thing to do in your office.”

In the absence of a piece of paper, one tip is an obvious onset and offset of the transient loss of consciousness characteristic of absence seizures. “You cannot snap the child out of it during an episode,” Dr. Duchowny said.

EEG can confirm the diagnosis of absence epilepsy. The readout will show bilateral, symmetric, and synchronous 3-Hz spikes and wave discharges against a normal EEG background, Dr. Duchowny said.

The age at which a child presents with absence seizures is an important consideration. Physicians who suspect a child is having absence seizures—which were formerly known as petit mal epilepsy—should rule out other conditions, said Dr. Duchowny, director of the comprehensive epilepsy program at Miami Children's Hospital.

Onset of absence seizures is usually at 5–12 years old. “A red flag should go up with any child who comes into your office before age 5 with absence seizures. This is unusual—you need to look for other developmental disorders,” Dr. Duchowny said at a meeting sponsored by Miami Children's Hospital.

First-line treatment includes antiepileptic drugs (AEDs) like ethosuximide, valproic acid, or clonazepam, Dr. Duchowny said. Newer AEDs are also effective, such as lamotrigine, levetiracetam, or topiramate. AEDS to avoid include carbamazepine, oxcarbazepine, phenytoin, and gabapentin. Dr. Duchowny received an honorarium from and is on the speakers bureau for GlaxoSmithKline Inc.

Despite timely treatment, children with absence epilepsy should be monitored for adverse psychosocial effects, Dr. Duchowny said. “If one looks long term at children with absence seizures, sometimes the outlook may not be as favorable as we think.”

For example, adults with a history of childhood absence seizures, even when they remained seizure-free, had greater difficulty with academic, social, and behavior domains, according to a cohort study (Arch. Pediatr. Adolesc. Med. 1997;151:152–8). The mean follow-up for the 58 patients in the study was 23 years.

Absence seizures can occur as a discrete seizure type or a robust epilepsy syndrome with associated symptoms. If the child has the syndrome, physicians and parents might see frequent automatisms, such as lip smacking or eye closure, especially during longer seizures.

“Absences tend to disappear around age 15 or 16 years,” Dr. Duchowny said. “You can tell families these seizures will not recur later in life. They 'time on' but they also 'time off.'” If the child experiences mixed seizure types, such as concomitant generalized tonic-clonic seizures, they can persist in some patients, he added.

Absence seizures must be the initial and most prominent type of seizure for the diagnosis of childhood absence epilepsy. “By and large, these children are neurologically healthy,” Dr. Duchowny said.

In contrast, a small subset of patients can have atypical absence seizures. Poor seizure control and persistence of epilepsy are more common with atypical seizures. “These typically occur in children with some type of associated neurologic disability,” Dr. Duchowny said. The seizures generally occur in children with development delay and often coexist with other seizure types, especially tonic-clonic, myoclonic, and tonic seizures. “These children often have a much poorer neurodevelopmental outcome, including less control of seizures, even with medication.”

MIAMI — Absence epilepsy seizures can be differentiated from daydreaming or ADHD with an office procedure involving nothing more than a piece of paper.

“Hyperventilate the child by having them blow on a paper or on their own, and you will see loss of consciousness [if they have absence epilepsy],” said Dr. Michael S. Duchowny. “It's a very easy thing to do in your office.”

In the absence of a piece of paper, one tip is an obvious onset and offset of the transient loss of consciousness characteristic of absence seizures. “You cannot snap the child out of it during an episode,” Dr. Duchowny said.

EEG can confirm the diagnosis of absence epilepsy. The readout will show bilateral, symmetric, and synchronous 3-Hz spikes and wave discharges against a normal EEG background, Dr. Duchowny said.

The age at which a child presents with absence seizures is an important consideration. Physicians who suspect a child is having absence seizures—which were formerly known as petit mal epilepsy—should rule out other conditions, said Dr. Duchowny, director of the comprehensive epilepsy program at Miami Children's Hospital.

Onset of absence seizures is usually at 5–12 years old. “A red flag should go up with any child who comes into your office before age 5 with absence seizures. This is unusual—you need to look for other developmental disorders,” Dr. Duchowny said at a meeting sponsored by Miami Children's Hospital.

First-line treatment includes antiepileptic drugs (AEDs) like ethosuximide, valproic acid, or clonazepam, Dr. Duchowny said. Newer AEDs are also effective, such as lamotrigine, levetiracetam, or topiramate. AEDS to avoid include carbamazepine, oxcarbazepine, phenytoin, and gabapentin. Dr. Duchowny received an honorarium from and is on the speakers bureau for GlaxoSmithKline Inc.

Despite timely treatment, children with absence epilepsy should be monitored for adverse psychosocial effects, Dr. Duchowny said. “If one looks long term at children with absence seizures, sometimes the outlook may not be as favorable as we think.”

For example, adults with a history of childhood absence seizures, even when they remained seizure-free, had greater difficulty with academic, social, and behavior domains, according to a cohort study (Arch. Pediatr. Adolesc. Med. 1997;151:152–8). The mean follow-up for the 58 patients in the study was 23 years.

Absence seizures can occur as a discrete seizure type or a robust epilepsy syndrome with associated symptoms. If the child has the syndrome, physicians and parents might see frequent automatisms, such as lip smacking or eye closure, especially during longer seizures.

“Absences tend to disappear around age 15 or 16 years,” Dr. Duchowny said. “You can tell families these seizures will not recur later in life. They 'time on' but they also 'time off.'” If the child experiences mixed seizure types, such as concomitant generalized tonic-clonic seizures, they can persist in some patients, he added.

Absence seizures must be the initial and most prominent type of seizure for the diagnosis of childhood absence epilepsy. “By and large, these children are neurologically healthy,” Dr. Duchowny said.

In contrast, a small subset of patients can have atypical absence seizures. Poor seizure control and persistence of epilepsy are more common with atypical seizures. “These typically occur in children with some type of associated neurologic disability,” Dr. Duchowny said. The seizures generally occur in children with development delay and often coexist with other seizure types, especially tonic-clonic, myoclonic, and tonic seizures. “These children often have a much poorer neurodevelopmental outcome, including less control of seizures, even with medication.”

MIAMI — Absence epilepsy seizures can be differentiated from daydreaming or ADHD with an office procedure involving nothing more than a piece of paper.

“Hyperventilate the child by having them blow on a paper or on their own, and you will see loss of consciousness [if they have absence epilepsy],” said Dr. Michael S. Duchowny. “It's a very easy thing to do in your office.”

In the absence of a piece of paper, one tip is an obvious onset and offset of the transient loss of consciousness characteristic of absence seizures. “You cannot snap the child out of it during an episode,” Dr. Duchowny said.

EEG can confirm the diagnosis of absence epilepsy. The readout will show bilateral, symmetric, and synchronous 3-Hz spikes and wave discharges against a normal EEG background, Dr. Duchowny said.

The age at which a child presents with absence seizures is an important consideration. Physicians who suspect a child is having absence seizures—which were formerly known as petit mal epilepsy—should rule out other conditions, said Dr. Duchowny, director of the comprehensive epilepsy program at Miami Children's Hospital.

Onset of absence seizures is usually at 5–12 years old. “A red flag should go up with any child who comes into your office before age 5 with absence seizures. This is unusual—you need to look for other developmental disorders,” Dr. Duchowny said at a meeting sponsored by Miami Children's Hospital.

First-line treatment includes antiepileptic drugs (AEDs) like ethosuximide, valproic acid, or clonazepam, Dr. Duchowny said. Newer AEDs are also effective, such as lamotrigine, levetiracetam, or topiramate. AEDS to avoid include carbamazepine, oxcarbazepine, phenytoin, and gabapentin. Dr. Duchowny received an honorarium from and is on the speakers bureau for GlaxoSmithKline Inc.

Despite timely treatment, children with absence epilepsy should be monitored for adverse psychosocial effects, Dr. Duchowny said. “If one looks long term at children with absence seizures, sometimes the outlook may not be as favorable as we think.”

For example, adults with a history of childhood absence seizures, even when they remained seizure-free, had greater difficulty with academic, social, and behavior domains, according to a cohort study (Arch. Pediatr. Adolesc. Med. 1997;151:152–8). The mean follow-up for the 58 patients in the study was 23 years.

Absence seizures can occur as a discrete seizure type or a robust epilepsy syndrome with associated symptoms. If the child has the syndrome, physicians and parents might see frequent automatisms, such as lip smacking or eye closure, especially during longer seizures.

“Absences tend to disappear around age 15 or 16 years,” Dr. Duchowny said. “You can tell families these seizures will not recur later in life. They 'time on' but they also 'time off.'” If the child experiences mixed seizure types, such as concomitant generalized tonic-clonic seizures, they can persist in some patients, he added.

Absence seizures must be the initial and most prominent type of seizure for the diagnosis of childhood absence epilepsy. “By and large, these children are neurologically healthy,” Dr. Duchowny said.

In contrast, a small subset of patients can have atypical absence seizures. Poor seizure control and persistence of epilepsy are more common with atypical seizures. “These typically occur in children with some type of associated neurologic disability,” Dr. Duchowny said. The seizures generally occur in children with development delay and often coexist with other seizure types, especially tonic-clonic, myoclonic, and tonic seizures. “These children often have a much poorer neurodevelopmental outcome, including less control of seizures, even with medication.”