Heidi Splete

A “medical home” for children means primary care as a combination of the place where care is provided, the process of care in that place, and the team of people delivering the care.

A medical home is not only about improving health and health care, but also about improving the experience of receiving and providing health care, said Dr. W. Carl Cooley, codirector of the Center for Medical Home Improvement in Greenfield, N.H.

“A medical home is not simply a program within a primary care practice, nor is it only for children with special health needs,” Dr. Cooley said. Creating a medical home for children is about practice-wide improvement that depends on being open to change and committed to listening to families and working with them to improve care. That said, children with special health issues account for about 80% of pediatric health care costs.

The model that has emerged in 21st century health care involves chronic condition management as the third leg of a primary care stool, along with preventive care and acute illness management, said Dr. Cooley. An efficient and effective process of chronic condition management in the general practice will benefit all patients in terms of office organization and quality of care.

The first step in providing chronic condition management in a medical home is to identify children with chronic conditions and special needs. If a practice creates a registry of these patients and flags their charts, their conditions are known each time the child comes in or a parent or caregiver calls. Some practices stratify patients by the severity and complexity of the child's condition. For example, on a scale of 1 to 4, 1 might be a child with mild asthma, and 4 might be a child with multiple system complications or home care services.

This type of structure ensures that children with chronic conditions are scheduled for separate visits to discuss specific issues related to chronic conditions. These visits create an opportunity to plan comanagement of the child with specialists and coordinate other aspects of care and services. The visits in the medical home might complement visits to a specialist and reinforce patient education and care strategies, Dr. Cooley said.

For example, a child with diabetes might visit a general practice regularly, alternating with visits to a diabetes clinic every 3 months. Data from the regular medical home visits could be forwarded to the specialty clinic.

In addition, a planned chronic condition management visit creates time for a nurse or nurse coordinator to update the medical history, which makes other preventive and acute visits more useful and productive.

These chronic care visits are among the easiest to bill, Dr. Cooley noted. The visit is a prolonged encounter with an established patient, and codes 99214 and 99215 are almost uniformly accepted as long as the documentation is consistent with this type of visit. “Many pediatricians underutilize the longer visit codes,” he said.

Scheduling longer visits can be difficult in a busy practice accustomed to rapid patient flow. Dr. Cooley recommends gradually blocking out certain times, such as the first hour or two after lunch on certain days, for chronic care visits. “Start with two or three patients a month and enroll them in a chronic conditions management program,” he suggested.

Grants are available to help general practices become more efficient as medical homes for children. Grantors include the Maternal and Child Health Bureau (MCHB) (www.mchb.hrsa.gov/grants/default.htmwww.ntlf.com/html/grants/122256.htm

Dr. H. Garry Gardner and his colleagues received a CATCH grant in 2004 for their primary care pediatric practice. The CATCH grants are geared toward physicians who are interested in community pediatrics. Physicians develop proposals for how they might make their practices become more community oriented and serve as medical homes for patients.

An important part of Dr. Gardner's grant proposal was the inclusion of the cost of a facilitator from the Division of Specialized Care for Children (DSCC), which is administered by the University of Illinois at Chicago, to help organize a program of caring for children with special needs. DSCC is the Title V federally funded Illinois state program for children with special health needs and disabilities. Similar programs exist under other names in other states.

“We learned through working with the facilitator that many of our patients qualified for Title V funding and they didn't know it,” Dr. Gardner said. After receiving the grant, Dr. Gardner, a pediatrician in private practice in Darien, Ill., formed an office quality improvement team. He serves as the physician representative on behalf of the physicians in the practice. The office manager, a nurse, a receptionist, and two patients' mothers complete the team, which meets monthly to discuss ways to improve the quality of care in the office.

The team established a complexity score to define children with special needs. They opted not to designate all children with ADHD or asthma as having chronic conditions. Instead, they reserved this definition for more severe problems, including diabetes, cerebral palsy, and autism.

“We literally labeled the kids by putting a sticker on the front of the chart, and an identifier on the computer screen that comes up when the name is entered,” he explained. “That identification process was important because it helped us know who the child was whenever the parent called with a question or to make an appointment,” he added. Dr. Gardner's practice currently includes 90 children with chronic conditions for whom they serve as a medical home.

Another successful project was creating a telephone script for use by the receptionist when the parent of a special needs child calls. The receptionist has a specific set of questions to ask, such as whether the visit will take extra time, or whether the child prefers to wait in a quiet exam room rather than a crowded waiting room. The office manager of the practice serves as a “care coordinator,” for these patients, and helps manage referral letters, letters of medical necessity, and insurance coverage, which removes some of the paperwork burden from the physicians. Feedback from the parents on the quality improvement team in Dr. Gardner's practice led to the creation of two additional features.

First, the office has a picture guidebook available for nonverbal patients, which includes pictures of the front door, the waiting room, the different doctors, and the different pieces of equipment. Pictures in this format, also known as picture exchange cards, are often used by parents of nonverbal autistic children, and such pictures have been shown to reassure children who might be anxious about the office visit, Dr. Gardner explained.

Second, children with chronic conditions or special needs have a written care plan, condensed to both sides of a single sheet of paper, that lists all of the child's diagnoses, medications, recent hospitalizations, therapist visits—“everything that goes on with this child,” Dr. Gardner said. “We put this page in the front of the chart, and parents have a copy that they can keep with them.”

For more information about the medical home concept and ideas for incorporating its strategies into your practice, visit www.medicalhomeimprovement.org

Creating a medical home is about practice-wide improvement and being open to change. DR. COOLEY

The definition 'chronic conditions' is for problems such as diabetes, cerebral palsy, and autism. Dr. gardner

A “medical home” for children means primary care as a combination of the place where care is provided, the process of care in that place, and the team of people delivering the care.

A medical home is not only about improving health and health care, but also about improving the experience of receiving and providing health care, said Dr. W. Carl Cooley, codirector of the Center for Medical Home Improvement in Greenfield, N.H.

“A medical home is not simply a program within a primary care practice, nor is it only for children with special health needs,” Dr. Cooley said. Creating a medical home for children is about practice-wide improvement that depends on being open to change and committed to listening to families and working with them to improve care. That said, children with special health issues account for about 80% of pediatric health care costs.

The model that has emerged in 21st century health care involves chronic condition management as the third leg of a primary care stool, along with preventive care and acute illness management, said Dr. Cooley. An efficient and effective process of chronic condition management in the general practice will benefit all patients in terms of office organization and quality of care.

The first step in providing chronic condition management in a medical home is to identify children with chronic conditions and special needs. If a practice creates a registry of these patients and flags their charts, their conditions are known each time the child comes in or a parent or caregiver calls. Some practices stratify patients by the severity and complexity of the child's condition. For example, on a scale of 1 to 4, 1 might be a child with mild asthma, and 4 might be a child with multiple system complications or home care services.

This type of structure ensures that children with chronic conditions are scheduled for separate visits to discuss specific issues related to chronic conditions. These visits create an opportunity to plan comanagement of the child with specialists and coordinate other aspects of care and services. The visits in the medical home might complement visits to a specialist and reinforce patient education and care strategies, Dr. Cooley said.

For example, a child with diabetes might visit a general practice regularly, alternating with visits to a diabetes clinic every 3 months. Data from the regular medical home visits could be forwarded to the specialty clinic.

In addition, a planned chronic condition management visit creates time for a nurse or nurse coordinator to update the medical history, which makes other preventive and acute visits more useful and productive.

These chronic care visits are among the easiest to bill, Dr. Cooley noted. The visit is a prolonged encounter with an established patient, and codes 99214 and 99215 are almost uniformly accepted as long as the documentation is consistent with this type of visit. “Many pediatricians underutilize the longer visit codes,” he said.

Scheduling longer visits can be difficult in a busy practice accustomed to rapid patient flow. Dr. Cooley recommends gradually blocking out certain times, such as the first hour or two after lunch on certain days, for chronic care visits. “Start with two or three patients a month and enroll them in a chronic conditions management program,” he suggested.

Grants are available to help general practices become more efficient as medical homes for children. Grantors include the Maternal and Child Health Bureau (MCHB) (www.mchb.hrsa.gov/grants/default.htmwww.ntlf.com/html/grants/122256.htm

Dr. H. Garry Gardner and his colleagues received a CATCH grant in 2004 for their primary care pediatric practice. The CATCH grants are geared toward physicians who are interested in community pediatrics. Physicians develop proposals for how they might make their practices become more community oriented and serve as medical homes for patients.

An important part of Dr. Gardner's grant proposal was the inclusion of the cost of a facilitator from the Division of Specialized Care for Children (DSCC), which is administered by the University of Illinois at Chicago, to help organize a program of caring for children with special needs. DSCC is the Title V federally funded Illinois state program for children with special health needs and disabilities. Similar programs exist under other names in other states.

“We learned through working with the facilitator that many of our patients qualified for Title V funding and they didn't know it,” Dr. Gardner said. After receiving the grant, Dr. Gardner, a pediatrician in private practice in Darien, Ill., formed an office quality improvement team. He serves as the physician representative on behalf of the physicians in the practice. The office manager, a nurse, a receptionist, and two patients' mothers complete the team, which meets monthly to discuss ways to improve the quality of care in the office.

The team established a complexity score to define children with special needs. They opted not to designate all children with ADHD or asthma as having chronic conditions. Instead, they reserved this definition for more severe problems, including diabetes, cerebral palsy, and autism.

“We literally labeled the kids by putting a sticker on the front of the chart, and an identifier on the computer screen that comes up when the name is entered,” he explained. “That identification process was important because it helped us know who the child was whenever the parent called with a question or to make an appointment,” he added. Dr. Gardner's practice currently includes 90 children with chronic conditions for whom they serve as a medical home.

Another successful project was creating a telephone script for use by the receptionist when the parent of a special needs child calls. The receptionist has a specific set of questions to ask, such as whether the visit will take extra time, or whether the child prefers to wait in a quiet exam room rather than a crowded waiting room. The office manager of the practice serves as a “care coordinator,” for these patients, and helps manage referral letters, letters of medical necessity, and insurance coverage, which removes some of the paperwork burden from the physicians. Feedback from the parents on the quality improvement team in Dr. Gardner's practice led to the creation of two additional features.

First, the office has a picture guidebook available for nonverbal patients, which includes pictures of the front door, the waiting room, the different doctors, and the different pieces of equipment. Pictures in this format, also known as picture exchange cards, are often used by parents of nonverbal autistic children, and such pictures have been shown to reassure children who might be anxious about the office visit, Dr. Gardner explained.

Second, children with chronic conditions or special needs have a written care plan, condensed to both sides of a single sheet of paper, that lists all of the child's diagnoses, medications, recent hospitalizations, therapist visits—“everything that goes on with this child,” Dr. Gardner said. “We put this page in the front of the chart, and parents have a copy that they can keep with them.”

For more information about the medical home concept and ideas for incorporating its strategies into your practice, visit www.medicalhomeimprovement.org

Creating a medical home is about practice-wide improvement and being open to change. DR. COOLEY

The definition 'chronic conditions' is for problems such as diabetes, cerebral palsy, and autism. Dr. gardner

A “medical home” for children means primary care as a combination of the place where care is provided, the process of care in that place, and the team of people delivering the care.

A medical home is not only about improving health and health care, but also about improving the experience of receiving and providing health care, said Dr. W. Carl Cooley, codirector of the Center for Medical Home Improvement in Greenfield, N.H.

“A medical home is not simply a program within a primary care practice, nor is it only for children with special health needs,” Dr. Cooley said. Creating a medical home for children is about practice-wide improvement that depends on being open to change and committed to listening to families and working with them to improve care. That said, children with special health issues account for about 80% of pediatric health care costs.

The model that has emerged in 21st century health care involves chronic condition management as the third leg of a primary care stool, along with preventive care and acute illness management, said Dr. Cooley. An efficient and effective process of chronic condition management in the general practice will benefit all patients in terms of office organization and quality of care.

The first step in providing chronic condition management in a medical home is to identify children with chronic conditions and special needs. If a practice creates a registry of these patients and flags their charts, their conditions are known each time the child comes in or a parent or caregiver calls. Some practices stratify patients by the severity and complexity of the child's condition. For example, on a scale of 1 to 4, 1 might be a child with mild asthma, and 4 might be a child with multiple system complications or home care services.

This type of structure ensures that children with chronic conditions are scheduled for separate visits to discuss specific issues related to chronic conditions. These visits create an opportunity to plan comanagement of the child with specialists and coordinate other aspects of care and services. The visits in the medical home might complement visits to a specialist and reinforce patient education and care strategies, Dr. Cooley said.

For example, a child with diabetes might visit a general practice regularly, alternating with visits to a diabetes clinic every 3 months. Data from the regular medical home visits could be forwarded to the specialty clinic.

In addition, a planned chronic condition management visit creates time for a nurse or nurse coordinator to update the medical history, which makes other preventive and acute visits more useful and productive.

These chronic care visits are among the easiest to bill, Dr. Cooley noted. The visit is a prolonged encounter with an established patient, and codes 99214 and 99215 are almost uniformly accepted as long as the documentation is consistent with this type of visit. “Many pediatricians underutilize the longer visit codes,” he said.

Scheduling longer visits can be difficult in a busy practice accustomed to rapid patient flow. Dr. Cooley recommends gradually blocking out certain times, such as the first hour or two after lunch on certain days, for chronic care visits. “Start with two or three patients a month and enroll them in a chronic conditions management program,” he suggested.

Grants are available to help general practices become more efficient as medical homes for children. Grantors include the Maternal and Child Health Bureau (MCHB) (www.mchb.hrsa.gov/grants/default.htmwww.ntlf.com/html/grants/122256.htm

Dr. H. Garry Gardner and his colleagues received a CATCH grant in 2004 for their primary care pediatric practice. The CATCH grants are geared toward physicians who are interested in community pediatrics. Physicians develop proposals for how they might make their practices become more community oriented and serve as medical homes for patients.

An important part of Dr. Gardner's grant proposal was the inclusion of the cost of a facilitator from the Division of Specialized Care for Children (DSCC), which is administered by the University of Illinois at Chicago, to help organize a program of caring for children with special needs. DSCC is the Title V federally funded Illinois state program for children with special health needs and disabilities. Similar programs exist under other names in other states.

“We learned through working with the facilitator that many of our patients qualified for Title V funding and they didn't know it,” Dr. Gardner said. After receiving the grant, Dr. Gardner, a pediatrician in private practice in Darien, Ill., formed an office quality improvement team. He serves as the physician representative on behalf of the physicians in the practice. The office manager, a nurse, a receptionist, and two patients' mothers complete the team, which meets monthly to discuss ways to improve the quality of care in the office.

The team established a complexity score to define children with special needs. They opted not to designate all children with ADHD or asthma as having chronic conditions. Instead, they reserved this definition for more severe problems, including diabetes, cerebral palsy, and autism.

“We literally labeled the kids by putting a sticker on the front of the chart, and an identifier on the computer screen that comes up when the name is entered,” he explained. “That identification process was important because it helped us know who the child was whenever the parent called with a question or to make an appointment,” he added. Dr. Gardner's practice currently includes 90 children with chronic conditions for whom they serve as a medical home.

Another successful project was creating a telephone script for use by the receptionist when the parent of a special needs child calls. The receptionist has a specific set of questions to ask, such as whether the visit will take extra time, or whether the child prefers to wait in a quiet exam room rather than a crowded waiting room. The office manager of the practice serves as a “care coordinator,” for these patients, and helps manage referral letters, letters of medical necessity, and insurance coverage, which removes some of the paperwork burden from the physicians. Feedback from the parents on the quality improvement team in Dr. Gardner's practice led to the creation of two additional features.

First, the office has a picture guidebook available for nonverbal patients, which includes pictures of the front door, the waiting room, the different doctors, and the different pieces of equipment. Pictures in this format, also known as picture exchange cards, are often used by parents of nonverbal autistic children, and such pictures have been shown to reassure children who might be anxious about the office visit, Dr. Gardner explained.

Second, children with chronic conditions or special needs have a written care plan, condensed to both sides of a single sheet of paper, that lists all of the child's diagnoses, medications, recent hospitalizations, therapist visits—“everything that goes on with this child,” Dr. Gardner said. “We put this page in the front of the chart, and parents have a copy that they can keep with them.”

For more information about the medical home concept and ideas for incorporating its strategies into your practice, visit www.medicalhomeimprovement.org

Creating a medical home is about practice-wide improvement and being open to change. DR. COOLEY

The definition 'chronic conditions' is for problems such as diabetes, cerebral palsy, and autism. Dr. gardner

Flu Pneumonia Rare, Mild in Children

Pneumonia was found in 14% of 936 children aged younger than 16 years with influenza, reported Dr. Elina Lahti of Turku (Finland) University Hospital and her colleagues. Nearly half (47%) of the children with both illnesses showed no specific clinical symptoms of pneumonia, and the impact of the influenza virus on the cause of pneumonia remains uncertain (Pediatr. Infect. Dis. J. 2006;25:160–4). The researchers reviewed the chest radiographs of children treated as both inpatients and outpatients in a university hospital from 1980 to 2003, including 743 cases of influenza A and 193 cases of influenza B. Pneumonia was found in 111 (15%) of children with influenza A and in 23 children (12%) with influenza B. There were no significant differences in laboratory or radiologic findings between the influenza A and B groups. Overall, 89% of the children with influenza and pneumonia had white blood cell counts below 15.0 × 109/L and 55% had C-reactive protein concentrations at normal levels or slightly increased (to less than 20 mg/L). About half of the chest radiographs showed alveolar infiltrates, which suggests viral pneumonia, the researchers noted. Almost all of the children recovered without severe adverse events, although four children required ventilator care and one 12-year-old girl with congenital muscular dystrophy died due to severe pneumonia. The findings suggest that influenza pneumonia usually is benign in children and that influenza does not significantly increase the overall burden of pneumonia in previously healthy children, Dr. Lahti and her colleagues said. However, the disease burden was greater among young children—nearly two-thirds of the children in the study were aged younger than 3 years and 75% of these children were hospitalized for their illnesses.

Climate Change Shortens RSV Season

Global warming could be curtailing the respiratory syncytial virus season in England and Wales, according to a study by Dr. Gavin C. Donaldson of University College London. The seasons associated with both respiratory syncytial virus (RSV) isolation rates in laboratories and with RSV-related emergency department admission rates in England and Wales were significantly shorter—3.1 weeks and 2.5 weeks, respectively—during 1981–2004 for laboratory RSV and 1990–2004 for patients admitted to the emergency department with bronchiolitis, compared with rates in previous years (Clin. Infect. Dis. 2006;42:677–9). Dr. Donaldson reviewed the annual mean daily temperatures recorded at four locations in order to calculate the average temperatures for central England during the study periods. Overall, the average temperature increased from 9.2° C in 1981 to 10.5° C in 2004. The start of the RSV season was defined as the first week in the year in which the number of viral isolations and hospital admissions topped an established threshold, and the end of the season was the first week of the year in which the numbers fell below that threshold. The threshold was set at 60% of each year's average weekly number of isolations and hospital admissions. The findings were essentially similar if the threshold was set at 50% or 70%, although the relationship between hospital admission and temperature was not statistically significant when the threshold was set at 50%. Despite these findings, data on the association between RSV and temperature remain contradictory.

Strep Changes Cut Rheumatic Fever

Nonrheumatogenic types of group A streptococcus may be replacing rheumatogenic types in cases of acute streptococcal pharyngitis in children, said Dr. Stanford T. Shulman of Northwestern University and his colleagues. This change could be contributing to the decline of acute rheumatic fever among children in the United States, based on a comparison of data on M-type isolates from children in Chicago during 1961–1968 with data from children from Chicago and nationwide during 2000–2004 (CID 2006;42:441–7). Several rheumatic types of group A streptococcus—3, 5, 6, 14, 18, 19, and 29—were present in nearly 50% of 468 pharyngeal isolates from the 1961–1968 period, but comprised only 11% of 450 isolates from the Chicago area and 18% of 3,969 isolates nationwide during the 2000–2004 period. In contrast, the proportion of several nonrheumatogenic types—2, 4, 22, and 28—increased significantly between the study periods, from about 5% to nearly 28% of isolates, both in Chicago and nationwide. Rheumatic types 14, 18, 19, and 29 essentially vanished during the years between the two study periods. The other most significant decreases occurred in rheumatic types 3, 5, and 6, which comprised 35% of the Chicago isolates during the first study period, when acute rheumatic fever was still prevalent, but only 10% of Chicago isolates during the second study period, when acute rheumatic fever had become rare.

Flu Pneumonia Rare, Mild in Children

Pneumonia was found in 14% of 936 children aged younger than 16 years with influenza, reported Dr. Elina Lahti of Turku (Finland) University Hospital and her colleagues. Nearly half (47%) of the children with both illnesses showed no specific clinical symptoms of pneumonia, and the impact of the influenza virus on the cause of pneumonia remains uncertain (Pediatr. Infect. Dis. J. 2006;25:160–4). The researchers reviewed the chest radiographs of children treated as both inpatients and outpatients in a university hospital from 1980 to 2003, including 743 cases of influenza A and 193 cases of influenza B. Pneumonia was found in 111 (15%) of children with influenza A and in 23 children (12%) with influenza B. There were no significant differences in laboratory or radiologic findings between the influenza A and B groups. Overall, 89% of the children with influenza and pneumonia had white blood cell counts below 15.0 × 109/L and 55% had C-reactive protein concentrations at normal levels or slightly increased (to less than 20 mg/L). About half of the chest radiographs showed alveolar infiltrates, which suggests viral pneumonia, the researchers noted. Almost all of the children recovered without severe adverse events, although four children required ventilator care and one 12-year-old girl with congenital muscular dystrophy died due to severe pneumonia. The findings suggest that influenza pneumonia usually is benign in children and that influenza does not significantly increase the overall burden of pneumonia in previously healthy children, Dr. Lahti and her colleagues said. However, the disease burden was greater among young children—nearly two-thirds of the children in the study were aged younger than 3 years and 75% of these children were hospitalized for their illnesses.

Climate Change Shortens RSV Season

Global warming could be curtailing the respiratory syncytial virus season in England and Wales, according to a study by Dr. Gavin C. Donaldson of University College London. The seasons associated with both respiratory syncytial virus (RSV) isolation rates in laboratories and with RSV-related emergency department admission rates in England and Wales were significantly shorter—3.1 weeks and 2.5 weeks, respectively—during 1981–2004 for laboratory RSV and 1990–2004 for patients admitted to the emergency department with bronchiolitis, compared with rates in previous years (Clin. Infect. Dis. 2006;42:677–9). Dr. Donaldson reviewed the annual mean daily temperatures recorded at four locations in order to calculate the average temperatures for central England during the study periods. Overall, the average temperature increased from 9.2° C in 1981 to 10.5° C in 2004. The start of the RSV season was defined as the first week in the year in which the number of viral isolations and hospital admissions topped an established threshold, and the end of the season was the first week of the year in which the numbers fell below that threshold. The threshold was set at 60% of each year's average weekly number of isolations and hospital admissions. The findings were essentially similar if the threshold was set at 50% or 70%, although the relationship between hospital admission and temperature was not statistically significant when the threshold was set at 50%. Despite these findings, data on the association between RSV and temperature remain contradictory.

Strep Changes Cut Rheumatic Fever

Nonrheumatogenic types of group A streptococcus may be replacing rheumatogenic types in cases of acute streptococcal pharyngitis in children, said Dr. Stanford T. Shulman of Northwestern University and his colleagues. This change could be contributing to the decline of acute rheumatic fever among children in the United States, based on a comparison of data on M-type isolates from children in Chicago during 1961–1968 with data from children from Chicago and nationwide during 2000–2004 (CID 2006;42:441–7). Several rheumatic types of group A streptococcus—3, 5, 6, 14, 18, 19, and 29—were present in nearly 50% of 468 pharyngeal isolates from the 1961–1968 period, but comprised only 11% of 450 isolates from the Chicago area and 18% of 3,969 isolates nationwide during the 2000–2004 period. In contrast, the proportion of several nonrheumatogenic types—2, 4, 22, and 28—increased significantly between the study periods, from about 5% to nearly 28% of isolates, both in Chicago and nationwide. Rheumatic types 14, 18, 19, and 29 essentially vanished during the years between the two study periods. The other most significant decreases occurred in rheumatic types 3, 5, and 6, which comprised 35% of the Chicago isolates during the first study period, when acute rheumatic fever was still prevalent, but only 10% of Chicago isolates during the second study period, when acute rheumatic fever had become rare.

Flu Pneumonia Rare, Mild in Children

Pneumonia was found in 14% of 936 children aged younger than 16 years with influenza, reported Dr. Elina Lahti of Turku (Finland) University Hospital and her colleagues. Nearly half (47%) of the children with both illnesses showed no specific clinical symptoms of pneumonia, and the impact of the influenza virus on the cause of pneumonia remains uncertain (Pediatr. Infect. Dis. J. 2006;25:160–4). The researchers reviewed the chest radiographs of children treated as both inpatients and outpatients in a university hospital from 1980 to 2003, including 743 cases of influenza A and 193 cases of influenza B. Pneumonia was found in 111 (15%) of children with influenza A and in 23 children (12%) with influenza B. There were no significant differences in laboratory or radiologic findings between the influenza A and B groups. Overall, 89% of the children with influenza and pneumonia had white blood cell counts below 15.0 × 109/L and 55% had C-reactive protein concentrations at normal levels or slightly increased (to less than 20 mg/L). About half of the chest radiographs showed alveolar infiltrates, which suggests viral pneumonia, the researchers noted. Almost all of the children recovered without severe adverse events, although four children required ventilator care and one 12-year-old girl with congenital muscular dystrophy died due to severe pneumonia. The findings suggest that influenza pneumonia usually is benign in children and that influenza does not significantly increase the overall burden of pneumonia in previously healthy children, Dr. Lahti and her colleagues said. However, the disease burden was greater among young children—nearly two-thirds of the children in the study were aged younger than 3 years and 75% of these children were hospitalized for their illnesses.

Climate Change Shortens RSV Season

Global warming could be curtailing the respiratory syncytial virus season in England and Wales, according to a study by Dr. Gavin C. Donaldson of University College London. The seasons associated with both respiratory syncytial virus (RSV) isolation rates in laboratories and with RSV-related emergency department admission rates in England and Wales were significantly shorter—3.1 weeks and 2.5 weeks, respectively—during 1981–2004 for laboratory RSV and 1990–2004 for patients admitted to the emergency department with bronchiolitis, compared with rates in previous years (Clin. Infect. Dis. 2006;42:677–9). Dr. Donaldson reviewed the annual mean daily temperatures recorded at four locations in order to calculate the average temperatures for central England during the study periods. Overall, the average temperature increased from 9.2° C in 1981 to 10.5° C in 2004. The start of the RSV season was defined as the first week in the year in which the number of viral isolations and hospital admissions topped an established threshold, and the end of the season was the first week of the year in which the numbers fell below that threshold. The threshold was set at 60% of each year's average weekly number of isolations and hospital admissions. The findings were essentially similar if the threshold was set at 50% or 70%, although the relationship between hospital admission and temperature was not statistically significant when the threshold was set at 50%. Despite these findings, data on the association between RSV and temperature remain contradictory.

Strep Changes Cut Rheumatic Fever

Nonrheumatogenic types of group A streptococcus may be replacing rheumatogenic types in cases of acute streptococcal pharyngitis in children, said Dr. Stanford T. Shulman of Northwestern University and his colleagues. This change could be contributing to the decline of acute rheumatic fever among children in the United States, based on a comparison of data on M-type isolates from children in Chicago during 1961–1968 with data from children from Chicago and nationwide during 2000–2004 (CID 2006;42:441–7). Several rheumatic types of group A streptococcus—3, 5, 6, 14, 18, 19, and 29—were present in nearly 50% of 468 pharyngeal isolates from the 1961–1968 period, but comprised only 11% of 450 isolates from the Chicago area and 18% of 3,969 isolates nationwide during the 2000–2004 period. In contrast, the proportion of several nonrheumatogenic types—2, 4, 22, and 28—increased significantly between the study periods, from about 5% to nearly 28% of isolates, both in Chicago and nationwide. Rheumatic types 14, 18, 19, and 29 essentially vanished during the years between the two study periods. The other most significant decreases occurred in rheumatic types 3, 5, and 6, which comprised 35% of the Chicago isolates during the first study period, when acute rheumatic fever was still prevalent, but only 10% of Chicago isolates during the second study period, when acute rheumatic fever had become rare.

A combination MMR-varicella vaccine can be substituted for the second dose of the MMR vaccine or for the second doses of coadministered MMR and varicella vaccines in children aged 4–6 years, reported Dr. Keith S. Reisinger of Primary Physicians Research in Pittsburgh, and his associates.

Dr. Reisinger and his colleagues found postvaccination seropositivity rates of nearly 100% for the combination measles, mumps, rubella, and varicella vaccine (ProQuad) in a randomized, double-blind multicenter study sponsored by Merck & Co., including 799 healthy children (Pediatrics 2006;117:265–72).

Dr. Reisinger serves as a speaker for Merck and receives research money from the company.

The children had received their primary doses of the measles, mumps, and rubella vaccine (Merck-brand MMRII vaccine) and the varicella vaccine (Varivax) at age 12 months or older at least 1 month before their enrollment in the study.

A total of 399 children received ProQuad as a single injection, plus a placebo, while 205 children received the standard MMRII plus a placebo, and 195 received MMRII plus Varivax. About half the children (53%) were male, most (79%) were white, and their mean age was 4 years.

Overall, the immune responses to all four viruses, as measured by geometric mean titers (GMTs), in children who received ProQuad were statistically similar to those in children who received the other vaccines, although there were differences in GMTs with respect to the individual viruses. The GMTs of antibodies to mumps alone were statistically lower in the ProQuad group, compared with the other groups, but the GMTs of antibodies to rubella and varicella in the ProQuad group were higher, compared with the other groups, Dr. Reisinger and his associates wrote.

No severe vaccine-related adverse events were reported, and the percentages of any adverse events were similar among the groups. The most common problems were fever, nasopharyngitis, and cough. There were no significant differences in injection-site adverse experiences in the ProQuad group, compared with the other groups.

The concentration of varicella vaccine virus was higher in the ProQuad vaccine than in the current Varivax varicella vaccine, but the concentrations of measles, mumps, and rubella viruses were the same as those in the current MMRII vaccine.

Dr. Reisinger said in an interview that the development of a combined vaccine to provide protection against four diseases—measles, mumps, rubella, and varicella (MMRV)—is an important step in children's health for a number of reasons. Although the utilization rates for MMR are approximately 93%, the rates for varicella vaccination have been significantly lower.

“The use of MMRV will increase varicella protection in a similar fashion that MMR did for lagging mumps and rubella vaccine utilization in the early ′70s. Secondly, some parents and physicians are concerned about the high number of injections that infants receive in the first 2 years of life. The use of MMRV will be helpful in reducing the number of shots,” he said.

“Although the above factors are important, the largest issue to me is the need [for the United States] to move toward a two-dose varicella policy. Every vaccine has a primary failure rate. For MMR this primary failure rate is corrected through the recommendation of two doses.

“The combination of lower utilization rates of varicella with the primary vaccine failure rate may allow many children to reach adulthood with susceptibility to varicella. Adults have a much higher rate of morbidity and mortality from a varicella infection.

“If the United States adopts a second varicella dose recommendation (as surely it must), then the combined MMRV administered at 4–6 years of age will be the vaccine of choice to accomplish this,” he said.

A combination MMR-varicella vaccine can be substituted for the second dose of the MMR vaccine or for the second doses of coadministered MMR and varicella vaccines in children aged 4–6 years, reported Dr. Keith S. Reisinger of Primary Physicians Research in Pittsburgh, and his associates.

Dr. Reisinger and his colleagues found postvaccination seropositivity rates of nearly 100% for the combination measles, mumps, rubella, and varicella vaccine (ProQuad) in a randomized, double-blind multicenter study sponsored by Merck & Co., including 799 healthy children (Pediatrics 2006;117:265–72).

Dr. Reisinger serves as a speaker for Merck and receives research money from the company.

The children had received their primary doses of the measles, mumps, and rubella vaccine (Merck-brand MMRII vaccine) and the varicella vaccine (Varivax) at age 12 months or older at least 1 month before their enrollment in the study.

A total of 399 children received ProQuad as a single injection, plus a placebo, while 205 children received the standard MMRII plus a placebo, and 195 received MMRII plus Varivax. About half the children (53%) were male, most (79%) were white, and their mean age was 4 years.

Overall, the immune responses to all four viruses, as measured by geometric mean titers (GMTs), in children who received ProQuad were statistically similar to those in children who received the other vaccines, although there were differences in GMTs with respect to the individual viruses. The GMTs of antibodies to mumps alone were statistically lower in the ProQuad group, compared with the other groups, but the GMTs of antibodies to rubella and varicella in the ProQuad group were higher, compared with the other groups, Dr. Reisinger and his associates wrote.

No severe vaccine-related adverse events were reported, and the percentages of any adverse events were similar among the groups. The most common problems were fever, nasopharyngitis, and cough. There were no significant differences in injection-site adverse experiences in the ProQuad group, compared with the other groups.

The concentration of varicella vaccine virus was higher in the ProQuad vaccine than in the current Varivax varicella vaccine, but the concentrations of measles, mumps, and rubella viruses were the same as those in the current MMRII vaccine.

Dr. Reisinger said in an interview that the development of a combined vaccine to provide protection against four diseases—measles, mumps, rubella, and varicella (MMRV)—is an important step in children's health for a number of reasons. Although the utilization rates for MMR are approximately 93%, the rates for varicella vaccination have been significantly lower.

“The use of MMRV will increase varicella protection in a similar fashion that MMR did for lagging mumps and rubella vaccine utilization in the early ′70s. Secondly, some parents and physicians are concerned about the high number of injections that infants receive in the first 2 years of life. The use of MMRV will be helpful in reducing the number of shots,” he said.

“Although the above factors are important, the largest issue to me is the need [for the United States] to move toward a two-dose varicella policy. Every vaccine has a primary failure rate. For MMR this primary failure rate is corrected through the recommendation of two doses.

“The combination of lower utilization rates of varicella with the primary vaccine failure rate may allow many children to reach adulthood with susceptibility to varicella. Adults have a much higher rate of morbidity and mortality from a varicella infection.

“If the United States adopts a second varicella dose recommendation (as surely it must), then the combined MMRV administered at 4–6 years of age will be the vaccine of choice to accomplish this,” he said.

A combination MMR-varicella vaccine can be substituted for the second dose of the MMR vaccine or for the second doses of coadministered MMR and varicella vaccines in children aged 4–6 years, reported Dr. Keith S. Reisinger of Primary Physicians Research in Pittsburgh, and his associates.

Dr. Reisinger and his colleagues found postvaccination seropositivity rates of nearly 100% for the combination measles, mumps, rubella, and varicella vaccine (ProQuad) in a randomized, double-blind multicenter study sponsored by Merck & Co., including 799 healthy children (Pediatrics 2006;117:265–72).

Dr. Reisinger serves as a speaker for Merck and receives research money from the company.

The children had received their primary doses of the measles, mumps, and rubella vaccine (Merck-brand MMRII vaccine) and the varicella vaccine (Varivax) at age 12 months or older at least 1 month before their enrollment in the study.

A total of 399 children received ProQuad as a single injection, plus a placebo, while 205 children received the standard MMRII plus a placebo, and 195 received MMRII plus Varivax. About half the children (53%) were male, most (79%) were white, and their mean age was 4 years.

Overall, the immune responses to all four viruses, as measured by geometric mean titers (GMTs), in children who received ProQuad were statistically similar to those in children who received the other vaccines, although there were differences in GMTs with respect to the individual viruses. The GMTs of antibodies to mumps alone were statistically lower in the ProQuad group, compared with the other groups, but the GMTs of antibodies to rubella and varicella in the ProQuad group were higher, compared with the other groups, Dr. Reisinger and his associates wrote.

No severe vaccine-related adverse events were reported, and the percentages of any adverse events were similar among the groups. The most common problems were fever, nasopharyngitis, and cough. There were no significant differences in injection-site adverse experiences in the ProQuad group, compared with the other groups.

The concentration of varicella vaccine virus was higher in the ProQuad vaccine than in the current Varivax varicella vaccine, but the concentrations of measles, mumps, and rubella viruses were the same as those in the current MMRII vaccine.

Dr. Reisinger said in an interview that the development of a combined vaccine to provide protection against four diseases—measles, mumps, rubella, and varicella (MMRV)—is an important step in children's health for a number of reasons. Although the utilization rates for MMR are approximately 93%, the rates for varicella vaccination have been significantly lower.

“The use of MMRV will increase varicella protection in a similar fashion that MMR did for lagging mumps and rubella vaccine utilization in the early ′70s. Secondly, some parents and physicians are concerned about the high number of injections that infants receive in the first 2 years of life. The use of MMRV will be helpful in reducing the number of shots,” he said.

“Although the above factors are important, the largest issue to me is the need [for the United States] to move toward a two-dose varicella policy. Every vaccine has a primary failure rate. For MMR this primary failure rate is corrected through the recommendation of two doses.

“The combination of lower utilization rates of varicella with the primary vaccine failure rate may allow many children to reach adulthood with susceptibility to varicella. Adults have a much higher rate of morbidity and mortality from a varicella infection.

“If the United States adopts a second varicella dose recommendation (as surely it must), then the combined MMRV administered at 4–6 years of age will be the vaccine of choice to accomplish this,” he said.

WASHINGTON — Recognize parenting strategies that hinder or support the development of healthy eating patterns, and you can help prevent obesity in toddlers, Jennifer Orlet Fisher, Ph.D., and Susan L. Johnson, Ph.D., said in a presentation at the annual meeting of the American Academy of Pediatrics.

Approximately 11% of American infants aged 0–23 months are above the 95th percentile for weight, said Dr. Fisher of Baylor College of Medicine in Houston.

Few studies of activity levels in toddlers exist, she said. The best data come from a recent study of 100 Scottish children. These data revealed that toddlers spend a majority of their time in sedentary activity followed by light activity, and surprisingly very little time is spent in moderate to vigorous activity. However, moderate to vigorous activity did not predict total energy expenditure, which suggests that light activity is the primary contributor to total energy expenditure. There was little daily variation or weekday/weekend variation.

Television watching contributes to increased sedentary time for toddlers. A national longitudinal study showed that nearly half of toddlers are watching more than 2 hours daily, and children who watched more than 2 hours as toddlers were almost three times more likely to watch more than 2 hours at age 6 years, Dr. Fisher said.

The other side of the equation is what foods toddlers eat, and where and how they eat. Toddlerhood is a time of transition to a modified adult diet, Dr. Fisher explained. “In a relatively short time you see a huge increase in the energy from table food.”

“On average, a 2-year-old's intake is 1,249 calories, which is 32% higher than the estimated daily requirement,” said Dr. Fisher.

Data from the Feeding Infants & Toddlers Study (FITS), a 2003 survey of eating patterns in more than 3,000 children aged 4–24 months conducted by Gerber, indicated that toddlers average seven eating occasions per day. Also, nearly 25% of 19- to 24-year-olds did not eat vegetables daily, and French fries were the most commonly consumed vegetable by children aged 15–24 months.

Some research has examined whether young children can adequately regulate their own energy intake. Dr. Fisher and colleagues conducted an observational study in which young children expressed preferences for the flavored beverage that had the highest energy, suggesting that energy content influenced preferences for flavor.

Data from another study of preschool children showed that children adjusted their energy intake by consuming less high-density drink when left to choose for themselves. Children are much better than adults in regulating energy intake, Dr. Fisher said.

“Opportunities to positively influence food preference begin at the earliest point in development,” she noted. She cited a study in which pregnant women consumed carrot juice during the last trimester and during early breast-feeding. Infants exposed to carrots showed better acceptance of carrot-flavored cereals on first introduction to those foods.

The influence of the environment on eating is a huge area of study; the increase in pediatric overweight can't be explained by genetics alone.

Parents have a very influential role on toddlers' eating habits, and food exposure is related to intake. If something is available and accessible in the home, children are more likely to eat it, but parents have to make the nutritious food available.

Often, well-meaning parents will reduce the variety of foods offered to children; they conclude after 3 or so presentations and rejections that the child doesn't like a particular food. In fact, evidence shows that it takes 5–10 exposures for a child to accept a novel food, Dr. Fisher said, and the number of foods liked in toddlerhood predicts the number liked at age 6–8 years.

Parents, take note: a study in 2000 showed that when adults enthusiastically modeled food, children were more likely to eat it. In addition, parents can be mindful of their feeding strategies for toddlers, including pressuring them to eat, or restricting specific foods. Some parents are controlling, while others provide minimal structure or supervision.

“We actually know very little about best practices for feeding children,” Dr. Fisher said, “but what we do know is that authoritarian feeding practices usually backfire.” Pressure to eat can create a dislike for certain foods and disrupt children's ability to regulate energy intake, and food restriction can encourage children to eat when they aren't hungry.

Doctors are strapped for time, but there are some points they can make in the office that might help parents prevent or control overweight and obesity in toddlers, said Dr. Johnson, director of the Children's Eating Laboratory at the University of Colorado, Denver.

Suggestions for parents, which may not be met with enthusiasm, include cutting down on sweetened drinks and making an effort to create a safe space in the home for toddlers to move freely, or to visit places, such as zoos, parks, or indoor play areas.

However, many physicians feel uncomfortable raising the issue of weight. No one wants to hear that their child is overweight, and especially not obese, said Dr. Johnson, who works with extremely obese pediatric patients and families in a tertiary care center. Also, in some cultures, plump babies are considered healthy, and parents don't recognize that they might be laying a foundation for childhood obesity by overfeeding their infants and toddlers.

It's also important to phrase questions about a young child's weight in a nonaccusatory way, Dr. Johnson said. Instead of saying “Your child needs to lose weight,” try asking, “Do you have any concerns about your child's weight?” Depending on the parent's response, offer some tips for reducing energy intake and increasing activity, or you may have to drop the subject for that particular visit if the family is not receptive or willing to make any changes.

A child who has exceeded the 95th percentile on growth charts can be a conversation starter. Dr. Johnson said that when she uses phrases such as “your child is growing faster than 95 of 100 children,” she can make an impact on parents. Use of sensitive language is important, however, because parents don't want to hear their children labeled as overweight or obese. Dr. Johnson uses phrases such as “Your child seems to be getting ahead of himself,” which sounds less accusatory than “your child is overweight.”

Ask parents, “What do you think is going to happen if this growth rate keeps up?” If the parent comes up with an answer, the doctor is taken out of the role of accuser, she noted. If parents get the idea at that point that their child needs to stop gaining weight so rapidly, the doctor can introduce some ways to “slow things down a bit.” If the parents don't recognize the problem, offer some information about potential health risks: “If your child continues to go on this way, here's what can happen.”

“I often start with 'is your child being teased?'” Dr. Johnson said. That gets people's attention because it's not a number or a percent; it is a painful situation for the child. Ask the parents what they want to do to mitigate the weight problem and thus cut down on the teasing. Listen to what the parents think is important, and have concrete strategies on hand to offer them.

Parents can't see how much food goes into the baby when they are breast-feeding, and some parents find security in “just topping it off” with some formula, because they can see an empty bottle. “It is important to stress that breast-feeding is enough, because the infant's growth is proceeding fine,” Dr. Johnson said.

Tips for Controlling Calories, Increasing Activity Levels

Dr. Johnson shared her tips for families about how to control calorie intake and keep toddlers from “getting ahead of themselves” in terms of weight:

▸ Cut down on sugar by avoiding sweetened beverages, except on special days.

▸ Limit juice to one-half cup per day of 100% fruit juice.

▸ Don't put juice in bottles. Promote children to a cup (not a sippy cup) by age 18 months.

▸ Find other ways to console a child besides candy. (Note to parents: granola bars are more like candy bars than “health food.”)

▸ Keep offering vegetables. Young children reject most foods on the first few tries; this behavior is not a poor reflection on parents.

▸ Choose foods in which whole grain is the first ingredient.

▸ Encourage breakfast. Breakfast provides children with cognitive benefits and prevents overweight. The number of toddlers reportedly consuming breakfast has dropped during the past two decades.

▸ Limit eating in the car. “I don't consider the car to be an eating environment,” Dr. Johnson said. It promotes overconsumption because parents can't keep track of what the child is eating, and it is unsafe, since parents behind the wheel can't help a child who starts to choke.

▸ Ask parents how many fruits and vegetables their child eats in a day, and which ones he or she likes. Help parents to focus on the ones that the child likes, and make sure these fruits and vegetables are available.

▸ Ask about both over- and underconsumption of milk. Current guidelines call for toddlers to consume 15–24 oz/day of milk; some children drink as much as 60 oz/day. You can have too much of a good thing.

▸ Teach children to serve themselves. When they do so, they tend to consume child-sized portions. This requires more patience and guidance from parents at the outset.

Dr. Johnson also offered several guidelines for promoting physical activity in toddlers:

▸ Make sure parents know about developmental milestones, such as standing and walking.

▸ Praise activity in children, and give them an opportunity to be active. Toddlers love routines; consider structured active time at a specific time during the day.

▸ Toddlers should not be sedentary for more than an hour at a time, unless they are sleeping.

▸ Create a safe area in the house where toddlers can be free to move, or take them to the zoo, park, or an indoor play area.

▸ Encourage dancing and play that is active.

Here are some questions for parents that serve as reminders:

▸ Do you, the parent, eat fruits and vegetables in front of your child? A parent's modeling of healthy eating can have a significant impact on a child's eating.

▸ Do you participate in active play with your child?

▸ Do you have family meals, in which the parents and children together eat healthy foods?

▸ Do you hide food from your children? Do they find it? All parents hide food from children, but it often doesn't work.

Sources: Susan L. Johnson, Ph.D.; Circulation 2005;112:2061–75; National Association for Sport and Physical Education Guidelines for Infants and Toddlers (

http://www.aahperd.org/NASPE/template.cfm?template=toddlers.html

WASHINGTON — Recognize parenting strategies that hinder or support the development of healthy eating patterns, and you can help prevent obesity in toddlers, Jennifer Orlet Fisher, Ph.D., and Susan L. Johnson, Ph.D., said in a presentation at the annual meeting of the American Academy of Pediatrics.

Approximately 11% of American infants aged 0–23 months are above the 95th percentile for weight, said Dr. Fisher of Baylor College of Medicine in Houston.

Few studies of activity levels in toddlers exist, she said. The best data come from a recent study of 100 Scottish children. These data revealed that toddlers spend a majority of their time in sedentary activity followed by light activity, and surprisingly very little time is spent in moderate to vigorous activity. However, moderate to vigorous activity did not predict total energy expenditure, which suggests that light activity is the primary contributor to total energy expenditure. There was little daily variation or weekday/weekend variation.

Television watching contributes to increased sedentary time for toddlers. A national longitudinal study showed that nearly half of toddlers are watching more than 2 hours daily, and children who watched more than 2 hours as toddlers were almost three times more likely to watch more than 2 hours at age 6 years, Dr. Fisher said.

The other side of the equation is what foods toddlers eat, and where and how they eat. Toddlerhood is a time of transition to a modified adult diet, Dr. Fisher explained. “In a relatively short time you see a huge increase in the energy from table food.”

“On average, a 2-year-old's intake is 1,249 calories, which is 32% higher than the estimated daily requirement,” said Dr. Fisher.

Data from the Feeding Infants & Toddlers Study (FITS), a 2003 survey of eating patterns in more than 3,000 children aged 4–24 months conducted by Gerber, indicated that toddlers average seven eating occasions per day. Also, nearly 25% of 19- to 24-year-olds did not eat vegetables daily, and French fries were the most commonly consumed vegetable by children aged 15–24 months.

Some research has examined whether young children can adequately regulate their own energy intake. Dr. Fisher and colleagues conducted an observational study in which young children expressed preferences for the flavored beverage that had the highest energy, suggesting that energy content influenced preferences for flavor.

Data from another study of preschool children showed that children adjusted their energy intake by consuming less high-density drink when left to choose for themselves. Children are much better than adults in regulating energy intake, Dr. Fisher said.

“Opportunities to positively influence food preference begin at the earliest point in development,” she noted. She cited a study in which pregnant women consumed carrot juice during the last trimester and during early breast-feeding. Infants exposed to carrots showed better acceptance of carrot-flavored cereals on first introduction to those foods.

The influence of the environment on eating is a huge area of study; the increase in pediatric overweight can't be explained by genetics alone.

Parents have a very influential role on toddlers' eating habits, and food exposure is related to intake. If something is available and accessible in the home, children are more likely to eat it, but parents have to make the nutritious food available.

Often, well-meaning parents will reduce the variety of foods offered to children; they conclude after 3 or so presentations and rejections that the child doesn't like a particular food. In fact, evidence shows that it takes 5–10 exposures for a child to accept a novel food, Dr. Fisher said, and the number of foods liked in toddlerhood predicts the number liked at age 6–8 years.

Parents, take note: a study in 2000 showed that when adults enthusiastically modeled food, children were more likely to eat it. In addition, parents can be mindful of their feeding strategies for toddlers, including pressuring them to eat, or restricting specific foods. Some parents are controlling, while others provide minimal structure or supervision.

“We actually know very little about best practices for feeding children,” Dr. Fisher said, “but what we do know is that authoritarian feeding practices usually backfire.” Pressure to eat can create a dislike for certain foods and disrupt children's ability to regulate energy intake, and food restriction can encourage children to eat when they aren't hungry.

Doctors are strapped for time, but there are some points they can make in the office that might help parents prevent or control overweight and obesity in toddlers, said Dr. Johnson, director of the Children's Eating Laboratory at the University of Colorado, Denver.

Suggestions for parents, which may not be met with enthusiasm, include cutting down on sweetened drinks and making an effort to create a safe space in the home for toddlers to move freely, or to visit places, such as zoos, parks, or indoor play areas.

However, many physicians feel uncomfortable raising the issue of weight. No one wants to hear that their child is overweight, and especially not obese, said Dr. Johnson, who works with extremely obese pediatric patients and families in a tertiary care center. Also, in some cultures, plump babies are considered healthy, and parents don't recognize that they might be laying a foundation for childhood obesity by overfeeding their infants and toddlers.

It's also important to phrase questions about a young child's weight in a nonaccusatory way, Dr. Johnson said. Instead of saying “Your child needs to lose weight,” try asking, “Do you have any concerns about your child's weight?” Depending on the parent's response, offer some tips for reducing energy intake and increasing activity, or you may have to drop the subject for that particular visit if the family is not receptive or willing to make any changes.

A child who has exceeded the 95th percentile on growth charts can be a conversation starter. Dr. Johnson said that when she uses phrases such as “your child is growing faster than 95 of 100 children,” she can make an impact on parents. Use of sensitive language is important, however, because parents don't want to hear their children labeled as overweight or obese. Dr. Johnson uses phrases such as “Your child seems to be getting ahead of himself,” which sounds less accusatory than “your child is overweight.”

Ask parents, “What do you think is going to happen if this growth rate keeps up?” If the parent comes up with an answer, the doctor is taken out of the role of accuser, she noted. If parents get the idea at that point that their child needs to stop gaining weight so rapidly, the doctor can introduce some ways to “slow things down a bit.” If the parents don't recognize the problem, offer some information about potential health risks: “If your child continues to go on this way, here's what can happen.”

“I often start with 'is your child being teased?'” Dr. Johnson said. That gets people's attention because it's not a number or a percent; it is a painful situation for the child. Ask the parents what they want to do to mitigate the weight problem and thus cut down on the teasing. Listen to what the parents think is important, and have concrete strategies on hand to offer them.

Parents can't see how much food goes into the baby when they are breast-feeding, and some parents find security in “just topping it off” with some formula, because they can see an empty bottle. “It is important to stress that breast-feeding is enough, because the infant's growth is proceeding fine,” Dr. Johnson said.

Tips for Controlling Calories, Increasing Activity Levels

Dr. Johnson shared her tips for families about how to control calorie intake and keep toddlers from “getting ahead of themselves” in terms of weight:

▸ Cut down on sugar by avoiding sweetened beverages, except on special days.

▸ Limit juice to one-half cup per day of 100% fruit juice.

▸ Don't put juice in bottles. Promote children to a cup (not a sippy cup) by age 18 months.

▸ Find other ways to console a child besides candy. (Note to parents: granola bars are more like candy bars than “health food.”)

▸ Keep offering vegetables. Young children reject most foods on the first few tries; this behavior is not a poor reflection on parents.

▸ Choose foods in which whole grain is the first ingredient.

▸ Encourage breakfast. Breakfast provides children with cognitive benefits and prevents overweight. The number of toddlers reportedly consuming breakfast has dropped during the past two decades.

▸ Limit eating in the car. “I don't consider the car to be an eating environment,” Dr. Johnson said. It promotes overconsumption because parents can't keep track of what the child is eating, and it is unsafe, since parents behind the wheel can't help a child who starts to choke.

▸ Ask parents how many fruits and vegetables their child eats in a day, and which ones he or she likes. Help parents to focus on the ones that the child likes, and make sure these fruits and vegetables are available.

▸ Ask about both over- and underconsumption of milk. Current guidelines call for toddlers to consume 15–24 oz/day of milk; some children drink as much as 60 oz/day. You can have too much of a good thing.

▸ Teach children to serve themselves. When they do so, they tend to consume child-sized portions. This requires more patience and guidance from parents at the outset.

Dr. Johnson also offered several guidelines for promoting physical activity in toddlers:

▸ Make sure parents know about developmental milestones, such as standing and walking.

▸ Praise activity in children, and give them an opportunity to be active. Toddlers love routines; consider structured active time at a specific time during the day.

▸ Toddlers should not be sedentary for more than an hour at a time, unless they are sleeping.

▸ Create a safe area in the house where toddlers can be free to move, or take them to the zoo, park, or an indoor play area.

▸ Encourage dancing and play that is active.

Here are some questions for parents that serve as reminders:

▸ Do you, the parent, eat fruits and vegetables in front of your child? A parent's modeling of healthy eating can have a significant impact on a child's eating.

▸ Do you participate in active play with your child?

▸ Do you have family meals, in which the parents and children together eat healthy foods?

▸ Do you hide food from your children? Do they find it? All parents hide food from children, but it often doesn't work.

Sources: Susan L. Johnson, Ph.D.; Circulation 2005;112:2061–75; National Association for Sport and Physical Education Guidelines for Infants and Toddlers (

http://www.aahperd.org/NASPE/template.cfm?template=toddlers.html

WASHINGTON — Recognize parenting strategies that hinder or support the development of healthy eating patterns, and you can help prevent obesity in toddlers, Jennifer Orlet Fisher, Ph.D., and Susan L. Johnson, Ph.D., said in a presentation at the annual meeting of the American Academy of Pediatrics.

Approximately 11% of American infants aged 0–23 months are above the 95th percentile for weight, said Dr. Fisher of Baylor College of Medicine in Houston.

Few studies of activity levels in toddlers exist, she said. The best data come from a recent study of 100 Scottish children. These data revealed that toddlers spend a majority of their time in sedentary activity followed by light activity, and surprisingly very little time is spent in moderate to vigorous activity. However, moderate to vigorous activity did not predict total energy expenditure, which suggests that light activity is the primary contributor to total energy expenditure. There was little daily variation or weekday/weekend variation.

Television watching contributes to increased sedentary time for toddlers. A national longitudinal study showed that nearly half of toddlers are watching more than 2 hours daily, and children who watched more than 2 hours as toddlers were almost three times more likely to watch more than 2 hours at age 6 years, Dr. Fisher said.

The other side of the equation is what foods toddlers eat, and where and how they eat. Toddlerhood is a time of transition to a modified adult diet, Dr. Fisher explained. “In a relatively short time you see a huge increase in the energy from table food.”

“On average, a 2-year-old's intake is 1,249 calories, which is 32% higher than the estimated daily requirement,” said Dr. Fisher.

Data from the Feeding Infants & Toddlers Study (FITS), a 2003 survey of eating patterns in more than 3,000 children aged 4–24 months conducted by Gerber, indicated that toddlers average seven eating occasions per day. Also, nearly 25% of 19- to 24-year-olds did not eat vegetables daily, and French fries were the most commonly consumed vegetable by children aged 15–24 months.

Some research has examined whether young children can adequately regulate their own energy intake. Dr. Fisher and colleagues conducted an observational study in which young children expressed preferences for the flavored beverage that had the highest energy, suggesting that energy content influenced preferences for flavor.

Data from another study of preschool children showed that children adjusted their energy intake by consuming less high-density drink when left to choose for themselves. Children are much better than adults in regulating energy intake, Dr. Fisher said.

“Opportunities to positively influence food preference begin at the earliest point in development,” she noted. She cited a study in which pregnant women consumed carrot juice during the last trimester and during early breast-feeding. Infants exposed to carrots showed better acceptance of carrot-flavored cereals on first introduction to those foods.

The influence of the environment on eating is a huge area of study; the increase in pediatric overweight can't be explained by genetics alone.

Parents have a very influential role on toddlers' eating habits, and food exposure is related to intake. If something is available and accessible in the home, children are more likely to eat it, but parents have to make the nutritious food available.

Often, well-meaning parents will reduce the variety of foods offered to children; they conclude after 3 or so presentations and rejections that the child doesn't like a particular food. In fact, evidence shows that it takes 5–10 exposures for a child to accept a novel food, Dr. Fisher said, and the number of foods liked in toddlerhood predicts the number liked at age 6–8 years.

Parents, take note: a study in 2000 showed that when adults enthusiastically modeled food, children were more likely to eat it. In addition, parents can be mindful of their feeding strategies for toddlers, including pressuring them to eat, or restricting specific foods. Some parents are controlling, while others provide minimal structure or supervision.

“We actually know very little about best practices for feeding children,” Dr. Fisher said, “but what we do know is that authoritarian feeding practices usually backfire.” Pressure to eat can create a dislike for certain foods and disrupt children's ability to regulate energy intake, and food restriction can encourage children to eat when they aren't hungry.

Doctors are strapped for time, but there are some points they can make in the office that might help parents prevent or control overweight and obesity in toddlers, said Dr. Johnson, director of the Children's Eating Laboratory at the University of Colorado, Denver.

Suggestions for parents, which may not be met with enthusiasm, include cutting down on sweetened drinks and making an effort to create a safe space in the home for toddlers to move freely, or to visit places, such as zoos, parks, or indoor play areas.

However, many physicians feel uncomfortable raising the issue of weight. No one wants to hear that their child is overweight, and especially not obese, said Dr. Johnson, who works with extremely obese pediatric patients and families in a tertiary care center. Also, in some cultures, plump babies are considered healthy, and parents don't recognize that they might be laying a foundation for childhood obesity by overfeeding their infants and toddlers.

It's also important to phrase questions about a young child's weight in a nonaccusatory way, Dr. Johnson said. Instead of saying “Your child needs to lose weight,” try asking, “Do you have any concerns about your child's weight?” Depending on the parent's response, offer some tips for reducing energy intake and increasing activity, or you may have to drop the subject for that particular visit if the family is not receptive or willing to make any changes.

A child who has exceeded the 95th percentile on growth charts can be a conversation starter. Dr. Johnson said that when she uses phrases such as “your child is growing faster than 95 of 100 children,” she can make an impact on parents. Use of sensitive language is important, however, because parents don't want to hear their children labeled as overweight or obese. Dr. Johnson uses phrases such as “Your child seems to be getting ahead of himself,” which sounds less accusatory than “your child is overweight.”

Ask parents, “What do you think is going to happen if this growth rate keeps up?” If the parent comes up with an answer, the doctor is taken out of the role of accuser, she noted. If parents get the idea at that point that their child needs to stop gaining weight so rapidly, the doctor can introduce some ways to “slow things down a bit.” If the parents don't recognize the problem, offer some information about potential health risks: “If your child continues to go on this way, here's what can happen.”

“I often start with 'is your child being teased?'” Dr. Johnson said. That gets people's attention because it's not a number or a percent; it is a painful situation for the child. Ask the parents what they want to do to mitigate the weight problem and thus cut down on the teasing. Listen to what the parents think is important, and have concrete strategies on hand to offer them.

Parents can't see how much food goes into the baby when they are breast-feeding, and some parents find security in “just topping it off” with some formula, because they can see an empty bottle. “It is important to stress that breast-feeding is enough, because the infant's growth is proceeding fine,” Dr. Johnson said.

Tips for Controlling Calories, Increasing Activity Levels

Dr. Johnson shared her tips for families about how to control calorie intake and keep toddlers from “getting ahead of themselves” in terms of weight:

▸ Cut down on sugar by avoiding sweetened beverages, except on special days.

▸ Limit juice to one-half cup per day of 100% fruit juice.

▸ Don't put juice in bottles. Promote children to a cup (not a sippy cup) by age 18 months.

▸ Find other ways to console a child besides candy. (Note to parents: granola bars are more like candy bars than “health food.”)

▸ Keep offering vegetables. Young children reject most foods on the first few tries; this behavior is not a poor reflection on parents.

▸ Choose foods in which whole grain is the first ingredient.

▸ Encourage breakfast. Breakfast provides children with cognitive benefits and prevents overweight. The number of toddlers reportedly consuming breakfast has dropped during the past two decades.

▸ Limit eating in the car. “I don't consider the car to be an eating environment,” Dr. Johnson said. It promotes overconsumption because parents can't keep track of what the child is eating, and it is unsafe, since parents behind the wheel can't help a child who starts to choke.

▸ Ask parents how many fruits and vegetables their child eats in a day, and which ones he or she likes. Help parents to focus on the ones that the child likes, and make sure these fruits and vegetables are available.

▸ Ask about both over- and underconsumption of milk. Current guidelines call for toddlers to consume 15–24 oz/day of milk; some children drink as much as 60 oz/day. You can have too much of a good thing.

▸ Teach children to serve themselves. When they do so, they tend to consume child-sized portions. This requires more patience and guidance from parents at the outset.

Dr. Johnson also offered several guidelines for promoting physical activity in toddlers:

▸ Make sure parents know about developmental milestones, such as standing and walking.

▸ Praise activity in children, and give them an opportunity to be active. Toddlers love routines; consider structured active time at a specific time during the day.

▸ Toddlers should not be sedentary for more than an hour at a time, unless they are sleeping.

▸ Create a safe area in the house where toddlers can be free to move, or take them to the zoo, park, or an indoor play area.

▸ Encourage dancing and play that is active.

Here are some questions for parents that serve as reminders:

▸ Do you, the parent, eat fruits and vegetables in front of your child? A parent's modeling of healthy eating can have a significant impact on a child's eating.

▸ Do you participate in active play with your child?

▸ Do you have family meals, in which the parents and children together eat healthy foods?

▸ Do you hide food from your children? Do they find it? All parents hide food from children, but it often doesn't work.

Sources: Susan L. Johnson, Ph.D.; Circulation 2005;112:2061–75; National Association for Sport and Physical Education Guidelines for Infants and Toddlers (

http://www.aahperd.org/NASPE/template.cfm?template=toddlers.html

WASHINGTON – Behavior modification can reduce the level of medication needed in school-aged children with attention-deficit hyperactivity disorder, William E. Pelham Jr., Ph.D., said at the annual meeting of the Association for Behavioral and Cognitive Therapies.

Few studies have addressed the issue of how behavioral and pharmacologic therapies should be sequenced in children, said Dr. Pelham, a professor of pediatrics and psychiatry at the State University of New York, Buffalo.

Dr. Pelham and his colleagues have completed two studies funded by the National Institutes of Health that examined dosing and sequencing of behavior modification and medication. “We measured impairment–not core symptoms–because impairment is what you want to focus on; that is what causes the most problems for kids,” said Dr. Pelham, who is also a professor of psychology at the university.

The first study included 154 children aged 5–12 years (130 boys and 24 girls) who participated in a summer day camp program. They were divided for 3 weeks into three behavior modification groups–no behavior modification, low-intensity behavior modification, and high-intensity behavior modification. In addition, the children were divided into four dosage groups for methylphenidate (placebo, 0.15 mg/kg, 0.3 mg/kg, and 0.6 mg/kg, three times daily).

Medication was randomized each day, and the program counselors recorded the children's behavior in areas such as failing to comply with staff requests, following activity rules, and exhibiting conduct problems.

When the data were reviewed at summer's end, the lowest dose of medication–0.15 mg/kg three times daily–had a surprising and substantial effect on reducing ADHD impairment. In fact, the maximum incremental value of medication to behavior modification occurred at this low dose.

“There was no incremental value for most children beyond the 0.15-mg/kg dose in combination with behavior modification, but the highest dose–0.6 mg/kg–produced the largest effects in the absence of behavior modification,” Dr. Pelham said. This dosage normalized the largest number of children when combined with behavior modification. The effects of behavior modification alone and medication alone were comparable.

“Medication alone does not normalize the children's performance,” he explained. “Even at the highest dose of 0.6 mg/kg three times daily, many children were not normalized; the effect of behavior modification is as strong as the effect of medication.” Lower doses produce a substantially lower level of side effects–a benefit of using behavior modification as the first-line intervention.

Parents also evaluated the treatment conditions; they ranked a high level of behavior modification therapy, either alone or in combination with medication, as their first choice for managing ADHD, compared with medication alone or with a lower level of behavior modification alone.

The investigators conducted a follow-up study to assess the effectiveness of sequencing medication and behavior modification in a school setting. The primary outcome measure was the maintenance of acceptable behavior without medication after summer exposure to both medication and behavioral therapy.

The study included 128 of the children from the summer program who were randomly assigned to one of three groups. A total of 44 children received high behavior modification treatment, 43 received low behavior modification treatment, and 41 received no behavior modification treatment.

Overall, nearly twice the number of children who received some level of behavior modification remained off medication at school during the fall semester, compared with children who received no behavior modification (60% vs. 30%).

In addition, about 80% of children who had received behavior modification remained off medication at home. A caveat, however, was that almost all the children (75%) had been taking medication before enrollment in the summer study, which influenced their ability to remain unmedicated, Dr. Pelham noted.

Children who received no behavior modification started taking medication during the school day after 13 weeks, compared with 19 weeks for the low-intensity behavioral therapy group and 20 weeks for the high-intensity behavioral therapy group. Similarly, children who received no behavior modification therapy started taking medication at home after 27 weeks, compared with 38 weeks for the low behavior modification group and 32 weeks for the high behavior modification group.

Future research will include younger, medication-naive children, recruited at age 5–6 years, he said. “If we could use a low level of behavior modification therapy in this group, we may be able to keep them off medication,” Dr. Pelham said.

Dr. Pelham has been a consultant, scientific adviser, speaker, and grant recipient for the following companies: McNeil Consumer Healthcare/ALZA (developers and marketers of the methylphenidate product known as Concerta), Abbott, Shire, Noven, Eli Lilly, and Cephalon.

WASHINGTON – Behavior modification can reduce the level of medication needed in school-aged children with attention-deficit hyperactivity disorder, William E. Pelham Jr., Ph.D., said at the annual meeting of the Association for Behavioral and Cognitive Therapies.

Few studies have addressed the issue of how behavioral and pharmacologic therapies should be sequenced in children, said Dr. Pelham, a professor of pediatrics and psychiatry at the State University of New York, Buffalo.

Dr. Pelham and his colleagues have completed two studies funded by the National Institutes of Health that examined dosing and sequencing of behavior modification and medication. “We measured impairment–not core symptoms–because impairment is what you want to focus on; that is what causes the most problems for kids,” said Dr. Pelham, who is also a professor of psychology at the university.

The first study included 154 children aged 5–12 years (130 boys and 24 girls) who participated in a summer day camp program. They were divided for 3 weeks into three behavior modification groups–no behavior modification, low-intensity behavior modification, and high-intensity behavior modification. In addition, the children were divided into four dosage groups for methylphenidate (placebo, 0.15 mg/kg, 0.3 mg/kg, and 0.6 mg/kg, three times daily).

Medication was randomized each day, and the program counselors recorded the children's behavior in areas such as failing to comply with staff requests, following activity rules, and exhibiting conduct problems.

When the data were reviewed at summer's end, the lowest dose of medication–0.15 mg/kg three times daily–had a surprising and substantial effect on reducing ADHD impairment. In fact, the maximum incremental value of medication to behavior modification occurred at this low dose.

“There was no incremental value for most children beyond the 0.15-mg/kg dose in combination with behavior modification, but the highest dose–0.6 mg/kg–produced the largest effects in the absence of behavior modification,” Dr. Pelham said. This dosage normalized the largest number of children when combined with behavior modification. The effects of behavior modification alone and medication alone were comparable.

“Medication alone does not normalize the children's performance,” he explained. “Even at the highest dose of 0.6 mg/kg three times daily, many children were not normalized; the effect of behavior modification is as strong as the effect of medication.” Lower doses produce a substantially lower level of side effects–a benefit of using behavior modification as the first-line intervention.

Parents also evaluated the treatment conditions; they ranked a high level of behavior modification therapy, either alone or in combination with medication, as their first choice for managing ADHD, compared with medication alone or with a lower level of behavior modification alone.

The investigators conducted a follow-up study to assess the effectiveness of sequencing medication and behavior modification in a school setting. The primary outcome measure was the maintenance of acceptable behavior without medication after summer exposure to both medication and behavioral therapy.

The study included 128 of the children from the summer program who were randomly assigned to one of three groups. A total of 44 children received high behavior modification treatment, 43 received low behavior modification treatment, and 41 received no behavior modification treatment.

Overall, nearly twice the number of children who received some level of behavior modification remained off medication at school during the fall semester, compared with children who received no behavior modification (60% vs. 30%).

In addition, about 80% of children who had received behavior modification remained off medication at home. A caveat, however, was that almost all the children (75%) had been taking medication before enrollment in the summer study, which influenced their ability to remain unmedicated, Dr. Pelham noted.

Children who received no behavior modification started taking medication during the school day after 13 weeks, compared with 19 weeks for the low-intensity behavioral therapy group and 20 weeks for the high-intensity behavioral therapy group. Similarly, children who received no behavior modification therapy started taking medication at home after 27 weeks, compared with 38 weeks for the low behavior modification group and 32 weeks for the high behavior modification group.

Future research will include younger, medication-naive children, recruited at age 5–6 years, he said. “If we could use a low level of behavior modification therapy in this group, we may be able to keep them off medication,” Dr. Pelham said.

Dr. Pelham has been a consultant, scientific adviser, speaker, and grant recipient for the following companies: McNeil Consumer Healthcare/ALZA (developers and marketers of the methylphenidate product known as Concerta), Abbott, Shire, Noven, Eli Lilly, and Cephalon.

WASHINGTON – Behavior modification can reduce the level of medication needed in school-aged children with attention-deficit hyperactivity disorder, William E. Pelham Jr., Ph.D., said at the annual meeting of the Association for Behavioral and Cognitive Therapies.

Few studies have addressed the issue of how behavioral and pharmacologic therapies should be sequenced in children, said Dr. Pelham, a professor of pediatrics and psychiatry at the State University of New York, Buffalo.

Dr. Pelham and his colleagues have completed two studies funded by the National Institutes of Health that examined dosing and sequencing of behavior modification and medication. “We measured impairment–not core symptoms–because impairment is what you want to focus on; that is what causes the most problems for kids,” said Dr. Pelham, who is also a professor of psychology at the university.

The first study included 154 children aged 5–12 years (130 boys and 24 girls) who participated in a summer day camp program. They were divided for 3 weeks into three behavior modification groups–no behavior modification, low-intensity behavior modification, and high-intensity behavior modification. In addition, the children were divided into four dosage groups for methylphenidate (placebo, 0.15 mg/kg, 0.3 mg/kg, and 0.6 mg/kg, three times daily).

Medication was randomized each day, and the program counselors recorded the children's behavior in areas such as failing to comply with staff requests, following activity rules, and exhibiting conduct problems.

When the data were reviewed at summer's end, the lowest dose of medication–0.15 mg/kg three times daily–had a surprising and substantial effect on reducing ADHD impairment. In fact, the maximum incremental value of medication to behavior modification occurred at this low dose.

“There was no incremental value for most children beyond the 0.15-mg/kg dose in combination with behavior modification, but the highest dose–0.6 mg/kg–produced the largest effects in the absence of behavior modification,” Dr. Pelham said. This dosage normalized the largest number of children when combined with behavior modification. The effects of behavior modification alone and medication alone were comparable.

“Medication alone does not normalize the children's performance,” he explained. “Even at the highest dose of 0.6 mg/kg three times daily, many children were not normalized; the effect of behavior modification is as strong as the effect of medication.” Lower doses produce a substantially lower level of side effects–a benefit of using behavior modification as the first-line intervention.

Parents also evaluated the treatment conditions; they ranked a high level of behavior modification therapy, either alone or in combination with medication, as their first choice for managing ADHD, compared with medication alone or with a lower level of behavior modification alone.

The investigators conducted a follow-up study to assess the effectiveness of sequencing medication and behavior modification in a school setting. The primary outcome measure was the maintenance of acceptable behavior without medication after summer exposure to both medication and behavioral therapy.

The study included 128 of the children from the summer program who were randomly assigned to one of three groups. A total of 44 children received high behavior modification treatment, 43 received low behavior modification treatment, and 41 received no behavior modification treatment.

Overall, nearly twice the number of children who received some level of behavior modification remained off medication at school during the fall semester, compared with children who received no behavior modification (60% vs. 30%).

In addition, about 80% of children who had received behavior modification remained off medication at home. A caveat, however, was that almost all the children (75%) had been taking medication before enrollment in the summer study, which influenced their ability to remain unmedicated, Dr. Pelham noted.

Children who received no behavior modification started taking medication during the school day after 13 weeks, compared with 19 weeks for the low-intensity behavioral therapy group and 20 weeks for the high-intensity behavioral therapy group. Similarly, children who received no behavior modification therapy started taking medication at home after 27 weeks, compared with 38 weeks for the low behavior modification group and 32 weeks for the high behavior modification group.

Future research will include younger, medication-naive children, recruited at age 5–6 years, he said. “If we could use a low level of behavior modification therapy in this group, we may be able to keep them off medication,” Dr. Pelham said.

Dr. Pelham has been a consultant, scientific adviser, speaker, and grant recipient for the following companies: McNeil Consumer Healthcare/ALZA (developers and marketers of the methylphenidate product known as Concerta), Abbott, Shire, Noven, Eli Lilly, and Cephalon.

WASHINGTON — Antibiotic resistance did not increase the number of nosocomial urinary tract infections among elderly patients in a long-term care facility, Dr. Walter Zingg reported in a poster presented at the Interscience Conference on Antimicrobial Agents and Chemotherapy.

Dr. Zingg, of the University Children's Hospital, and his colleagues at University Hospital, Zürich, tested urine samples for Escherichia coli to determine the impact of resistant E. coli on the development and outcome of UTIs in long-term care facility residents.

Prevalence studies were conducted from June 2002 to May 2004. The 80 patients with E. coli (mean age 86 years) and 91 controls (mean age 85 years) were observed for an average of 278 days and 365 days, respectively. Overall, 96% of the E. coli cases showed reduced susceptibility against combination amoxicillin/clavulanic acid, 55% showed reduced susceptibility against trimethoprim/sulfamethoxazole, 41% showed reduced susceptibility against norfloxacin, and 10% showed reduced susceptibility against ciprofloxacin.

Surprisingly, the level of resistance did not result in more frequent nosocomial infections, the investigators found. The incidence density (the estimated rate of occurrence of infection) was 3.3 per 1,000 days among patients with E. coli, compared with 3.2 per 1,000 days among controls.

The meeting was sponsored by the American Society for Microbiology.

WASHINGTON — Antibiotic resistance did not increase the number of nosocomial urinary tract infections among elderly patients in a long-term care facility, Dr. Walter Zingg reported in a poster presented at the Interscience Conference on Antimicrobial Agents and Chemotherapy.

Dr. Zingg, of the University Children's Hospital, and his colleagues at University Hospital, Zürich, tested urine samples for Escherichia coli to determine the impact of resistant E. coli on the development and outcome of UTIs in long-term care facility residents.

Prevalence studies were conducted from June 2002 to May 2004. The 80 patients with E. coli (mean age 86 years) and 91 controls (mean age 85 years) were observed for an average of 278 days and 365 days, respectively. Overall, 96% of the E. coli cases showed reduced susceptibility against combination amoxicillin/clavulanic acid, 55% showed reduced susceptibility against trimethoprim/sulfamethoxazole, 41% showed reduced susceptibility against norfloxacin, and 10% showed reduced susceptibility against ciprofloxacin.

Surprisingly, the level of resistance did not result in more frequent nosocomial infections, the investigators found. The incidence density (the estimated rate of occurrence of infection) was 3.3 per 1,000 days among patients with E. coli, compared with 3.2 per 1,000 days among controls.

The meeting was sponsored by the American Society for Microbiology.

WASHINGTON — Antibiotic resistance did not increase the number of nosocomial urinary tract infections among elderly patients in a long-term care facility, Dr. Walter Zingg reported in a poster presented at the Interscience Conference on Antimicrobial Agents and Chemotherapy.

Dr. Zingg, of the University Children's Hospital, and his colleagues at University Hospital, Zürich, tested urine samples for Escherichia coli to determine the impact of resistant E. coli on the development and outcome of UTIs in long-term care facility residents.

Prevalence studies were conducted from June 2002 to May 2004. The 80 patients with E. coli (mean age 86 years) and 91 controls (mean age 85 years) were observed for an average of 278 days and 365 days, respectively. Overall, 96% of the E. coli cases showed reduced susceptibility against combination amoxicillin/clavulanic acid, 55% showed reduced susceptibility against trimethoprim/sulfamethoxazole, 41% showed reduced susceptibility against norfloxacin, and 10% showed reduced susceptibility against ciprofloxacin.

Surprisingly, the level of resistance did not result in more frequent nosocomial infections, the investigators found. The incidence density (the estimated rate of occurrence of infection) was 3.3 per 1,000 days among patients with E. coli, compared with 3.2 per 1,000 days among controls.

The meeting was sponsored by the American Society for Microbiology.

SAN DIEGO — The best way to avoid safety and quality violations is to stay abreast of guidelines prescribed by the Occupational Safety and Health Administration and by the Clinical Laboratory Improvement Amendments, Dr. Richard Hoang said at a meeting sponsored by the American Society for Mohs Surgery.

The lack of an up-to-date plan for control of blood-borne-pathogen exposure was among the most common violations for which Mohs surgeons were cited by OSHA during the period from January to August 2003, said Dr. Hoang, a dermatologist and dermatologic surgeon in private practice in San Diego.

"There are always unusually high fines for blood-borne-pathogen-exposure control-plan citations, so make sure yours is updated annually," Dr. Hoang said.

OSHA inspections are typically prompted by complaints or accidents. If an OSHA citation is given, there is always an opportunity to contest the violation, he noted.

In addition to the need for a blood-borne-pathogen-exposure control plan, OSHA guidelines that are particularly relevant to Mohs surgery practices include those on the identification of hazardous materials in the office. OSHA requires a safety data sheet for each chemical. Also, surgeons who work with hazardous materials must label all chemical containers and, when transferring chemicals to other containers, make sure all transfer containers reflect the original information about the chemical, Dr. Hoang said.

The Clinical Laboratory Improvement Amendments (CLIA), first published in 1992, were prompted by the poor quality of Pap smear results produced by large laboratories. CLIA classifies laboratory tests based on levels of complexity, and ranks Mohs histopathology tests as highly complex, Dr. Hoang said. Because of that ranking, Mohs practices must apply for a certificate, pay the required fees, and participate in proficiency testing.

The manual includes directions for performing tests. "All you have to do is make any revisions to the basic manual that are specific to your lab, and update it annually," Dr. Hoang explained.

In the section on specimen collection and handling, for example, Mohs surgeons should note that the surgeon will correlate the tissue with the Mohs map. Any tests performed should be documented with a test requisition in the patient's chart. In addition to this required documentation, Dr. Hoang recommends keeping a special Mohs log with the patient's name, the site worked on, and the number of slides to help the surgeon create an operative report.

Quality control in a Mohs practice—defined as the monitoring of testing procedures to achieve accurate, consistent results—also falls under CLIA requirements. To achieve accurate, consistent results, confirm the quality and sterility of reagents and record the expiration dates and lot numbers. Document the cleaning and maintenance of microscopes and report the daily temperature of the cryostat. The cryostat should be cleaned regularly.

SAN DIEGO — The best way to avoid safety and quality violations is to stay abreast of guidelines prescribed by the Occupational Safety and Health Administration and by the Clinical Laboratory Improvement Amendments, Dr. Richard Hoang said at a meeting sponsored by the American Society for Mohs Surgery.

The lack of an up-to-date plan for control of blood-borne-pathogen exposure was among the most common violations for which Mohs surgeons were cited by OSHA during the period from January to August 2003, said Dr. Hoang, a dermatologist and dermatologic surgeon in private practice in San Diego.

"There are always unusually high fines for blood-borne-pathogen-exposure control-plan citations, so make sure yours is updated annually," Dr. Hoang said.

OSHA inspections are typically prompted by complaints or accidents. If an OSHA citation is given, there is always an opportunity to contest the violation, he noted.

In addition to the need for a blood-borne-pathogen-exposure control plan, OSHA guidelines that are particularly relevant to Mohs surgery practices include those on the identification of hazardous materials in the office. OSHA requires a safety data sheet for each chemical. Also, surgeons who work with hazardous materials must label all chemical containers and, when transferring chemicals to other containers, make sure all transfer containers reflect the original information about the chemical, Dr. Hoang said.

The Clinical Laboratory Improvement Amendments (CLIA), first published in 1992, were prompted by the poor quality of Pap smear results produced by large laboratories. CLIA classifies laboratory tests based on levels of complexity, and ranks Mohs histopathology tests as highly complex, Dr. Hoang said. Because of that ranking, Mohs practices must apply for a certificate, pay the required fees, and participate in proficiency testing.

The manual includes directions for performing tests. "All you have to do is make any revisions to the basic manual that are specific to your lab, and update it annually," Dr. Hoang explained.

In the section on specimen collection and handling, for example, Mohs surgeons should note that the surgeon will correlate the tissue with the Mohs map. Any tests performed should be documented with a test requisition in the patient's chart. In addition to this required documentation, Dr. Hoang recommends keeping a special Mohs log with the patient's name, the site worked on, and the number of slides to help the surgeon create an operative report.

Quality control in a Mohs practice—defined as the monitoring of testing procedures to achieve accurate, consistent results—also falls under CLIA requirements. To achieve accurate, consistent results, confirm the quality and sterility of reagents and record the expiration dates and lot numbers. Document the cleaning and maintenance of microscopes and report the daily temperature of the cryostat. The cryostat should be cleaned regularly.

SAN DIEGO — The best way to avoid safety and quality violations is to stay abreast of guidelines prescribed by the Occupational Safety and Health Administration and by the Clinical Laboratory Improvement Amendments, Dr. Richard Hoang said at a meeting sponsored by the American Society for Mohs Surgery.

The lack of an up-to-date plan for control of blood-borne-pathogen exposure was among the most common violations for which Mohs surgeons were cited by OSHA during the period from January to August 2003, said Dr. Hoang, a dermatologist and dermatologic surgeon in private practice in San Diego.

"There are always unusually high fines for blood-borne-pathogen-exposure control-plan citations, so make sure yours is updated annually," Dr. Hoang said.

OSHA inspections are typically prompted by complaints or accidents. If an OSHA citation is given, there is always an opportunity to contest the violation, he noted.

In addition to the need for a blood-borne-pathogen-exposure control plan, OSHA guidelines that are particularly relevant to Mohs surgery practices include those on the identification of hazardous materials in the office. OSHA requires a safety data sheet for each chemical. Also, surgeons who work with hazardous materials must label all chemical containers and, when transferring chemicals to other containers, make sure all transfer containers reflect the original information about the chemical, Dr. Hoang said.

The Clinical Laboratory Improvement Amendments (CLIA), first published in 1992, were prompted by the poor quality of Pap smear results produced by large laboratories. CLIA classifies laboratory tests based on levels of complexity, and ranks Mohs histopathology tests as highly complex, Dr. Hoang said. Because of that ranking, Mohs practices must apply for a certificate, pay the required fees, and participate in proficiency testing.

The manual includes directions for performing tests. "All you have to do is make any revisions to the basic manual that are specific to your lab, and update it annually," Dr. Hoang explained.

In the section on specimen collection and handling, for example, Mohs surgeons should note that the surgeon will correlate the tissue with the Mohs map. Any tests performed should be documented with a test requisition in the patient's chart. In addition to this required documentation, Dr. Hoang recommends keeping a special Mohs log with the patient's name, the site worked on, and the number of slides to help the surgeon create an operative report.

Quality control in a Mohs practice—defined as the monitoring of testing procedures to achieve accurate, consistent results—also falls under CLIA requirements. To achieve accurate, consistent results, confirm the quality and sterility of reagents and record the expiration dates and lot numbers. Document the cleaning and maintenance of microscopes and report the daily temperature of the cryostat. The cryostat should be cleaned regularly.

SAN DIEGO — Most Mohs surgeons don't have the luxury of designing an ideal office from scratch—they must work with their preexisting office space, said Dr. James Del Rosso at a meeting sponsored by the American Society for Mohs Surgery.

Think of the acronym SPACE: Skills, Personnel, Area, Coordination, and Equipment, said Dr. Del Rosso of the University of Nevada, Las Vegas.

▸ Skills. To succeed as a Mohs surgeon, build on your basic surgical skills, and remember to start slow, small, and safe, Dr. Del Rosso said. Mohs involves a change in surgical technique with regard to removing skin cancer; the difference is in the conceptualization of lesion removal. Mohs surgeons consider tangential margin control, which calls for a different approach than a standard surgical excision. A dermatology residency, attendance at Mohs surgery courses, and observation of Mohs colleagues during procedures will help refine your skills.

▸ Personnel. Educate the office staff about Mohs surgery, what it involves, and why you have decided to offer it. Consider cross-training staff members so that they know how to cut tissue sections if the regular technician calls in sick, for example. Division of responsibility is crucial. You will also need to hire laboratory staff. Designate individuals for certain paperwork responsibilities, including logs on patient care and on instrument maintenance, and designate backup staff for all duties. In addition, educate staff about anatomical landmarks. "Make sure that everyone who is documenting procedures uses the same terminology," Dr. Del Rosso said. Also, train patients to be observers, and notice other problems.

Define office procedures, and document them in office manuals. "I recommend having someone in the office put together a short 'Cliff's Notes' version of one or two pages with highlights of the basic office procedures," he said.

▸ Area. Ideally, a Mohs surgeon can design an office space to specifications, but most surgeons work with the space they have. However, a standard surgical room that will be used for Mohs surgery should have eyewash stations, appropriately sized adjustable chairs for both the doctor and patient, and step stools for nurses or other staff who need a higher view of the procedures. If you have a step stool, make this rule: The person who uses it moves it out of the way when he or she is done. Kick buckets—buckets on wheels that can be moved with the feet while the surgeon is gloved during a procedure—are extremely helpful in a Mohs surgical suite.

▸ Coordination. Think about how the patients, the staff, and the specimens will flow through the office. A separate waiting room is ideal, but a separate section of the waiting room is the next best thing. Be sure that staff members know which patients are waiting between surgical sections, and that these patients are monitored and kept comfortable. "These patients will be waiting with bandages between layers, they may bleed and contaminate other patients, or they could faint, or become vasovagal," Dr. Del Rosso said.

▸ Equipment. The equipment for Mohs is expensive, and equipment maintenance goes without saying. "It is penny wise and pound foolish not to buy good surgical tools," Dr. Del Rosso said. "The way to save money is to make sure that equipment is properly cared for in the future." Establishing a Mohs laboratory—with its unique processing of specimens and methods of record keeping—is one of the biggest challenges for beginning Mohs surgeons, as is interpreting the sections.

"I would plan for two cryostats, even if you don't have two in the beginning," he said. "You will also need to allow for an inking station." Use color-coded glass slides for different stages to help keep samples organized.

Keep a prepared tray with the entire collection of surgical equipment ready, including small cups with saline and peroxide to soak the instruments between sections. Make sure the trays are organized so that the instruments are easy to locate, and discourage staff from tossing gauze on the trays and obscuring the instruments. "Hemostats should be on every tray, whether it is a repair tray or a Mohs tray," Dr. Del Rosso noted.

His favorite instruments include tenotomy scissors, Bishop-Harmon forceps, and blunt-edged dedicated undermining scissors. Some surgeons use sharp scissors for undermining.

Although many surgeons use disposable blades, Dr. Del Rosso recommends purchasing good quality blades and either sharpening them on-site or sending them out for regular sharpening. "If your knives aren't kept sharp, you will have problems with the quality of your sections," he explained. Reusable blades are more cost effective and allow the surgeon greater control over the blade quality.

SAN DIEGO — Most Mohs surgeons don't have the luxury of designing an ideal office from scratch—they must work with their preexisting office space, said Dr. James Del Rosso at a meeting sponsored by the American Society for Mohs Surgery.

Think of the acronym SPACE: Skills, Personnel, Area, Coordination, and Equipment, said Dr. Del Rosso of the University of Nevada, Las Vegas.

▸ Skills. To succeed as a Mohs surgeon, build on your basic surgical skills, and remember to start slow, small, and safe, Dr. Del Rosso said. Mohs involves a change in surgical technique with regard to removing skin cancer; the difference is in the conceptualization of lesion removal. Mohs surgeons consider tangential margin control, which calls for a different approach than a standard surgical excision. A dermatology residency, attendance at Mohs surgery courses, and observation of Mohs colleagues during procedures will help refine your skills.

▸ Personnel. Educate the office staff about Mohs surgery, what it involves, and why you have decided to offer it. Consider cross-training staff members so that they know how to cut tissue sections if the regular technician calls in sick, for example. Division of responsibility is crucial. You will also need to hire laboratory staff. Designate individuals for certain paperwork responsibilities, including logs on patient care and on instrument maintenance, and designate backup staff for all duties. In addition, educate staff about anatomical landmarks. "Make sure that everyone who is documenting procedures uses the same terminology," Dr. Del Rosso said. Also, train patients to be observers, and notice other problems.

Define office procedures, and document them in office manuals. "I recommend having someone in the office put together a short 'Cliff's Notes' version of one or two pages with highlights of the basic office procedures," he said.

▸ Area. Ideally, a Mohs surgeon can design an office space to specifications, but most surgeons work with the space they have. However, a standard surgical room that will be used for Mohs surgery should have eyewash stations, appropriately sized adjustable chairs for both the doctor and patient, and step stools for nurses or other staff who need a higher view of the procedures. If you have a step stool, make this rule: The person who uses it moves it out of the way when he or she is done. Kick buckets—buckets on wheels that can be moved with the feet while the surgeon is gloved during a procedure—are extremely helpful in a Mohs surgical suite.

▸ Coordination. Think about how the patients, the staff, and the specimens will flow through the office. A separate waiting room is ideal, but a separate section of the waiting room is the next best thing. Be sure that staff members know which patients are waiting between surgical sections, and that these patients are monitored and kept comfortable. "These patients will be waiting with bandages between layers, they may bleed and contaminate other patients, or they could faint, or become vasovagal," Dr. Del Rosso said.

▸ Equipment. The equipment for Mohs is expensive, and equipment maintenance goes without saying. "It is penny wise and pound foolish not to buy good surgical tools," Dr. Del Rosso said. "The way to save money is to make sure that equipment is properly cared for in the future." Establishing a Mohs laboratory—with its unique processing of specimens and methods of record keeping—is one of the biggest challenges for beginning Mohs surgeons, as is interpreting the sections.

"I would plan for two cryostats, even if you don't have two in the beginning," he said. "You will also need to allow for an inking station." Use color-coded glass slides for different stages to help keep samples organized.

Keep a prepared tray with the entire collection of surgical equipment ready, including small cups with saline and peroxide to soak the instruments between sections. Make sure the trays are organized so that the instruments are easy to locate, and discourage staff from tossing gauze on the trays and obscuring the instruments. "Hemostats should be on every tray, whether it is a repair tray or a Mohs tray," Dr. Del Rosso noted.

His favorite instruments include tenotomy scissors, Bishop-Harmon forceps, and blunt-edged dedicated undermining scissors. Some surgeons use sharp scissors for undermining.

Although many surgeons use disposable blades, Dr. Del Rosso recommends purchasing good quality blades and either sharpening them on-site or sending them out for regular sharpening. "If your knives aren't kept sharp, you will have problems with the quality of your sections," he explained. Reusable blades are more cost effective and allow the surgeon greater control over the blade quality.

SAN DIEGO — Most Mohs surgeons don't have the luxury of designing an ideal office from scratch—they must work with their preexisting office space, said Dr. James Del Rosso at a meeting sponsored by the American Society for Mohs Surgery.

Think of the acronym SPACE: Skills, Personnel, Area, Coordination, and Equipment, said Dr. Del Rosso of the University of Nevada, Las Vegas.

▸ Skills. To succeed as a Mohs surgeon, build on your basic surgical skills, and remember to start slow, small, and safe, Dr. Del Rosso said. Mohs involves a change in surgical technique with regard to removing skin cancer; the difference is in the conceptualization of lesion removal. Mohs surgeons consider tangential margin control, which calls for a different approach than a standard surgical excision. A dermatology residency, attendance at Mohs surgery courses, and observation of Mohs colleagues during procedures will help refine your skills.

▸ Personnel. Educate the office staff about Mohs surgery, what it involves, and why you have decided to offer it. Consider cross-training staff members so that they know how to cut tissue sections if the regular technician calls in sick, for example. Division of responsibility is crucial. You will also need to hire laboratory staff. Designate individuals for certain paperwork responsibilities, including logs on patient care and on instrument maintenance, and designate backup staff for all duties. In addition, educate staff about anatomical landmarks. "Make sure that everyone who is documenting procedures uses the same terminology," Dr. Del Rosso said. Also, train patients to be observers, and notice other problems.

Define office procedures, and document them in office manuals. "I recommend having someone in the office put together a short 'Cliff's Notes' version of one or two pages with highlights of the basic office procedures," he said.

▸ Area. Ideally, a Mohs surgeon can design an office space to specifications, but most surgeons work with the space they have. However, a standard surgical room that will be used for Mohs surgery should have eyewash stations, appropriately sized adjustable chairs for both the doctor and patient, and step stools for nurses or other staff who need a higher view of the procedures. If you have a step stool, make this rule: The person who uses it moves it out of the way when he or she is done. Kick buckets—buckets on wheels that can be moved with the feet while the surgeon is gloved during a procedure—are extremely helpful in a Mohs surgical suite.

▸ Coordination. Think about how the patients, the staff, and the specimens will flow through the office. A separate waiting room is ideal, but a separate section of the waiting room is the next best thing. Be sure that staff members know which patients are waiting between surgical sections, and that these patients are monitored and kept comfortable. "These patients will be waiting with bandages between layers, they may bleed and contaminate other patients, or they could faint, or become vasovagal," Dr. Del Rosso said.

▸ Equipment. The equipment for Mohs is expensive, and equipment maintenance goes without saying. "It is penny wise and pound foolish not to buy good surgical tools," Dr. Del Rosso said. "The way to save money is to make sure that equipment is properly cared for in the future." Establishing a Mohs laboratory—with its unique processing of specimens and methods of record keeping—is one of the biggest challenges for beginning Mohs surgeons, as is interpreting the sections.

"I would plan for two cryostats, even if you don't have two in the beginning," he said. "You will also need to allow for an inking station." Use color-coded glass slides for different stages to help keep samples organized.

Keep a prepared tray with the entire collection of surgical equipment ready, including small cups with saline and peroxide to soak the instruments between sections. Make sure the trays are organized so that the instruments are easy to locate, and discourage staff from tossing gauze on the trays and obscuring the instruments. "Hemostats should be on every tray, whether it is a repair tray or a Mohs tray," Dr. Del Rosso noted.

His favorite instruments include tenotomy scissors, Bishop-Harmon forceps, and blunt-edged dedicated undermining scissors. Some surgeons use sharp scissors for undermining.

Although many surgeons use disposable blades, Dr. Del Rosso recommends purchasing good quality blades and either sharpening them on-site or sending them out for regular sharpening. "If your knives aren't kept sharp, you will have problems with the quality of your sections," he explained. Reusable blades are more cost effective and allow the surgeon greater control over the blade quality.

WASHINGTON — The role of parental depression is not a consistent, equivalent risk factor for youth depression, Benjamin L. Hankin, Ph.D., said at the annual meeting of the Association for Behavioral and Cognitive Therapies.

Parental depression affects children in two main ways, Dr. Hankin noted. First, children can be exposed to such high levels of stress due to parental depression that the children's normal coping skills cannot handle the initial stress and hence they develop depressive symptoms when confronted with additional outside stressors.

Second, depressed parents model poor skills for coping with stress, which leaves the child susceptible to depressive symptoms in the face of additional stress.

The extent to which parental depression is a risk factor for youth depression depends on the contextual domain of the stressor, said Dr. Hankin, of the University of South Carolina, Columbia.

Dr. Hankin and associates conducted a longitudinal study of 421 8th- and 10th-grade students from 18 suburban Chicago high schools. About 55% were female, and 87% were white. The youth were evaluated at baseline, 6 months, and 12 months.

The results were based on reports from both the parents and the youths. The data included self-report questionnaires and a 7-day reporting of events at each of the three measurement times using a daily diary in which the youth recorded the worst events of each day. Entries ranged from dropping books in the hallway and receiving poor test grades to fighting with a girlfriend or being kicked out of school.

The researchers analyzed the responses and divided the events into categories of interpersonal stressors, such as family, romantic, peer, and athletic. Parental depressive symptoms interacted with youth stressors to increase the odds of depression in the youth when the interpersonal stressors fell into the family or romantic categories, Dr. Hankin said.

Parental depressive symptoms also contributed to poor coping skills among youth. These poor coping skills, when combined with stressors in the family or romantic categories, left the youth more vulnerable to depressive symptoms, Dr. Hankin said.

The results were consistent with the limited studies on depressive symptoms in youths whose parents are depressed.

WASHINGTON — The role of parental depression is not a consistent, equivalent risk factor for youth depression, Benjamin L. Hankin, Ph.D., said at the annual meeting of the Association for Behavioral and Cognitive Therapies.

Parental depression affects children in two main ways, Dr. Hankin noted. First, children can be exposed to such high levels of stress due to parental depression that the children's normal coping skills cannot handle the initial stress and hence they develop depressive symptoms when confronted with additional outside stressors.

Second, depressed parents model poor skills for coping with stress, which leaves the child susceptible to depressive symptoms in the face of additional stress.

The extent to which parental depression is a risk factor for youth depression depends on the contextual domain of the stressor, said Dr. Hankin, of the University of South Carolina, Columbia.

Dr. Hankin and associates conducted a longitudinal study of 421 8th- and 10th-grade students from 18 suburban Chicago high schools. About 55% were female, and 87% were white. The youth were evaluated at baseline, 6 months, and 12 months.

The results were based on reports from both the parents and the youths. The data included self-report questionnaires and a 7-day reporting of events at each of the three measurement times using a daily diary in which the youth recorded the worst events of each day. Entries ranged from dropping books in the hallway and receiving poor test grades to fighting with a girlfriend or being kicked out of school.

The researchers analyzed the responses and divided the events into categories of interpersonal stressors, such as family, romantic, peer, and athletic. Parental depressive symptoms interacted with youth stressors to increase the odds of depression in the youth when the interpersonal stressors fell into the family or romantic categories, Dr. Hankin said.

Parental depressive symptoms also contributed to poor coping skills among youth. These poor coping skills, when combined with stressors in the family or romantic categories, left the youth more vulnerable to depressive symptoms, Dr. Hankin said.

The results were consistent with the limited studies on depressive symptoms in youths whose parents are depressed.

WASHINGTON — The role of parental depression is not a consistent, equivalent risk factor for youth depression, Benjamin L. Hankin, Ph.D., said at the annual meeting of the Association for Behavioral and Cognitive Therapies.

Parental depression affects children in two main ways, Dr. Hankin noted. First, children can be exposed to such high levels of stress due to parental depression that the children's normal coping skills cannot handle the initial stress and hence they develop depressive symptoms when confronted with additional outside stressors.

Second, depressed parents model poor skills for coping with stress, which leaves the child susceptible to depressive symptoms in the face of additional stress.

The extent to which parental depression is a risk factor for youth depression depends on the contextual domain of the stressor, said Dr. Hankin, of the University of South Carolina, Columbia.

Dr. Hankin and associates conducted a longitudinal study of 421 8th- and 10th-grade students from 18 suburban Chicago high schools. About 55% were female, and 87% were white. The youth were evaluated at baseline, 6 months, and 12 months.

The results were based on reports from both the parents and the youths. The data included self-report questionnaires and a 7-day reporting of events at each of the three measurement times using a daily diary in which the youth recorded the worst events of each day. Entries ranged from dropping books in the hallway and receiving poor test grades to fighting with a girlfriend or being kicked out of school.

The researchers analyzed the responses and divided the events into categories of interpersonal stressors, such as family, romantic, peer, and athletic. Parental depressive symptoms interacted with youth stressors to increase the odds of depression in the youth when the interpersonal stressors fell into the family or romantic categories, Dr. Hankin said.

Parental depressive symptoms also contributed to poor coping skills among youth. These poor coping skills, when combined with stressors in the family or romantic categories, left the youth more vulnerable to depressive symptoms, Dr. Hankin said.

The results were consistent with the limited studies on depressive symptoms in youths whose parents are depressed.

WASHINGTON — Depression in a best friend was significantly associated with the development of depressive symptoms in adolescents under conditions of social anxiety, Mitchell Prinstein, Ph.D., said at the annual meeting of the Association for Behavioral and Cognitive Therapies.

Peer relationships during adolescence are characterized by high levels of emotional disclosure and intimacy. Adolescents often use feedback from peers, and their perceived standing among peers is a primary source of their own identity, said Dr. Prinstein of the University of North Carolina, Chapel Hill.

Previous research has shown that adolescents and their friends have remarkably similar characteristics, both concurrently and longitudinally.

Adolescents are likely to choose friends with similar social and psychological characteristics, attitudes, and behavior preferences, and previous research has shown that exposure to these friends extends these similar attitudes and behaviors longitudinally.

Dr. Prinstein and his colleagues studied 100 community-dwelling adolescents, each of whom chose a friend who was also in the data set. No friend was allowed to be selected more than once. The mean age was 16 years at baseline, and 60% were female.

Among girls, a best friend's depression as reported by that friend was associated with depression in the primary adolescent under conditions of social anxiety. Among boys, a lesser level of friendship intimacy was associated with a greater level of association between a best friend's depression and the development of depressive symptoms in the primary adolescent. Among both girls and boys, the higher the level of the best friend's popularity, as rated by peers, the stronger the association between depression in that best friend and the development of depressive symptoms in the primary adolescent.

The results support previous studies of the relevance of peer contagion as a potential contributor to depression in adolescents. “Interventions should not seek to detach teens from relationships, but [should] work to influence adolescent resilience by moderating factors such as anxiety,” Dr. Prinstein said. “Getting adolescents to change who their friends are is generally unsuccessful.”

WASHINGTON — Depression in a best friend was significantly associated with the development of depressive symptoms in adolescents under conditions of social anxiety, Mitchell Prinstein, Ph.D., said at the annual meeting of the Association for Behavioral and Cognitive Therapies.

Peer relationships during adolescence are characterized by high levels of emotional disclosure and intimacy. Adolescents often use feedback from peers, and their perceived standing among peers is a primary source of their own identity, said Dr. Prinstein of the University of North Carolina, Chapel Hill.

Previous research has shown that adolescents and their friends have remarkably similar characteristics, both concurrently and longitudinally.

Adolescents are likely to choose friends with similar social and psychological characteristics, attitudes, and behavior preferences, and previous research has shown that exposure to these friends extends these similar attitudes and behaviors longitudinally.

Dr. Prinstein and his colleagues studied 100 community-dwelling adolescents, each of whom chose a friend who was also in the data set. No friend was allowed to be selected more than once. The mean age was 16 years at baseline, and 60% were female.

Among girls, a best friend's depression as reported by that friend was associated with depression in the primary adolescent under conditions of social anxiety. Among boys, a lesser level of friendship intimacy was associated with a greater level of association between a best friend's depression and the development of depressive symptoms in the primary adolescent. Among both girls and boys, the higher the level of the best friend's popularity, as rated by peers, the stronger the association between depression in that best friend and the development of depressive symptoms in the primary adolescent.

The results support previous studies of the relevance of peer contagion as a potential contributor to depression in adolescents. “Interventions should not seek to detach teens from relationships, but [should] work to influence adolescent resilience by moderating factors such as anxiety,” Dr. Prinstein said. “Getting adolescents to change who their friends are is generally unsuccessful.”

WASHINGTON — Depression in a best friend was significantly associated with the development of depressive symptoms in adolescents under conditions of social anxiety, Mitchell Prinstein, Ph.D., said at the annual meeting of the Association for Behavioral and Cognitive Therapies.

Peer relationships during adolescence are characterized by high levels of emotional disclosure and intimacy. Adolescents often use feedback from peers, and their perceived standing among peers is a primary source of their own identity, said Dr. Prinstein of the University of North Carolina, Chapel Hill.

Previous research has shown that adolescents and their friends have remarkably similar characteristics, both concurrently and longitudinally.

Adolescents are likely to choose friends with similar social and psychological characteristics, attitudes, and behavior preferences, and previous research has shown that exposure to these friends extends these similar attitudes and behaviors longitudinally.

Dr. Prinstein and his colleagues studied 100 community-dwelling adolescents, each of whom chose a friend who was also in the data set. No friend was allowed to be selected more than once. The mean age was 16 years at baseline, and 60% were female.

Among girls, a best friend's depression as reported by that friend was associated with depression in the primary adolescent under conditions of social anxiety. Among boys, a lesser level of friendship intimacy was associated with a greater level of association between a best friend's depression and the development of depressive symptoms in the primary adolescent. Among both girls and boys, the higher the level of the best friend's popularity, as rated by peers, the stronger the association between depression in that best friend and the development of depressive symptoms in the primary adolescent.

The results support previous studies of the relevance of peer contagion as a potential contributor to depression in adolescents. “Interventions should not seek to detach teens from relationships, but [should] work to influence adolescent resilience by moderating factors such as anxiety,” Dr. Prinstein said. “Getting adolescents to change who their friends are is generally unsuccessful.”