Tara Haelle

Children whose autism was not detected by the Modified Checklist for Autism in Toddlers (M-CHAT) at 18 months old were more likely to have delays in social, communication, and fine and gross motor skills at the time of the screen, compared with other children who had negative results, according to findings from a retrospective analysis of 68,197 screen-negative cases in the Norwegian Mother and Child Cohort Study.

Parents of children with false-negative M-CHAT results rated their children’s gross and fine motor skills and social and communication skills at 18 months as less developed than did parents of children with true-negative screens. For girls who had false-negative results and were later diagnosed with autism, the delays were more pronounced, compared with girls with true-negative results. Also, girls later diagnosed with autism were rated as less shy than girls with true-negative scores. Shyness was more common in boys later diagnosed with autism than in boys with true-negative scores.

“When trying to determine if a young child is exhibiting autism symptoms, clinicians should not rely solely on a single instrument but consider parental concerns and draw on other developmental surveillance instruments, as well as their clinical judgment. ... The clinicians also need to be particularly wary about discounting symptoms of social difficulties in girls because they may be masked by limited shyness or social inhibition,” wrote Roald A. Øien, MA, of the University of Tromsø (Norway) and Yale University in New Haven, Conn., and his associates in Pediatrics.

The researchers noted that the study was based on use of a previous M-CHAT version. The findings may not be relevant to the updated M-CHAT-R/F, which has 20 questions, new cutoffs, and a recommended follow-up interview.

Of the Norwegian children who were at least 40 months old at the time of the study, 67,969 had true-negative M-CHAT screens, and 228 had false-negative screens based on later diagnoses reported in the Autism Birth Cohort, a substudy of the Norwegian Mother and Child Cohort Study.

The 18-month-olds had been assessed with the M-CHAT, selected items from the Ages and Stages Questionnaire and the Emotionality Activity Sociability Temperament Survey. Of the 23 pass-fail M-CHAT items, 6 are highly predictive of a later ASD diagnosis; a positive screen is failure of at least 2 of those 6 items.

Both boys and girls with false negatives were less social and had lower communication and gross motor skills, compared with their true-negative counterparts, but these differences were greater between false-negative and true-negative girls. Fine motor skills were also significantly lower in those with false negatives than in those with true negatives, but the magnitude was no different between girls and boys.

Overall, boys had more advanced gross motor skills and higher activity levels than girls, independent of true- or false-negative status.

In post hoc analyses, boys with false-negative results were rated as more shy than boys with true-negative results. Girls with false negatives were rated as less shy than girls with true negatives and boys with false negatives. Ratings of emotionality and activity did not differ among the children with true or false negatives.

The authors speculated that girls with false negatives may have “somewhat lower levels of social fearfulness or lower inhibitory control, compared with boys.”

The authors also suggested possible reasons for the false negatives, including parents’ difficulty in matching behaviors described in the M-CHAT with their children’s behaviors and the lack of graded responses on the M-CHAT, which may influence parents’ responses.

By comparison, the Ages and Stages Questionnaire “gives parents the opportunity to express that the children exhibit skills occasionally albeit inconsistently, which may allow them to express their concerns and perceptions in a more graded manner,” the authors wrote.

Another possible reason for false negatives, the authors suggested, is that symptoms in those with autism spectrum disorder may manifest differently in early childhood, partly depending on the level of the child’s verbal and nonverbal skills.

“We believe that our results contribute, at a fundamental level, to our understanding of early screening for ASD, and we highlight the discrepancy between hard cutoff criteria for autism and the social-communicative, developmental, and temperamental signatures of emerging or subthreshold autism phenotypes,” the authors wrote. They noted a need for screens that take into account temperament and verbal and nonverbal skill levels.

The research was funded by the Norwegian Ministry of Health and Care Services, the Norwegian Ministry of Education and Research, the Research Council of Norway and Functional Genomics in Norway, the National Institute of Neurological Disorders and Stroke and the National Institute of Environmental Health Sciences. Dr Hornig coinvented an intestinal microbiome biomarker for autism which has patents assigned to Columbia University.

SOURCE: Øien RA et al. Pediatrics. 2018;141(6):e20173596.

Children whose autism was not detected by the Modified Checklist for Autism in Toddlers (M-CHAT) at 18 months old were more likely to have delays in social, communication, and fine and gross motor skills at the time of the screen, compared with other children who had negative results, according to findings from a retrospective analysis of 68,197 screen-negative cases in the Norwegian Mother and Child Cohort Study.

Parents of children with false-negative M-CHAT results rated their children’s gross and fine motor skills and social and communication skills at 18 months as less developed than did parents of children with true-negative screens. For girls who had false-negative results and were later diagnosed with autism, the delays were more pronounced, compared with girls with true-negative results. Also, girls later diagnosed with autism were rated as less shy than girls with true-negative scores. Shyness was more common in boys later diagnosed with autism than in boys with true-negative scores.

“When trying to determine if a young child is exhibiting autism symptoms, clinicians should not rely solely on a single instrument but consider parental concerns and draw on other developmental surveillance instruments, as well as their clinical judgment. ... The clinicians also need to be particularly wary about discounting symptoms of social difficulties in girls because they may be masked by limited shyness or social inhibition,” wrote Roald A. Øien, MA, of the University of Tromsø (Norway) and Yale University in New Haven, Conn., and his associates in Pediatrics.

The researchers noted that the study was based on use of a previous M-CHAT version. The findings may not be relevant to the updated M-CHAT-R/F, which has 20 questions, new cutoffs, and a recommended follow-up interview.

Of the Norwegian children who were at least 40 months old at the time of the study, 67,969 had true-negative M-CHAT screens, and 228 had false-negative screens based on later diagnoses reported in the Autism Birth Cohort, a substudy of the Norwegian Mother and Child Cohort Study.

The 18-month-olds had been assessed with the M-CHAT, selected items from the Ages and Stages Questionnaire and the Emotionality Activity Sociability Temperament Survey. Of the 23 pass-fail M-CHAT items, 6 are highly predictive of a later ASD diagnosis; a positive screen is failure of at least 2 of those 6 items.

Both boys and girls with false negatives were less social and had lower communication and gross motor skills, compared with their true-negative counterparts, but these differences were greater between false-negative and true-negative girls. Fine motor skills were also significantly lower in those with false negatives than in those with true negatives, but the magnitude was no different between girls and boys.

Overall, boys had more advanced gross motor skills and higher activity levels than girls, independent of true- or false-negative status.

In post hoc analyses, boys with false-negative results were rated as more shy than boys with true-negative results. Girls with false negatives were rated as less shy than girls with true negatives and boys with false negatives. Ratings of emotionality and activity did not differ among the children with true or false negatives.

The authors speculated that girls with false negatives may have “somewhat lower levels of social fearfulness or lower inhibitory control, compared with boys.”

The authors also suggested possible reasons for the false negatives, including parents’ difficulty in matching behaviors described in the M-CHAT with their children’s behaviors and the lack of graded responses on the M-CHAT, which may influence parents’ responses.

By comparison, the Ages and Stages Questionnaire “gives parents the opportunity to express that the children exhibit skills occasionally albeit inconsistently, which may allow them to express their concerns and perceptions in a more graded manner,” the authors wrote.

Another possible reason for false negatives, the authors suggested, is that symptoms in those with autism spectrum disorder may manifest differently in early childhood, partly depending on the level of the child’s verbal and nonverbal skills.

“We believe that our results contribute, at a fundamental level, to our understanding of early screening for ASD, and we highlight the discrepancy between hard cutoff criteria for autism and the social-communicative, developmental, and temperamental signatures of emerging or subthreshold autism phenotypes,” the authors wrote. They noted a need for screens that take into account temperament and verbal and nonverbal skill levels.

The research was funded by the Norwegian Ministry of Health and Care Services, the Norwegian Ministry of Education and Research, the Research Council of Norway and Functional Genomics in Norway, the National Institute of Neurological Disorders and Stroke and the National Institute of Environmental Health Sciences. Dr Hornig coinvented an intestinal microbiome biomarker for autism which has patents assigned to Columbia University.

SOURCE: Øien RA et al. Pediatrics. 2018;141(6):e20173596.

Children whose autism was not detected by the Modified Checklist for Autism in Toddlers (M-CHAT) at 18 months old were more likely to have delays in social, communication, and fine and gross motor skills at the time of the screen, compared with other children who had negative results, according to findings from a retrospective analysis of 68,197 screen-negative cases in the Norwegian Mother and Child Cohort Study.

Parents of children with false-negative M-CHAT results rated their children’s gross and fine motor skills and social and communication skills at 18 months as less developed than did parents of children with true-negative screens. For girls who had false-negative results and were later diagnosed with autism, the delays were more pronounced, compared with girls with true-negative results. Also, girls later diagnosed with autism were rated as less shy than girls with true-negative scores. Shyness was more common in boys later diagnosed with autism than in boys with true-negative scores.

“When trying to determine if a young child is exhibiting autism symptoms, clinicians should not rely solely on a single instrument but consider parental concerns and draw on other developmental surveillance instruments, as well as their clinical judgment. ... The clinicians also need to be particularly wary about discounting symptoms of social difficulties in girls because they may be masked by limited shyness or social inhibition,” wrote Roald A. Øien, MA, of the University of Tromsø (Norway) and Yale University in New Haven, Conn., and his associates in Pediatrics.

The researchers noted that the study was based on use of a previous M-CHAT version. The findings may not be relevant to the updated M-CHAT-R/F, which has 20 questions, new cutoffs, and a recommended follow-up interview.

Of the Norwegian children who were at least 40 months old at the time of the study, 67,969 had true-negative M-CHAT screens, and 228 had false-negative screens based on later diagnoses reported in the Autism Birth Cohort, a substudy of the Norwegian Mother and Child Cohort Study.

The 18-month-olds had been assessed with the M-CHAT, selected items from the Ages and Stages Questionnaire and the Emotionality Activity Sociability Temperament Survey. Of the 23 pass-fail M-CHAT items, 6 are highly predictive of a later ASD diagnosis; a positive screen is failure of at least 2 of those 6 items.

Both boys and girls with false negatives were less social and had lower communication and gross motor skills, compared with their true-negative counterparts, but these differences were greater between false-negative and true-negative girls. Fine motor skills were also significantly lower in those with false negatives than in those with true negatives, but the magnitude was no different between girls and boys.

Overall, boys had more advanced gross motor skills and higher activity levels than girls, independent of true- or false-negative status.

In post hoc analyses, boys with false-negative results were rated as more shy than boys with true-negative results. Girls with false negatives were rated as less shy than girls with true negatives and boys with false negatives. Ratings of emotionality and activity did not differ among the children with true or false negatives.

The authors speculated that girls with false negatives may have “somewhat lower levels of social fearfulness or lower inhibitory control, compared with boys.”

The authors also suggested possible reasons for the false negatives, including parents’ difficulty in matching behaviors described in the M-CHAT with their children’s behaviors and the lack of graded responses on the M-CHAT, which may influence parents’ responses.

By comparison, the Ages and Stages Questionnaire “gives parents the opportunity to express that the children exhibit skills occasionally albeit inconsistently, which may allow them to express their concerns and perceptions in a more graded manner,” the authors wrote.

Another possible reason for false negatives, the authors suggested, is that symptoms in those with autism spectrum disorder may manifest differently in early childhood, partly depending on the level of the child’s verbal and nonverbal skills.

“We believe that our results contribute, at a fundamental level, to our understanding of early screening for ASD, and we highlight the discrepancy between hard cutoff criteria for autism and the social-communicative, developmental, and temperamental signatures of emerging or subthreshold autism phenotypes,” the authors wrote. They noted a need for screens that take into account temperament and verbal and nonverbal skill levels.

The research was funded by the Norwegian Ministry of Health and Care Services, the Norwegian Ministry of Education and Research, the Research Council of Norway and Functional Genomics in Norway, the National Institute of Neurological Disorders and Stroke and the National Institute of Environmental Health Sciences. Dr Hornig coinvented an intestinal microbiome biomarker for autism which has patents assigned to Columbia University.

SOURCE: Øien RA et al. Pediatrics. 2018;141(6):e20173596.

Substantial percentages of children with sickle cell disease are not receiving certain recommended vaccines on time or at all, found a study examining receipt of pneumococcal and meningococcal vaccines among children born in Michigan.

Although these children were more likely to be up-to-date on their pneumococcal vaccines than others their age without sickle cell disease (SCD), nearly one-third had not received all their pneumococcal vaccines by 36 months old. These children are at higher risk of meningococcal and invasive pneumococcal disease because they lack normal spleen function.

CDC/Janice Haney Carr

The researchers matched 1,022 children with SCD to 3,725 children without SCD based on age, sex, race, and zip code. The data was based on the Michigan Care Improvement Registry (MCIR), Michigan Vital Records live birth file, and the Michigan Newborn Screening Program for children born in the state between April 1, 1995, and January 1, 2014.

At age 36 months, 69% of children with SCD had been fully vaccinated with the pneumococcal conjugate vaccine series, compared with 45% of children without SCD. The meningococcal vaccine had been administered to 59% of children with SCD.

Children with SCD were more likely than those without the disease to be up-to-date on their pneumococcal vaccine(s) at 5, 7 and 16 months old.

Nevertheless, substantial percentages of children with SCD who received the complete series of the 7-valent pneumococcal conjugate vaccine had not received two other pneumococcal vaccines. Just over 29% were missing a dose of PCV13, 21.8% of children over 2 years old had not received any dose of PPV23, and 50.7% had not received a second dose of PPV23 by the age of 10 years.

The authors drew attention to the complexity of ACIP recommendations, however: ACIP released 7 recommendations a year, on average, between 2006 and 2015.

“Although providers have a responsibility to educate themselves on how best to protect children with high-risk conditions, these figures speak to the need for MCIR, the state’s immunization information system, to provide additional information on children, such as those who have sickle cell disease, who have special vaccination recommendations,” the authors wrote.

The authors reported no conflicts of interest. No external funding was noted.

SOURCE: Wagner AL et al. J Pediatr. J Pediatr. 2018 May;196:223-9.

Substantial percentages of children with sickle cell disease are not receiving certain recommended vaccines on time or at all, found a study examining receipt of pneumococcal and meningococcal vaccines among children born in Michigan.

Although these children were more likely to be up-to-date on their pneumococcal vaccines than others their age without sickle cell disease (SCD), nearly one-third had not received all their pneumococcal vaccines by 36 months old. These children are at higher risk of meningococcal and invasive pneumococcal disease because they lack normal spleen function.

CDC/Janice Haney Carr

The researchers matched 1,022 children with SCD to 3,725 children without SCD based on age, sex, race, and zip code. The data was based on the Michigan Care Improvement Registry (MCIR), Michigan Vital Records live birth file, and the Michigan Newborn Screening Program for children born in the state between April 1, 1995, and January 1, 2014.

At age 36 months, 69% of children with SCD had been fully vaccinated with the pneumococcal conjugate vaccine series, compared with 45% of children without SCD. The meningococcal vaccine had been administered to 59% of children with SCD.

Children with SCD were more likely than those without the disease to be up-to-date on their pneumococcal vaccine(s) at 5, 7 and 16 months old.

Nevertheless, substantial percentages of children with SCD who received the complete series of the 7-valent pneumococcal conjugate vaccine had not received two other pneumococcal vaccines. Just over 29% were missing a dose of PCV13, 21.8% of children over 2 years old had not received any dose of PPV23, and 50.7% had not received a second dose of PPV23 by the age of 10 years.

The authors drew attention to the complexity of ACIP recommendations, however: ACIP released 7 recommendations a year, on average, between 2006 and 2015.

“Although providers have a responsibility to educate themselves on how best to protect children with high-risk conditions, these figures speak to the need for MCIR, the state’s immunization information system, to provide additional information on children, such as those who have sickle cell disease, who have special vaccination recommendations,” the authors wrote.

The authors reported no conflicts of interest. No external funding was noted.

SOURCE: Wagner AL et al. J Pediatr. J Pediatr. 2018 May;196:223-9.

Substantial percentages of children with sickle cell disease are not receiving certain recommended vaccines on time or at all, found a study examining receipt of pneumococcal and meningococcal vaccines among children born in Michigan.

Although these children were more likely to be up-to-date on their pneumococcal vaccines than others their age without sickle cell disease (SCD), nearly one-third had not received all their pneumococcal vaccines by 36 months old. These children are at higher risk of meningococcal and invasive pneumococcal disease because they lack normal spleen function.

CDC/Janice Haney Carr

The researchers matched 1,022 children with SCD to 3,725 children without SCD based on age, sex, race, and zip code. The data was based on the Michigan Care Improvement Registry (MCIR), Michigan Vital Records live birth file, and the Michigan Newborn Screening Program for children born in the state between April 1, 1995, and January 1, 2014.

At age 36 months, 69% of children with SCD had been fully vaccinated with the pneumococcal conjugate vaccine series, compared with 45% of children without SCD. The meningococcal vaccine had been administered to 59% of children with SCD.

Children with SCD were more likely than those without the disease to be up-to-date on their pneumococcal vaccine(s) at 5, 7 and 16 months old.

Nevertheless, substantial percentages of children with SCD who received the complete series of the 7-valent pneumococcal conjugate vaccine had not received two other pneumococcal vaccines. Just over 29% were missing a dose of PCV13, 21.8% of children over 2 years old had not received any dose of PPV23, and 50.7% had not received a second dose of PPV23 by the age of 10 years.

The authors drew attention to the complexity of ACIP recommendations, however: ACIP released 7 recommendations a year, on average, between 2006 and 2015.

“Although providers have a responsibility to educate themselves on how best to protect children with high-risk conditions, these figures speak to the need for MCIR, the state’s immunization information system, to provide additional information on children, such as those who have sickle cell disease, who have special vaccination recommendations,” the authors wrote.

The authors reported no conflicts of interest. No external funding was noted.

SOURCE: Wagner AL et al. J Pediatr. J Pediatr. 2018 May;196:223-9.

Individuals with certain sleeping disorders may have a higher risk of crashes, near-crashes or unsafe maneuvering prior to such events, suggests a study.

“The results confirm that some sleep disorders generally increase driving risk as defined by our dependent measures,” wrote Shu-Yuan Liu, a doctoral student, and two colleagues at Virginia Tech, Blacksburg (Sleep. 2018 Apr 1. doi: 10.1093/sleep/zsy023). “Furthermore, the results also provide some insights into how risk varies across specific types of sleep disorder and some moderating factors.”

GummyBone/iStock/Getty Images

“Drivers who reported frequency of sleepy driving as ‘never,’ ‘rarely,’ and ‘sometimes’ also had higher a risk, indicating that crash or near-crash risk is also associated with sources other than these sleeping disorders,” the authors noted. These drivers’ increased odds of getting into or nearly getting into a crash ranged from 31% to 53% greater (P less than .05).

All drivers with shift work sleep disorder, except for those aged 20-24, had a crash or near-crash rate that was 7.5 times greater than that of drivers without any sleeping disorders. The rate among drivers aged 20-24 with this disorder had a 90% lower rate (risk ratio [RR] = 0.1, P less than .05) compared with control drivers.

When the researchers analyzed the drivers’ maneuvers just before a crash or near-crash, they found females with sleep apnea had a 36% greater odds of doing an unsafe maneuver in crash/near-crash circumstances (AOR = 1.36). Females with RLS and any drivers with shift work sleep disorder were more than twice as likely to perform unsafe maneuvers (AOR = 3.38 and 3.53, respectively, P less than .05).

The only drivers with a sleeping disorder who were more likely to be involved in crashes of greater severity were those with periodic limb movement disorder (AOR = 1.43, P less than .05).

However, young drivers, senior drivers, and nighttime drivers also all had higher odds of being involved in more severe crashes and in performing unsafe maneuvers prior to a crash or near-crash. Nighttime drivers seemed to be most at risk for these, and they were linked to having more than 5 times greater odds of unsafely maneuvering their vehicles prior to getting into a crash or near crash (AOR = 6.71, P less than .05).

“This is a strong piece of evidence that nighttime driving is less safe than daytime driving and limiting amount of nighttime driving could be one method to moderate road risk for some individuals,” the authors wrote.

The study’s limitations include its observational nature, low numbers of participants with several of the sleeping disorders (at levels below the disorder’s prevalence in the general population), and the complexities involved in what causes a crash or near crash.

One limitation of this study was that sleep hygiene and sleep quality were not examined, even though these might contribute significantly to roadway safety, the researchers noted. This study also did not take into account what medications or other treatment (such as continuous positive airway pressure for those with sleep apnea) the participants might be receiving for their condition.

The study’s implications include the need for physicians to advise patients with insomnia or females with sleep apnea to use caution while driving without “exaggerating risks that introduce undue fear to patients with other sleep disorders and thereby limiting mobility unnecessarily,” the authors wrote. The researchers also suggested that employers consider providing alternative transportation to shift workers and/or that insurance companies offer employers lower rates for offering such alternatives.

SOURCE: Liu Shu-Yuan et al. Sleep J. 2018 Apr 1. doi: 10.1093/sleep/zsy023.

Individuals with certain sleeping disorders may have a higher risk of crashes, near-crashes or unsafe maneuvering prior to such events, suggests a study.

“The results confirm that some sleep disorders generally increase driving risk as defined by our dependent measures,” wrote Shu-Yuan Liu, a doctoral student, and two colleagues at Virginia Tech, Blacksburg (Sleep. 2018 Apr 1. doi: 10.1093/sleep/zsy023). “Furthermore, the results also provide some insights into how risk varies across specific types of sleep disorder and some moderating factors.”

GummyBone/iStock/Getty Images

“Drivers who reported frequency of sleepy driving as ‘never,’ ‘rarely,’ and ‘sometimes’ also had higher a risk, indicating that crash or near-crash risk is also associated with sources other than these sleeping disorders,” the authors noted. These drivers’ increased odds of getting into or nearly getting into a crash ranged from 31% to 53% greater (P less than .05).

All drivers with shift work sleep disorder, except for those aged 20-24, had a crash or near-crash rate that was 7.5 times greater than that of drivers without any sleeping disorders. The rate among drivers aged 20-24 with this disorder had a 90% lower rate (risk ratio [RR] = 0.1, P less than .05) compared with control drivers.

When the researchers analyzed the drivers’ maneuvers just before a crash or near-crash, they found females with sleep apnea had a 36% greater odds of doing an unsafe maneuver in crash/near-crash circumstances (AOR = 1.36). Females with RLS and any drivers with shift work sleep disorder were more than twice as likely to perform unsafe maneuvers (AOR = 3.38 and 3.53, respectively, P less than .05).

The only drivers with a sleeping disorder who were more likely to be involved in crashes of greater severity were those with periodic limb movement disorder (AOR = 1.43, P less than .05).

However, young drivers, senior drivers, and nighttime drivers also all had higher odds of being involved in more severe crashes and in performing unsafe maneuvers prior to a crash or near-crash. Nighttime drivers seemed to be most at risk for these, and they were linked to having more than 5 times greater odds of unsafely maneuvering their vehicles prior to getting into a crash or near crash (AOR = 6.71, P less than .05).

“This is a strong piece of evidence that nighttime driving is less safe than daytime driving and limiting amount of nighttime driving could be one method to moderate road risk for some individuals,” the authors wrote.

The study’s limitations include its observational nature, low numbers of participants with several of the sleeping disorders (at levels below the disorder’s prevalence in the general population), and the complexities involved in what causes a crash or near crash.

One limitation of this study was that sleep hygiene and sleep quality were not examined, even though these might contribute significantly to roadway safety, the researchers noted. This study also did not take into account what medications or other treatment (such as continuous positive airway pressure for those with sleep apnea) the participants might be receiving for their condition.

The study’s implications include the need for physicians to advise patients with insomnia or females with sleep apnea to use caution while driving without “exaggerating risks that introduce undue fear to patients with other sleep disorders and thereby limiting mobility unnecessarily,” the authors wrote. The researchers also suggested that employers consider providing alternative transportation to shift workers and/or that insurance companies offer employers lower rates for offering such alternatives.

SOURCE: Liu Shu-Yuan et al. Sleep J. 2018 Apr 1. doi: 10.1093/sleep/zsy023.

Individuals with certain sleeping disorders may have a higher risk of crashes, near-crashes or unsafe maneuvering prior to such events, suggests a study.

“The results confirm that some sleep disorders generally increase driving risk as defined by our dependent measures,” wrote Shu-Yuan Liu, a doctoral student, and two colleagues at Virginia Tech, Blacksburg (Sleep. 2018 Apr 1. doi: 10.1093/sleep/zsy023). “Furthermore, the results also provide some insights into how risk varies across specific types of sleep disorder and some moderating factors.”

GummyBone/iStock/Getty Images

“Drivers who reported frequency of sleepy driving as ‘never,’ ‘rarely,’ and ‘sometimes’ also had higher a risk, indicating that crash or near-crash risk is also associated with sources other than these sleeping disorders,” the authors noted. These drivers’ increased odds of getting into or nearly getting into a crash ranged from 31% to 53% greater (P less than .05).

All drivers with shift work sleep disorder, except for those aged 20-24, had a crash or near-crash rate that was 7.5 times greater than that of drivers without any sleeping disorders. The rate among drivers aged 20-24 with this disorder had a 90% lower rate (risk ratio [RR] = 0.1, P less than .05) compared with control drivers.

When the researchers analyzed the drivers’ maneuvers just before a crash or near-crash, they found females with sleep apnea had a 36% greater odds of doing an unsafe maneuver in crash/near-crash circumstances (AOR = 1.36). Females with RLS and any drivers with shift work sleep disorder were more than twice as likely to perform unsafe maneuvers (AOR = 3.38 and 3.53, respectively, P less than .05).

The only drivers with a sleeping disorder who were more likely to be involved in crashes of greater severity were those with periodic limb movement disorder (AOR = 1.43, P less than .05).

However, young drivers, senior drivers, and nighttime drivers also all had higher odds of being involved in more severe crashes and in performing unsafe maneuvers prior to a crash or near-crash. Nighttime drivers seemed to be most at risk for these, and they were linked to having more than 5 times greater odds of unsafely maneuvering their vehicles prior to getting into a crash or near crash (AOR = 6.71, P less than .05).

“This is a strong piece of evidence that nighttime driving is less safe than daytime driving and limiting amount of nighttime driving could be one method to moderate road risk for some individuals,” the authors wrote.

The study’s limitations include its observational nature, low numbers of participants with several of the sleeping disorders (at levels below the disorder’s prevalence in the general population), and the complexities involved in what causes a crash or near crash.

One limitation of this study was that sleep hygiene and sleep quality were not examined, even though these might contribute significantly to roadway safety, the researchers noted. This study also did not take into account what medications or other treatment (such as continuous positive airway pressure for those with sleep apnea) the participants might be receiving for their condition.

The study’s implications include the need for physicians to advise patients with insomnia or females with sleep apnea to use caution while driving without “exaggerating risks that introduce undue fear to patients with other sleep disorders and thereby limiting mobility unnecessarily,” the authors wrote. The researchers also suggested that employers consider providing alternative transportation to shift workers and/or that insurance companies offer employers lower rates for offering such alternatives.

SOURCE: Liu Shu-Yuan et al. Sleep J. 2018 Apr 1. doi: 10.1093/sleep/zsy023.

It’s time to introduce a new paradigm for comprehensive care of women’s physical and mental health in the 3 months after giving birth, according to the American College of Obstetricians and Gynecologists.

In their newly revised committee opinion on postpartum care, ACOG encouraged doctors to think of a woman’s immediate postpartum period as a “fourth trimester” during which better care for women may help reduce maternal deaths and morbidity. That care includes a 3-week postpartum visit and a more comprehensive one within 3 months post partum.

Components of comprehensive postpartum care

ACOG recommends the prenatal preparation for the postpartum period include discussions about infant feeding, “baby blues,” postpartum emotional health, parenting challenges, postpartum recovery from birth, long-term management of chronic health conditions, choosing a primary care provider for the mother’s ongoing care, her reproductive desires and choices, and any concerns about interpersonal or partner violence.

Before giving birth, a woman should develop a postpartum care plan with her physician and assemble a care team that includes her primary care providers along with family and friends who can provide support. The plan should include contact information for questions and written instructions about postpartum visits and follow-up care.

Prenatal planning also provides an opportunity to discuss a woman’s breastfeeding plans, goals, and questions as well as common physical problems that women may experience in the weeks after giving birth, such as heavy bleeding, pain, physical exhaustion, and urinary incontinence.

Physicians should inform women of the risks and benefits of becoming pregnant within 18 months and advise them not to have pregnancy intervals of less than 6 months. They should also ensure women know all their contraceptive options and should provide any information necessary for women to determine which methods best meet her needs.

The committee recommended a postpartum visit within the first 3 weeks after birth, instead of the current “6-week check,” that is timed and tailored to each woman’s particular needs. This visit allows assessment of postpartum depression risk and/or treatment and discussion of breastfeeding goals and/or difficulties. Approximately one in five women who stopped breastfeeding earlier than they wanted to had ceased within first 6 weeks post partum.

Woman-centered follow-up should be tailored to women’s individual needs and include a comprehensive postpartum visit no later than 12 weeks after giving birth. The comprehensive visit should include a complete assessment of the woman’s physical, social, and psychological well-being, including discussion of “mood and emotional well-being, infant care and feeding, sexuality, contraception, birth spacing, sleep and fatigue, physical recovery from birth, chronic disease management, and health maintenance,” the committee wrote.

The comprehensive visit should include the following components:

• Postpartum depression and anxiety screening.
• Screening for tobacco use and substance use.
• Follow-up on preexisting mental and physical health conditions.
• Assessment of mother’s confidence and comfort with newborn care, including feeding method, childcare strategy, identification of the child’s medical home, and recommended immunizations for all caregivers.
• Comfort and confidence with breastfeeding and management of any challenges, such as breastfeeding-associated pain; logistics and legal rights after returning to work or school; and fertility and contraception with breastfeeding.
• Assessment of material needs, including housing, utilities, food, and diapers.
• Guidance on sexuality, dyspareunia, reproductive life plans, contraception, and management of recurrent pregnancy complications, such as daily low-dose aspirin to reduce preeclampsia risk and 17a-hydroxyprogesterone caproate to reduce recurrent preterm birth.
• Sleep, fatigue, and coping options.
• Physical recovery from birth, including assessment of urinary and fecal continence and guidance on physical activity and a healthy weight.
• Chronic disease management and long-term implications of those conditions.
• Health maintenance, including review of vaccination history, needed vaccinations, and well-woman screenings, including Pap test and pelvic examination as indicated.

“However timed, the comprehensive postpartum visit is a medical appointment; it is not an ‘all-clear’ signal,” the authors wrote. “Obstetrician-gynecologists and other obstetric care providers should ensure that women, their families, and their employers understand that completion of the comprehensive postpartum visit does not obviate the need for continued recovery and support through 6 weeks’ post partum and beyond.”

Women with comorbidities or adverse birth outcomes

Women who had gestational diabetes, gestational hypertension, preeclampsia, eclampsia, or a preterm birth should be informed of their increased lifetime risk of cardiovascular and metabolic disease, the committee recommended. Women who have experienced a miscarriage, stillbirth, or neonatal death should also follow up with their provider, who can offer resources for emotional support and bereavement counseling, referrals as needed, a review of any laboratory or pathology results related to the loss and counseling regarding future risks and pregnancies.

The committee recommended that women with chronic medical conditions follow up with their ob.gyn. or other primary care providers to ensure ongoing coordinated care for hypertension, obesity, diabetes, thyroid disorders, renal disease, mood disorders, substance use disorders, seizure disorders, and any other chronic issues. Care should include assessment of medications, including antiepileptics and psychotropic drugs, that may require adjustment for postpartum physiology and, if relevant, breastfeeding.

Since half of postpartum strokes occur within the first 10 days after discharge, ACOG recommends women with other hypertensive disorders of pregnancy have a postpartum visit within 7-10 days after birth to assess blood pressure. A follow-up visit should occur within 72 hours for those with severe hypertension.

ACOG also recommended early postpartum follow-up for women with increased risk of complications, including postpartum depression, cesarean or perennial wound infections, lactation difficulties, or chronic conditions.

SOURCE: Obstet Gynecol 2018;131:e140-50.

It’s time to introduce a new paradigm for comprehensive care of women’s physical and mental health in the 3 months after giving birth, according to the American College of Obstetricians and Gynecologists.

In their newly revised committee opinion on postpartum care, ACOG encouraged doctors to think of a woman’s immediate postpartum period as a “fourth trimester” during which better care for women may help reduce maternal deaths and morbidity. That care includes a 3-week postpartum visit and a more comprehensive one within 3 months post partum.

Components of comprehensive postpartum care

ACOG recommends the prenatal preparation for the postpartum period include discussions about infant feeding, “baby blues,” postpartum emotional health, parenting challenges, postpartum recovery from birth, long-term management of chronic health conditions, choosing a primary care provider for the mother’s ongoing care, her reproductive desires and choices, and any concerns about interpersonal or partner violence.

Before giving birth, a woman should develop a postpartum care plan with her physician and assemble a care team that includes her primary care providers along with family and friends who can provide support. The plan should include contact information for questions and written instructions about postpartum visits and follow-up care.

Prenatal planning also provides an opportunity to discuss a woman’s breastfeeding plans, goals, and questions as well as common physical problems that women may experience in the weeks after giving birth, such as heavy bleeding, pain, physical exhaustion, and urinary incontinence.

Physicians should inform women of the risks and benefits of becoming pregnant within 18 months and advise them not to have pregnancy intervals of less than 6 months. They should also ensure women know all their contraceptive options and should provide any information necessary for women to determine which methods best meet her needs.

The committee recommended a postpartum visit within the first 3 weeks after birth, instead of the current “6-week check,” that is timed and tailored to each woman’s particular needs. This visit allows assessment of postpartum depression risk and/or treatment and discussion of breastfeeding goals and/or difficulties. Approximately one in five women who stopped breastfeeding earlier than they wanted to had ceased within first 6 weeks post partum.

Woman-centered follow-up should be tailored to women’s individual needs and include a comprehensive postpartum visit no later than 12 weeks after giving birth. The comprehensive visit should include a complete assessment of the woman’s physical, social, and psychological well-being, including discussion of “mood and emotional well-being, infant care and feeding, sexuality, contraception, birth spacing, sleep and fatigue, physical recovery from birth, chronic disease management, and health maintenance,” the committee wrote.

The comprehensive visit should include the following components:

• Postpartum depression and anxiety screening.
• Screening for tobacco use and substance use.
• Follow-up on preexisting mental and physical health conditions.
• Assessment of mother’s confidence and comfort with newborn care, including feeding method, childcare strategy, identification of the child’s medical home, and recommended immunizations for all caregivers.
• Comfort and confidence with breastfeeding and management of any challenges, such as breastfeeding-associated pain; logistics and legal rights after returning to work or school; and fertility and contraception with breastfeeding.
• Assessment of material needs, including housing, utilities, food, and diapers.
• Guidance on sexuality, dyspareunia, reproductive life plans, contraception, and management of recurrent pregnancy complications, such as daily low-dose aspirin to reduce preeclampsia risk and 17a-hydroxyprogesterone caproate to reduce recurrent preterm birth.
• Sleep, fatigue, and coping options.
• Physical recovery from birth, including assessment of urinary and fecal continence and guidance on physical activity and a healthy weight.
• Chronic disease management and long-term implications of those conditions.
• Health maintenance, including review of vaccination history, needed vaccinations, and well-woman screenings, including Pap test and pelvic examination as indicated.

“However timed, the comprehensive postpartum visit is a medical appointment; it is not an ‘all-clear’ signal,” the authors wrote. “Obstetrician-gynecologists and other obstetric care providers should ensure that women, their families, and their employers understand that completion of the comprehensive postpartum visit does not obviate the need for continued recovery and support through 6 weeks’ post partum and beyond.”

Women with comorbidities or adverse birth outcomes

Women who had gestational diabetes, gestational hypertension, preeclampsia, eclampsia, or a preterm birth should be informed of their increased lifetime risk of cardiovascular and metabolic disease, the committee recommended. Women who have experienced a miscarriage, stillbirth, or neonatal death should also follow up with their provider, who can offer resources for emotional support and bereavement counseling, referrals as needed, a review of any laboratory or pathology results related to the loss and counseling regarding future risks and pregnancies.

The committee recommended that women with chronic medical conditions follow up with their ob.gyn. or other primary care providers to ensure ongoing coordinated care for hypertension, obesity, diabetes, thyroid disorders, renal disease, mood disorders, substance use disorders, seizure disorders, and any other chronic issues. Care should include assessment of medications, including antiepileptics and psychotropic drugs, that may require adjustment for postpartum physiology and, if relevant, breastfeeding.

Since half of postpartum strokes occur within the first 10 days after discharge, ACOG recommends women with other hypertensive disorders of pregnancy have a postpartum visit within 7-10 days after birth to assess blood pressure. A follow-up visit should occur within 72 hours for those with severe hypertension.

ACOG also recommended early postpartum follow-up for women with increased risk of complications, including postpartum depression, cesarean or perennial wound infections, lactation difficulties, or chronic conditions.

SOURCE: Obstet Gynecol 2018;131:e140-50.

It’s time to introduce a new paradigm for comprehensive care of women’s physical and mental health in the 3 months after giving birth, according to the American College of Obstetricians and Gynecologists.

In their newly revised committee opinion on postpartum care, ACOG encouraged doctors to think of a woman’s immediate postpartum period as a “fourth trimester” during which better care for women may help reduce maternal deaths and morbidity. That care includes a 3-week postpartum visit and a more comprehensive one within 3 months post partum.

Components of comprehensive postpartum care

ACOG recommends the prenatal preparation for the postpartum period include discussions about infant feeding, “baby blues,” postpartum emotional health, parenting challenges, postpartum recovery from birth, long-term management of chronic health conditions, choosing a primary care provider for the mother’s ongoing care, her reproductive desires and choices, and any concerns about interpersonal or partner violence.

Before giving birth, a woman should develop a postpartum care plan with her physician and assemble a care team that includes her primary care providers along with family and friends who can provide support. The plan should include contact information for questions and written instructions about postpartum visits and follow-up care.

Prenatal planning also provides an opportunity to discuss a woman’s breastfeeding plans, goals, and questions as well as common physical problems that women may experience in the weeks after giving birth, such as heavy bleeding, pain, physical exhaustion, and urinary incontinence.

Physicians should inform women of the risks and benefits of becoming pregnant within 18 months and advise them not to have pregnancy intervals of less than 6 months. They should also ensure women know all their contraceptive options and should provide any information necessary for women to determine which methods best meet her needs.

The committee recommended a postpartum visit within the first 3 weeks after birth, instead of the current “6-week check,” that is timed and tailored to each woman’s particular needs. This visit allows assessment of postpartum depression risk and/or treatment and discussion of breastfeeding goals and/or difficulties. Approximately one in five women who stopped breastfeeding earlier than they wanted to had ceased within first 6 weeks post partum.

Woman-centered follow-up should be tailored to women’s individual needs and include a comprehensive postpartum visit no later than 12 weeks after giving birth. The comprehensive visit should include a complete assessment of the woman’s physical, social, and psychological well-being, including discussion of “mood and emotional well-being, infant care and feeding, sexuality, contraception, birth spacing, sleep and fatigue, physical recovery from birth, chronic disease management, and health maintenance,” the committee wrote.

The comprehensive visit should include the following components:

• Postpartum depression and anxiety screening.
• Screening for tobacco use and substance use.
• Follow-up on preexisting mental and physical health conditions.
• Assessment of mother’s confidence and comfort with newborn care, including feeding method, childcare strategy, identification of the child’s medical home, and recommended immunizations for all caregivers.
• Comfort and confidence with breastfeeding and management of any challenges, such as breastfeeding-associated pain; logistics and legal rights after returning to work or school; and fertility and contraception with breastfeeding.
• Assessment of material needs, including housing, utilities, food, and diapers.
• Guidance on sexuality, dyspareunia, reproductive life plans, contraception, and management of recurrent pregnancy complications, such as daily low-dose aspirin to reduce preeclampsia risk and 17a-hydroxyprogesterone caproate to reduce recurrent preterm birth.
• Sleep, fatigue, and coping options.
• Physical recovery from birth, including assessment of urinary and fecal continence and guidance on physical activity and a healthy weight.
• Chronic disease management and long-term implications of those conditions.
• Health maintenance, including review of vaccination history, needed vaccinations, and well-woman screenings, including Pap test and pelvic examination as indicated.

“However timed, the comprehensive postpartum visit is a medical appointment; it is not an ‘all-clear’ signal,” the authors wrote. “Obstetrician-gynecologists and other obstetric care providers should ensure that women, their families, and their employers understand that completion of the comprehensive postpartum visit does not obviate the need for continued recovery and support through 6 weeks’ post partum and beyond.”

Women with comorbidities or adverse birth outcomes

Women who had gestational diabetes, gestational hypertension, preeclampsia, eclampsia, or a preterm birth should be informed of their increased lifetime risk of cardiovascular and metabolic disease, the committee recommended. Women who have experienced a miscarriage, stillbirth, or neonatal death should also follow up with their provider, who can offer resources for emotional support and bereavement counseling, referrals as needed, a review of any laboratory or pathology results related to the loss and counseling regarding future risks and pregnancies.

The committee recommended that women with chronic medical conditions follow up with their ob.gyn. or other primary care providers to ensure ongoing coordinated care for hypertension, obesity, diabetes, thyroid disorders, renal disease, mood disorders, substance use disorders, seizure disorders, and any other chronic issues. Care should include assessment of medications, including antiepileptics and psychotropic drugs, that may require adjustment for postpartum physiology and, if relevant, breastfeeding.

Since half of postpartum strokes occur within the first 10 days after discharge, ACOG recommends women with other hypertensive disorders of pregnancy have a postpartum visit within 7-10 days after birth to assess blood pressure. A follow-up visit should occur within 72 hours for those with severe hypertension.

ACOG also recommended early postpartum follow-up for women with increased risk of complications, including postpartum depression, cesarean or perennial wound infections, lactation difficulties, or chronic conditions.

SOURCE: Obstet Gynecol 2018;131:e140-50.

Neither the first nor second dose of the monovalent rotavirus vaccine increased the risk of intussusception in the 3 weeks after immunization, a recent study found.

“This finding contrasts with previous studies in high- and upper-middle-income countries, in which an association with intussusception was found,” Jacqueline E. Tate, PhD, of the Centers for Disease Control and Prevention, and her associates reported in the New England Journal of Medicine.

Esben H/iStock/Getty Images

SOURCE: Tate JE et al. N Engl J Med. 2018;378:1521-8.

Neither the first nor second dose of the monovalent rotavirus vaccine increased the risk of intussusception in the 3 weeks after immunization, a recent study found.

“This finding contrasts with previous studies in high- and upper-middle-income countries, in which an association with intussusception was found,” Jacqueline E. Tate, PhD, of the Centers for Disease Control and Prevention, and her associates reported in the New England Journal of Medicine.

Esben H/iStock/Getty Images

SOURCE: Tate JE et al. N Engl J Med. 2018;378:1521-8.

Neither the first nor second dose of the monovalent rotavirus vaccine increased the risk of intussusception in the 3 weeks after immunization, a recent study found.

“This finding contrasts with previous studies in high- and upper-middle-income countries, in which an association with intussusception was found,” Jacqueline E. Tate, PhD, of the Centers for Disease Control and Prevention, and her associates reported in the New England Journal of Medicine.

Esben H/iStock/Getty Images

SOURCE: Tate JE et al. N Engl J Med. 2018;378:1521-8.

A hospital quality improvement initiative reduced antibiotic use by more than half when well-appearing newborns exposed to chorioamnionitis were initially monitored for symptoms instead of routinely given antibiotics, found a study in Pediatrics.

“The reduction in both antibiotic use and laboratory testing occurred without clinically relevant delays in care or poor outcomes,” wrote Neha S. Joshi, MD, of Stanford (Calif.) University and her associates.

tatyana_tomsickova/Thinkstock

The researchers collected data on antibiotic use, lab tests, cultures, and clinical outcomes from the remaining 277 well-appearing newborns; 88% did not receive antibiotics during their hospital stay, and 83% underwent no laboratory testing. Only 17% of infants had lab testing for sepsis; none had culture result–positive, early-onset sepsis.

Only 12% of infants who initially appeared well developed signs/symptoms of sepsis, underwent laboratory testing, and received antibiotics. Nearly half of these (5% of all infants) received antibiotic treatment for at least 5 days despite negative cultures, while the other 7% received antibiotics for less than 48 hours, Dr. Joshi and her colleagues reported.

Infants with at least 34 weeks’ gestation receiving antibiotics at the hospital dropped from 12.3% before the initiative to 5.5% afterward, a 55% decrease (95% confidence interval, 40%-60%), the researchers said. Study limitations included a lack of postdischarge follow-up, the variability in physician decisions about which infants were symptomatic and which ones needed antibiotics, and an inability to generalize findings to institutions without 24/7 availability of neonatal hospitalists.

Past studies have found that all newborns with positive cultures showed symptoms at birth and needed resuscitation, continuous positive airway pressure, or intubation.

“An infant who is well-appearing at birth likely has an even lower risk of early-onset sepsis even in the setting of chorioamnionitis, and an empirical antibiotic treatment strategy for chorioamnionitis-exposed infants will result in a large number of uninfected infants being treated,” Dr. Joshi and her associates said. “Updated treatment approaches are needed to reduce unnecessary antibiotic exposure and provide higher-value care in this population.”

The study did not use external funding. The authors had no disclosures.

SOURCE: Joshi NS et al. Pediatrics. 2018;141(4):e20172056.

A hospital quality improvement initiative reduced antibiotic use by more than half when well-appearing newborns exposed to chorioamnionitis were initially monitored for symptoms instead of routinely given antibiotics, found a study in Pediatrics.

“The reduction in both antibiotic use and laboratory testing occurred without clinically relevant delays in care or poor outcomes,” wrote Neha S. Joshi, MD, of Stanford (Calif.) University and her associates.

tatyana_tomsickova/Thinkstock

The researchers collected data on antibiotic use, lab tests, cultures, and clinical outcomes from the remaining 277 well-appearing newborns; 88% did not receive antibiotics during their hospital stay, and 83% underwent no laboratory testing. Only 17% of infants had lab testing for sepsis; none had culture result–positive, early-onset sepsis.

Only 12% of infants who initially appeared well developed signs/symptoms of sepsis, underwent laboratory testing, and received antibiotics. Nearly half of these (5% of all infants) received antibiotic treatment for at least 5 days despite negative cultures, while the other 7% received antibiotics for less than 48 hours, Dr. Joshi and her colleagues reported.

Infants with at least 34 weeks’ gestation receiving antibiotics at the hospital dropped from 12.3% before the initiative to 5.5% afterward, a 55% decrease (95% confidence interval, 40%-60%), the researchers said. Study limitations included a lack of postdischarge follow-up, the variability in physician decisions about which infants were symptomatic and which ones needed antibiotics, and an inability to generalize findings to institutions without 24/7 availability of neonatal hospitalists.

Past studies have found that all newborns with positive cultures showed symptoms at birth and needed resuscitation, continuous positive airway pressure, or intubation.

“An infant who is well-appearing at birth likely has an even lower risk of early-onset sepsis even in the setting of chorioamnionitis, and an empirical antibiotic treatment strategy for chorioamnionitis-exposed infants will result in a large number of uninfected infants being treated,” Dr. Joshi and her associates said. “Updated treatment approaches are needed to reduce unnecessary antibiotic exposure and provide higher-value care in this population.”

The study did not use external funding. The authors had no disclosures.

SOURCE: Joshi NS et al. Pediatrics. 2018;141(4):e20172056.

A hospital quality improvement initiative reduced antibiotic use by more than half when well-appearing newborns exposed to chorioamnionitis were initially monitored for symptoms instead of routinely given antibiotics, found a study in Pediatrics.

“The reduction in both antibiotic use and laboratory testing occurred without clinically relevant delays in care or poor outcomes,” wrote Neha S. Joshi, MD, of Stanford (Calif.) University and her associates.

tatyana_tomsickova/Thinkstock

The researchers collected data on antibiotic use, lab tests, cultures, and clinical outcomes from the remaining 277 well-appearing newborns; 88% did not receive antibiotics during their hospital stay, and 83% underwent no laboratory testing. Only 17% of infants had lab testing for sepsis; none had culture result–positive, early-onset sepsis.

Only 12% of infants who initially appeared well developed signs/symptoms of sepsis, underwent laboratory testing, and received antibiotics. Nearly half of these (5% of all infants) received antibiotic treatment for at least 5 days despite negative cultures, while the other 7% received antibiotics for less than 48 hours, Dr. Joshi and her colleagues reported.

Infants with at least 34 weeks’ gestation receiving antibiotics at the hospital dropped from 12.3% before the initiative to 5.5% afterward, a 55% decrease (95% confidence interval, 40%-60%), the researchers said. Study limitations included a lack of postdischarge follow-up, the variability in physician decisions about which infants were symptomatic and which ones needed antibiotics, and an inability to generalize findings to institutions without 24/7 availability of neonatal hospitalists.

Past studies have found that all newborns with positive cultures showed symptoms at birth and needed resuscitation, continuous positive airway pressure, or intubation.

“An infant who is well-appearing at birth likely has an even lower risk of early-onset sepsis even in the setting of chorioamnionitis, and an empirical antibiotic treatment strategy for chorioamnionitis-exposed infants will result in a large number of uninfected infants being treated,” Dr. Joshi and her associates said. “Updated treatment approaches are needed to reduce unnecessary antibiotic exposure and provide higher-value care in this population.”

The study did not use external funding. The authors had no disclosures.

SOURCE: Joshi NS et al. Pediatrics. 2018;141(4):e20172056.

Burnout affects the mental health of pediatricians and other health care providers treating children – and the quality of care they provide, according to two Pediatrics articles highlighted by editor in chief Lewis R. First, MD, MS.

The studies investigated the prevalence and effects of burnout among pediatric residents, and all health care providers, working in intensive care units. They were among those published in 2017 that Dr. First deemed potentially practice changing – ones whose clinical implications may have immediate relevance in your daily work.

“There are a variety of ways to overcome burnout and promote our resiliency that starts with our ability to find joy in caring for children and our lifelong learning” through professional development sessions and academic journals, according to Dr. First, professor and chair of pediatrics at the University of Vermont in Burlington. He also serves as chief of pediatrics at the University of Vermont Children’s Hospital. He spoke at the 2017 annual meeting of the American Academy of Pediatrics and in later interviews.
 

High prevalence of burnout

The study by Baer et al. found that almost two in five pediatric residents experience burnout, often accompanied by poorer care of patients (Pediatrics. 2017. doi: 10.1542/peds.2016-2163). Using a 7-point Likert scale ranging from “never” to “every day,” 258 residents from 11 different residency programs filled out an anonymous Web-based survey on how often they felt emotional exhaustion (“I feel burnout from my work”) and depersonalization (“I’ve become more callous toward people since I took this job”).

humonia/Thinkstock

Of the 258 respondents, 39% had burnout, defined as answering affirmatively to either of the above questions with at least “weekly.” Most of the respondents were female, white, and married or in a long-term relationship without children, but the burnout rates did not vary across gender, race/ethnicity, relationship or parental status, or among different characteristics of the residency program and schedule. Higher burnout rates did occur among those feeling sleep deprived.

Those with burnout also had substantially higher odds of providing lower-quality care. Residents with burnout were seven times more likely to make treatment or medication errors not related to inadequate knowledge or experience, six times more likely to feel guilty about how they had treated a patient, more than four times more likely to report having little emotional reaction to a patient’s death, and four times more likely to discharge a patient earlier to make service more manageable. Burned-out residents had more than nine times greater odds of paying “little attention to the social or personal impact of an illness on a patient,” the study showed.
 

Burnout symptoms and solutions

Symptoms of potential burnout, Dr. First said in an interview, include emotional exhaustion, feeling a loss of meaning in work, feelings of ineffectiveness, a tendency to view people as objects instead of human beings, increasingly poor communication, and poor interpersonal and clinical skills and behaviors.

• Reduce the burden of bureaucratic tasks.
• Examine how many hours physicians spend at home or work at home.
• Improve efficiency, such as in EHR use.
• Provide individuals time to discuss stressors and ways to resolve them collaboratively with peers and leadership.

Burnout risk in the NICU

Similar interventions may help with burnout in neonatal ICUs (NICUs), the focus of the second study Dr. First discussed. Tawfik et al. surveyed 2,760 personnel from 41 NICUs in the United States to learn the prevalence of burnout and how it was associated with NICU organization (Pediatrics. 2017. doi: 10.1542/peds.2016-4134).

Among the 1,934 providers who replied (a response rate of 70%), 27% had burnout; at individual NICUs, burnout prevalence varied from 8% to 43%. The majority of respondents (72%) were registered nurses, followed by respiratory therapists, physicians, neonatal nurse practitioners, and others. The highest burnout rates occurred in NICUs with higher average daily admissions and higher average occupancy – and those using EHRs.

“Don’t assume that just because you use the EHR every day means you know how best to use this tool to improve your efficiency and effectiveness in generating and deriving information on your patients,” Dr. First said in the interview. He encouraged physicians to find out what resources their institutions might offer to help, such as EHR hospital teams or office support who can look at providers’ EHR usage, and show them shortcuts and time-savers to improve efficiency based on their usage patterns.

“Nursing burnout was more sensitive to the setting than physician burnout, especially in regard to average daily admissions, late transfer numbers, nursing hours per patient day, and mortality per 1,000 infants,” Dr. First noted.

Interestingly, burnout prevalence was not associated with the proportion of high-risk patients seen in the NICUs, the number of attending physicians in the unit, or whether the institution was a teaching hospital or not, he said.

Dr. First listed strategies to reduce burnout risk in NICUs that the study authors also described: expressing thankfulness each day, focusing on positive events at the start or end of each day, performing random acts of kindness for colleagues and staff, and encouraging providers to identify the strengths in one another.
 

Addressing burnout requires efforts from everyone

“Given the potential effects of burnout on patient care and professionalism and physician wellness, it is important for physicians to speak up if they have concerns about burnout in their colleagues,” Dr. Baer said in the interview.

Burnout is common, she said, occurring in more than half of physicians at some point in time, so a doctor experiencing it is almost certainly not alone among colleagues.

“Physicians can work together and with their leadership to prevent and mitigate the effects of burnout by promoting personal and professional wellness, effective teamwork, and reducing the administrative burdens that impact time spent directly with patients and have been demonstrated to contribute to physician burnout,” Dr. Baer noted.

She also pointed to the need to address it in medical education, given the downstream risks of burnout on the next generation of physicians.

“Medical schools and residency and fellowship programs should address the risks and signs of burnout, as medical students and trainees are likely seeing signs of burnout in some of their physician teachers and mentors,” Dr. Baer said in the interview.

Some burnout among providers may be inevitable at times, but it’s important to continue looking for ways to combat it.

“We need to do more to remind each other of why we chose our profession, and how good it makes us feel to strive to make a difference in our patients and families each and every day,” Dr. First said in the interview.

Dr. First reported having no disclosures and no external funding. The residents’ study by Baer et al. was funded by the Boston Children’s Hospital’s Fred Lovejoy Resident Research Award and a grant from the Health Resources and Services Administration. The NICU study by Tamfik et al. was funded by the National Institutes of Health, grants from the National Institute of Child Health and Human Development, and the Jackson Vaughan Critical Care Research Fund. The authors of both studies had no relevant financial disclosures.

Burnout affects the mental health of pediatricians and other health care providers treating children – and the quality of care they provide, according to two Pediatrics articles highlighted by editor in chief Lewis R. First, MD, MS.

The studies investigated the prevalence and effects of burnout among pediatric residents, and all health care providers, working in intensive care units. They were among those published in 2017 that Dr. First deemed potentially practice changing – ones whose clinical implications may have immediate relevance in your daily work.

“There are a variety of ways to overcome burnout and promote our resiliency that starts with our ability to find joy in caring for children and our lifelong learning” through professional development sessions and academic journals, according to Dr. First, professor and chair of pediatrics at the University of Vermont in Burlington. He also serves as chief of pediatrics at the University of Vermont Children’s Hospital. He spoke at the 2017 annual meeting of the American Academy of Pediatrics and in later interviews.
 

High prevalence of burnout

The study by Baer et al. found that almost two in five pediatric residents experience burnout, often accompanied by poorer care of patients (Pediatrics. 2017. doi: 10.1542/peds.2016-2163). Using a 7-point Likert scale ranging from “never” to “every day,” 258 residents from 11 different residency programs filled out an anonymous Web-based survey on how often they felt emotional exhaustion (“I feel burnout from my work”) and depersonalization (“I’ve become more callous toward people since I took this job”).

humonia/Thinkstock

Of the 258 respondents, 39% had burnout, defined as answering affirmatively to either of the above questions with at least “weekly.” Most of the respondents were female, white, and married or in a long-term relationship without children, but the burnout rates did not vary across gender, race/ethnicity, relationship or parental status, or among different characteristics of the residency program and schedule. Higher burnout rates did occur among those feeling sleep deprived.

Those with burnout also had substantially higher odds of providing lower-quality care. Residents with burnout were seven times more likely to make treatment or medication errors not related to inadequate knowledge or experience, six times more likely to feel guilty about how they had treated a patient, more than four times more likely to report having little emotional reaction to a patient’s death, and four times more likely to discharge a patient earlier to make service more manageable. Burned-out residents had more than nine times greater odds of paying “little attention to the social or personal impact of an illness on a patient,” the study showed.
 

Burnout symptoms and solutions

Symptoms of potential burnout, Dr. First said in an interview, include emotional exhaustion, feeling a loss of meaning in work, feelings of ineffectiveness, a tendency to view people as objects instead of human beings, increasingly poor communication, and poor interpersonal and clinical skills and behaviors.

• Reduce the burden of bureaucratic tasks.
• Examine how many hours physicians spend at home or work at home.
• Improve efficiency, such as in EHR use.
• Provide individuals time to discuss stressors and ways to resolve them collaboratively with peers and leadership.

Burnout risk in the NICU

Similar interventions may help with burnout in neonatal ICUs (NICUs), the focus of the second study Dr. First discussed. Tawfik et al. surveyed 2,760 personnel from 41 NICUs in the United States to learn the prevalence of burnout and how it was associated with NICU organization (Pediatrics. 2017. doi: 10.1542/peds.2016-4134).

Among the 1,934 providers who replied (a response rate of 70%), 27% had burnout; at individual NICUs, burnout prevalence varied from 8% to 43%. The majority of respondents (72%) were registered nurses, followed by respiratory therapists, physicians, neonatal nurse practitioners, and others. The highest burnout rates occurred in NICUs with higher average daily admissions and higher average occupancy – and those using EHRs.

“Don’t assume that just because you use the EHR every day means you know how best to use this tool to improve your efficiency and effectiveness in generating and deriving information on your patients,” Dr. First said in the interview. He encouraged physicians to find out what resources their institutions might offer to help, such as EHR hospital teams or office support who can look at providers’ EHR usage, and show them shortcuts and time-savers to improve efficiency based on their usage patterns.

“Nursing burnout was more sensitive to the setting than physician burnout, especially in regard to average daily admissions, late transfer numbers, nursing hours per patient day, and mortality per 1,000 infants,” Dr. First noted.

Interestingly, burnout prevalence was not associated with the proportion of high-risk patients seen in the NICUs, the number of attending physicians in the unit, or whether the institution was a teaching hospital or not, he said.

Dr. First listed strategies to reduce burnout risk in NICUs that the study authors also described: expressing thankfulness each day, focusing on positive events at the start or end of each day, performing random acts of kindness for colleagues and staff, and encouraging providers to identify the strengths in one another.
 

Addressing burnout requires efforts from everyone

“Given the potential effects of burnout on patient care and professionalism and physician wellness, it is important for physicians to speak up if they have concerns about burnout in their colleagues,” Dr. Baer said in the interview.

Burnout is common, she said, occurring in more than half of physicians at some point in time, so a doctor experiencing it is almost certainly not alone among colleagues.

“Physicians can work together and with their leadership to prevent and mitigate the effects of burnout by promoting personal and professional wellness, effective teamwork, and reducing the administrative burdens that impact time spent directly with patients and have been demonstrated to contribute to physician burnout,” Dr. Baer noted.

She also pointed to the need to address it in medical education, given the downstream risks of burnout on the next generation of physicians.

“Medical schools and residency and fellowship programs should address the risks and signs of burnout, as medical students and trainees are likely seeing signs of burnout in some of their physician teachers and mentors,” Dr. Baer said in the interview.

Some burnout among providers may be inevitable at times, but it’s important to continue looking for ways to combat it.

“We need to do more to remind each other of why we chose our profession, and how good it makes us feel to strive to make a difference in our patients and families each and every day,” Dr. First said in the interview.

Dr. First reported having no disclosures and no external funding. The residents’ study by Baer et al. was funded by the Boston Children’s Hospital’s Fred Lovejoy Resident Research Award and a grant from the Health Resources and Services Administration. The NICU study by Tamfik et al. was funded by the National Institutes of Health, grants from the National Institute of Child Health and Human Development, and the Jackson Vaughan Critical Care Research Fund. The authors of both studies had no relevant financial disclosures.

Burnout affects the mental health of pediatricians and other health care providers treating children – and the quality of care they provide, according to two Pediatrics articles highlighted by editor in chief Lewis R. First, MD, MS.

The studies investigated the prevalence and effects of burnout among pediatric residents, and all health care providers, working in intensive care units. They were among those published in 2017 that Dr. First deemed potentially practice changing – ones whose clinical implications may have immediate relevance in your daily work.

“There are a variety of ways to overcome burnout and promote our resiliency that starts with our ability to find joy in caring for children and our lifelong learning” through professional development sessions and academic journals, according to Dr. First, professor and chair of pediatrics at the University of Vermont in Burlington. He also serves as chief of pediatrics at the University of Vermont Children’s Hospital. He spoke at the 2017 annual meeting of the American Academy of Pediatrics and in later interviews.
 

High prevalence of burnout

The study by Baer et al. found that almost two in five pediatric residents experience burnout, often accompanied by poorer care of patients (Pediatrics. 2017. doi: 10.1542/peds.2016-2163). Using a 7-point Likert scale ranging from “never” to “every day,” 258 residents from 11 different residency programs filled out an anonymous Web-based survey on how often they felt emotional exhaustion (“I feel burnout from my work”) and depersonalization (“I’ve become more callous toward people since I took this job”).

humonia/Thinkstock

Of the 258 respondents, 39% had burnout, defined as answering affirmatively to either of the above questions with at least “weekly.” Most of the respondents were female, white, and married or in a long-term relationship without children, but the burnout rates did not vary across gender, race/ethnicity, relationship or parental status, or among different characteristics of the residency program and schedule. Higher burnout rates did occur among those feeling sleep deprived.

Those with burnout also had substantially higher odds of providing lower-quality care. Residents with burnout were seven times more likely to make treatment or medication errors not related to inadequate knowledge or experience, six times more likely to feel guilty about how they had treated a patient, more than four times more likely to report having little emotional reaction to a patient’s death, and four times more likely to discharge a patient earlier to make service more manageable. Burned-out residents had more than nine times greater odds of paying “little attention to the social or personal impact of an illness on a patient,” the study showed.
 

Burnout symptoms and solutions

Symptoms of potential burnout, Dr. First said in an interview, include emotional exhaustion, feeling a loss of meaning in work, feelings of ineffectiveness, a tendency to view people as objects instead of human beings, increasingly poor communication, and poor interpersonal and clinical skills and behaviors.

• Reduce the burden of bureaucratic tasks.
• Examine how many hours physicians spend at home or work at home.
• Improve efficiency, such as in EHR use.
• Provide individuals time to discuss stressors and ways to resolve them collaboratively with peers and leadership.

Burnout risk in the NICU

Similar interventions may help with burnout in neonatal ICUs (NICUs), the focus of the second study Dr. First discussed. Tawfik et al. surveyed 2,760 personnel from 41 NICUs in the United States to learn the prevalence of burnout and how it was associated with NICU organization (Pediatrics. 2017. doi: 10.1542/peds.2016-4134).

Among the 1,934 providers who replied (a response rate of 70%), 27% had burnout; at individual NICUs, burnout prevalence varied from 8% to 43%. The majority of respondents (72%) were registered nurses, followed by respiratory therapists, physicians, neonatal nurse practitioners, and others. The highest burnout rates occurred in NICUs with higher average daily admissions and higher average occupancy – and those using EHRs.

“Don’t assume that just because you use the EHR every day means you know how best to use this tool to improve your efficiency and effectiveness in generating and deriving information on your patients,” Dr. First said in the interview. He encouraged physicians to find out what resources their institutions might offer to help, such as EHR hospital teams or office support who can look at providers’ EHR usage, and show them shortcuts and time-savers to improve efficiency based on their usage patterns.

“Nursing burnout was more sensitive to the setting than physician burnout, especially in regard to average daily admissions, late transfer numbers, nursing hours per patient day, and mortality per 1,000 infants,” Dr. First noted.

Interestingly, burnout prevalence was not associated with the proportion of high-risk patients seen in the NICUs, the number of attending physicians in the unit, or whether the institution was a teaching hospital or not, he said.

Dr. First listed strategies to reduce burnout risk in NICUs that the study authors also described: expressing thankfulness each day, focusing on positive events at the start or end of each day, performing random acts of kindness for colleagues and staff, and encouraging providers to identify the strengths in one another.
 

Addressing burnout requires efforts from everyone

“Given the potential effects of burnout on patient care and professionalism and physician wellness, it is important for physicians to speak up if they have concerns about burnout in their colleagues,” Dr. Baer said in the interview.

Burnout is common, she said, occurring in more than half of physicians at some point in time, so a doctor experiencing it is almost certainly not alone among colleagues.

“Physicians can work together and with their leadership to prevent and mitigate the effects of burnout by promoting personal and professional wellness, effective teamwork, and reducing the administrative burdens that impact time spent directly with patients and have been demonstrated to contribute to physician burnout,” Dr. Baer noted.

She also pointed to the need to address it in medical education, given the downstream risks of burnout on the next generation of physicians.

“Medical schools and residency and fellowship programs should address the risks and signs of burnout, as medical students and trainees are likely seeing signs of burnout in some of their physician teachers and mentors,” Dr. Baer said in the interview.

Some burnout among providers may be inevitable at times, but it’s important to continue looking for ways to combat it.

“We need to do more to remind each other of why we chose our profession, and how good it makes us feel to strive to make a difference in our patients and families each and every day,” Dr. First said in the interview.

Dr. First reported having no disclosures and no external funding. The residents’ study by Baer et al. was funded by the Boston Children’s Hospital’s Fred Lovejoy Resident Research Award and a grant from the Health Resources and Services Administration. The NICU study by Tamfik et al. was funded by the National Institutes of Health, grants from the National Institute of Child Health and Human Development, and the Jackson Vaughan Critical Care Research Fund. The authors of both studies had no relevant financial disclosures.

CHICAGO – While neurologists treat children’s seizure conditions, you or an emergency physician usually sees the child first and must determine whether a seizure has occurred and how to proceed.

Knowing the characteristics of seizures – and their imitators – helps you appropriately evaluate and treat these children, said Sucheta Joshi, MD, of the University of Michigan, Ann Arbor, and Linda C. Laux, MD, the medical director of the Comprehensive Epilepsy Center at the Ann & Robert H. Lurie Children’s Hospital of Chicago. You also must consider the long-term management and well-being of a child with epilepsy.

A primer on seizures

Abnormal electrical discharges in the brain cause seizures, and various acute conditions can cause them, including fevers, infections, trauma, and metabolic abnormalities. But an epilepsy diagnosis requires at least two unprovoked seizures occurring more than 1 day apart. More than two dozen different epilepsy syndromes exist, determined based on age of onset, seizure type, the child’s development, and EEG patterns.

You also should be aware of what seizure imitators to rule out: movement disorders such as tics and Sandifer’s syndrome, daydreaming and inattention, fainting, migraines, panic attacks, psychogenic nonepileptic seizures (PNES), self-stimulatory behaviors, periods of the child holding her breath, and sleep parasomnias, such as night terrors, sleepwalking, and sleep myoclonus.

“It’s often difficult to tell if it’s a seizure or a nonepileptic paroxysmal event,” said Dr. Joshi. An interictal EEG can be helpful, but “there’s no reliable test to differentiate the two.”

Knowing the environment where the incident occurred, what provoking factors might have been present, what the seizure looked like, how long it lasted, and what happened afterward can help you differentiate paroxysmal spells from seizures.
 

Febrile seizures

About 4% of all children experience febrile seizures, particularly between 6 months and 6 years of age, Dr. Joshi said. The two types are simple and complex. A simple febrile seizure is generalized and brief, lasting less than 15 minutes, and is not followed by another within 24 hours. The child may have a family history of epilepsy but appear normal. Complex febrile seizures are focal, last more than 15 minutes, and occur more than once within 24 hours.

Determining seizure causes

If the child’s seizure is not clearly febrile with a known cause, you should run through other possibilities. Did the child have head trauma? A central nervous system infection? Are metabolic abnormalities present, such as renal or hepatic disease or an electrolyte abnormality? Has the patient ingested something, such as a recreational drug or other toxic substance?

Lab work is unlikely to offer much information without clinical signs or symptoms present, but you may consider glucose, electrolytes, serum alcohol level, and a toxicology drug screen on a case-by-case basis: A child’s first unprovoked seizure should not lead to a lumbar puncture, Dr. Laux said. But if you suspect a CNS infection or the child is under 6 months old and does not return to baseline, you should consider a lumbar puncture. Modest increases in cerebrospinal fluid cell count (pleocytosis) occur after a seizure, but a “CSF above 20 WBC/mm³ or above 10 PMN/mm³ should not be attributed to a seizure,” she said.

An outpatient EEG, preferably performed within 24-48 hours, shows abnormalities 70% of the time after a seizure, but a normal EEG cannot rule out a seizure. EEG data also may suggest recurrence risk or a specific epilepsy syndrome and long-term prognosis.
 

Epilepsy management

After a second unprovoked seizure occurrs more than 24 hours after the first, you should diagnose new onset epilepsy, order an EEG and head MRI, and refer the child to a neurologist. Metabolic or genetic tests may be indicated depending on signs and symptoms.

Managing epilepsy requires much more than just treating seizures, Dr. Laux emphasized, so you play an important role in educating the family, considering safety issues, monitoring bone and reproductive health, and considering the condition’s effect on learning and mental, behavioral, and physical health.

shironosov/iStockphoto

Physical health and learning differences

Epilepsy increases risk of poor bone mineralization, and seizures can lead to falls and fractures. You therefore should keep tabs on the child’s vitamin D intake, physical activity levels, neuromotor dysfunction, and overall nutrition. Vitamin D insufficiency is more common in those with epilepsy than in the general population, particularly females and those with obesity. Evidence suggests both anticonvulsants and epilepsy syndromes contribute to low vitamin D levels, so daily supplements may be wise.

Antiepileptic drugs also reduce the effectiveness of hormonal contraception, and teens with epilepsy already have a higher risk for unplanned pregnancy. You should ensure that sexually active female teens get folic acid daily and educate them on valproate’s increased risk of causing birth defects. For pregnant teens, levetiracetam and lamotrigine present less risk to a fetus.

You should ask about the patient’s school performance and consider requesting an Individualized Education Plan or a 504 plan at school if it seems needed. Even in youths with a normal IQ and well-managed seizures, lower academic achievement and difficulties with memory and behavior are more likely. Risk increases in disorganized or unsupportive homes and with comorbidities. ADHD occurs in 38% of children with epilepsy, but stimulants such as methylphenidate are not contraindicated with epilepsy medications.

Epilepsy affects the whole family: About half of all mothers of children with epilepsy have depression – which can adversely affect her children – and risk increases for younger moms with lower education and income. Siblings have added burdens, too: In one study, 95% of siblings had witnessed a seizure, and 79% believed their siblings suffered during seizures. More than two-thirds (68%) say their sibling with epilepsy gets more attention, and 42% feel responsible for their sibling, often restricting their own activities. You should be considering all these factors in managing the well-being of a child with epilepsy.

Dr. Joshi summed up the complex management of epilepsy with an acrostic that may be helpful to share with parents:

• Education

• Parenting

• Independence (including driving)

• Learning

• Eating (nutrition and bone health)

• Pharmacotherapy (anticonvulsants)

• School

• You (the child’s caretakers).

Dr. Joshi and Dr. Laux reported having no relevant financial disclosures and no external funding.

CHICAGO – While neurologists treat children’s seizure conditions, you or an emergency physician usually sees the child first and must determine whether a seizure has occurred and how to proceed.

Knowing the characteristics of seizures – and their imitators – helps you appropriately evaluate and treat these children, said Sucheta Joshi, MD, of the University of Michigan, Ann Arbor, and Linda C. Laux, MD, the medical director of the Comprehensive Epilepsy Center at the Ann & Robert H. Lurie Children’s Hospital of Chicago. You also must consider the long-term management and well-being of a child with epilepsy.

A primer on seizures

Abnormal electrical discharges in the brain cause seizures, and various acute conditions can cause them, including fevers, infections, trauma, and metabolic abnormalities. But an epilepsy diagnosis requires at least two unprovoked seizures occurring more than 1 day apart. More than two dozen different epilepsy syndromes exist, determined based on age of onset, seizure type, the child’s development, and EEG patterns.

You also should be aware of what seizure imitators to rule out: movement disorders such as tics and Sandifer’s syndrome, daydreaming and inattention, fainting, migraines, panic attacks, psychogenic nonepileptic seizures (PNES), self-stimulatory behaviors, periods of the child holding her breath, and sleep parasomnias, such as night terrors, sleepwalking, and sleep myoclonus.

“It’s often difficult to tell if it’s a seizure or a nonepileptic paroxysmal event,” said Dr. Joshi. An interictal EEG can be helpful, but “there’s no reliable test to differentiate the two.”

Knowing the environment where the incident occurred, what provoking factors might have been present, what the seizure looked like, how long it lasted, and what happened afterward can help you differentiate paroxysmal spells from seizures.
 

Febrile seizures

About 4% of all children experience febrile seizures, particularly between 6 months and 6 years of age, Dr. Joshi said. The two types are simple and complex. A simple febrile seizure is generalized and brief, lasting less than 15 minutes, and is not followed by another within 24 hours. The child may have a family history of epilepsy but appear normal. Complex febrile seizures are focal, last more than 15 minutes, and occur more than once within 24 hours.

Determining seizure causes

If the child’s seizure is not clearly febrile with a known cause, you should run through other possibilities. Did the child have head trauma? A central nervous system infection? Are metabolic abnormalities present, such as renal or hepatic disease or an electrolyte abnormality? Has the patient ingested something, such as a recreational drug or other toxic substance?

Lab work is unlikely to offer much information without clinical signs or symptoms present, but you may consider glucose, electrolytes, serum alcohol level, and a toxicology drug screen on a case-by-case basis: A child’s first unprovoked seizure should not lead to a lumbar puncture, Dr. Laux said. But if you suspect a CNS infection or the child is under 6 months old and does not return to baseline, you should consider a lumbar puncture. Modest increases in cerebrospinal fluid cell count (pleocytosis) occur after a seizure, but a “CSF above 20 WBC/mm³ or above 10 PMN/mm³ should not be attributed to a seizure,” she said.

An outpatient EEG, preferably performed within 24-48 hours, shows abnormalities 70% of the time after a seizure, but a normal EEG cannot rule out a seizure. EEG data also may suggest recurrence risk or a specific epilepsy syndrome and long-term prognosis.
 

Epilepsy management

After a second unprovoked seizure occurrs more than 24 hours after the first, you should diagnose new onset epilepsy, order an EEG and head MRI, and refer the child to a neurologist. Metabolic or genetic tests may be indicated depending on signs and symptoms.

Managing epilepsy requires much more than just treating seizures, Dr. Laux emphasized, so you play an important role in educating the family, considering safety issues, monitoring bone and reproductive health, and considering the condition’s effect on learning and mental, behavioral, and physical health.

shironosov/iStockphoto

Physical health and learning differences

Epilepsy increases risk of poor bone mineralization, and seizures can lead to falls and fractures. You therefore should keep tabs on the child’s vitamin D intake, physical activity levels, neuromotor dysfunction, and overall nutrition. Vitamin D insufficiency is more common in those with epilepsy than in the general population, particularly females and those with obesity. Evidence suggests both anticonvulsants and epilepsy syndromes contribute to low vitamin D levels, so daily supplements may be wise.

Antiepileptic drugs also reduce the effectiveness of hormonal contraception, and teens with epilepsy already have a higher risk for unplanned pregnancy. You should ensure that sexually active female teens get folic acid daily and educate them on valproate’s increased risk of causing birth defects. For pregnant teens, levetiracetam and lamotrigine present less risk to a fetus.

You should ask about the patient’s school performance and consider requesting an Individualized Education Plan or a 504 plan at school if it seems needed. Even in youths with a normal IQ and well-managed seizures, lower academic achievement and difficulties with memory and behavior are more likely. Risk increases in disorganized or unsupportive homes and with comorbidities. ADHD occurs in 38% of children with epilepsy, but stimulants such as methylphenidate are not contraindicated with epilepsy medications.

Epilepsy affects the whole family: About half of all mothers of children with epilepsy have depression – which can adversely affect her children – and risk increases for younger moms with lower education and income. Siblings have added burdens, too: In one study, 95% of siblings had witnessed a seizure, and 79% believed their siblings suffered during seizures. More than two-thirds (68%) say their sibling with epilepsy gets more attention, and 42% feel responsible for their sibling, often restricting their own activities. You should be considering all these factors in managing the well-being of a child with epilepsy.

Dr. Joshi summed up the complex management of epilepsy with an acrostic that may be helpful to share with parents:

• Education

• Parenting

• Independence (including driving)

• Learning

• Eating (nutrition and bone health)

• Pharmacotherapy (anticonvulsants)

• School

• You (the child’s caretakers).

Dr. Joshi and Dr. Laux reported having no relevant financial disclosures and no external funding.

CHICAGO – While neurologists treat children’s seizure conditions, you or an emergency physician usually sees the child first and must determine whether a seizure has occurred and how to proceed.

Knowing the characteristics of seizures – and their imitators – helps you appropriately evaluate and treat these children, said Sucheta Joshi, MD, of the University of Michigan, Ann Arbor, and Linda C. Laux, MD, the medical director of the Comprehensive Epilepsy Center at the Ann & Robert H. Lurie Children’s Hospital of Chicago. You also must consider the long-term management and well-being of a child with epilepsy.

A primer on seizures

Abnormal electrical discharges in the brain cause seizures, and various acute conditions can cause them, including fevers, infections, trauma, and metabolic abnormalities. But an epilepsy diagnosis requires at least two unprovoked seizures occurring more than 1 day apart. More than two dozen different epilepsy syndromes exist, determined based on age of onset, seizure type, the child’s development, and EEG patterns.

You also should be aware of what seizure imitators to rule out: movement disorders such as tics and Sandifer’s syndrome, daydreaming and inattention, fainting, migraines, panic attacks, psychogenic nonepileptic seizures (PNES), self-stimulatory behaviors, periods of the child holding her breath, and sleep parasomnias, such as night terrors, sleepwalking, and sleep myoclonus.

“It’s often difficult to tell if it’s a seizure or a nonepileptic paroxysmal event,” said Dr. Joshi. An interictal EEG can be helpful, but “there’s no reliable test to differentiate the two.”

Knowing the environment where the incident occurred, what provoking factors might have been present, what the seizure looked like, how long it lasted, and what happened afterward can help you differentiate paroxysmal spells from seizures.
 

Febrile seizures

About 4% of all children experience febrile seizures, particularly between 6 months and 6 years of age, Dr. Joshi said. The two types are simple and complex. A simple febrile seizure is generalized and brief, lasting less than 15 minutes, and is not followed by another within 24 hours. The child may have a family history of epilepsy but appear normal. Complex febrile seizures are focal, last more than 15 minutes, and occur more than once within 24 hours.

Determining seizure causes

If the child’s seizure is not clearly febrile with a known cause, you should run through other possibilities. Did the child have head trauma? A central nervous system infection? Are metabolic abnormalities present, such as renal or hepatic disease or an electrolyte abnormality? Has the patient ingested something, such as a recreational drug or other toxic substance?

Lab work is unlikely to offer much information without clinical signs or symptoms present, but you may consider glucose, electrolytes, serum alcohol level, and a toxicology drug screen on a case-by-case basis: A child’s first unprovoked seizure should not lead to a lumbar puncture, Dr. Laux said. But if you suspect a CNS infection or the child is under 6 months old and does not return to baseline, you should consider a lumbar puncture. Modest increases in cerebrospinal fluid cell count (pleocytosis) occur after a seizure, but a “CSF above 20 WBC/mm³ or above 10 PMN/mm³ should not be attributed to a seizure,” she said.

An outpatient EEG, preferably performed within 24-48 hours, shows abnormalities 70% of the time after a seizure, but a normal EEG cannot rule out a seizure. EEG data also may suggest recurrence risk or a specific epilepsy syndrome and long-term prognosis.
 

Epilepsy management

After a second unprovoked seizure occurrs more than 24 hours after the first, you should diagnose new onset epilepsy, order an EEG and head MRI, and refer the child to a neurologist. Metabolic or genetic tests may be indicated depending on signs and symptoms.

Managing epilepsy requires much more than just treating seizures, Dr. Laux emphasized, so you play an important role in educating the family, considering safety issues, monitoring bone and reproductive health, and considering the condition’s effect on learning and mental, behavioral, and physical health.

shironosov/iStockphoto

Physical health and learning differences

Epilepsy increases risk of poor bone mineralization, and seizures can lead to falls and fractures. You therefore should keep tabs on the child’s vitamin D intake, physical activity levels, neuromotor dysfunction, and overall nutrition. Vitamin D insufficiency is more common in those with epilepsy than in the general population, particularly females and those with obesity. Evidence suggests both anticonvulsants and epilepsy syndromes contribute to low vitamin D levels, so daily supplements may be wise.

Antiepileptic drugs also reduce the effectiveness of hormonal contraception, and teens with epilepsy already have a higher risk for unplanned pregnancy. You should ensure that sexually active female teens get folic acid daily and educate them on valproate’s increased risk of causing birth defects. For pregnant teens, levetiracetam and lamotrigine present less risk to a fetus.

You should ask about the patient’s school performance and consider requesting an Individualized Education Plan or a 504 plan at school if it seems needed. Even in youths with a normal IQ and well-managed seizures, lower academic achievement and difficulties with memory and behavior are more likely. Risk increases in disorganized or unsupportive homes and with comorbidities. ADHD occurs in 38% of children with epilepsy, but stimulants such as methylphenidate are not contraindicated with epilepsy medications.

Epilepsy affects the whole family: About half of all mothers of children with epilepsy have depression – which can adversely affect her children – and risk increases for younger moms with lower education and income. Siblings have added burdens, too: In one study, 95% of siblings had witnessed a seizure, and 79% believed their siblings suffered during seizures. More than two-thirds (68%) say their sibling with epilepsy gets more attention, and 42% feel responsible for their sibling, often restricting their own activities. You should be considering all these factors in managing the well-being of a child with epilepsy.

Dr. Joshi summed up the complex management of epilepsy with an acrostic that may be helpful to share with parents:

• Education

• Parenting

• Independence (including driving)

• Learning

• Eating (nutrition and bone health)

• Pharmacotherapy (anticonvulsants)

• School

• You (the child’s caretakers).

Dr. Joshi and Dr. Laux reported having no relevant financial disclosures and no external funding.

The clinical challenges of celiac disease go beyond identifying the condition and helping families adjust to a child’s gluten-free diet. Behavioral problems and/or an eating disorder may predate celiac disease, according to Alex R. Kemper, MD, MPH, division chief of ambulatory pediatrics at Nationwide Children’s Hospital, Columbus, Ohio, and deputy editor of Pediatrics.

designer491/Thinkstock

Impact of undiagnosed celiac disease on behavior

At the 2017 annual meeting of the American Academy of Pediatrics and, in a later interview, Dr. Kemper discussed a study that explored how behavior and celiac disease might be interrelated, particularly among children whose families don’t yet know their child has the condition.

“It’s challenging to assess the psychological impact of celiac disease autoimmunity when families aren’t aware a child has it, because prospective studies are difficult to do and recall bias can distort findings,” he noted.

Link between celiac disease and anorexia nervosa

The eating disorders study Dr. Kemper discussed examined possible associations between celiac disease and anorexia nervosa (Pediatrics. 2017. doi: 10.1542/peds.2016-4367). Researchers compared 17,959 Swedish females diagnosed with celiac disease between 1969 and 2008, at a median 28 years old, to 89,379 controls matched by sex and age.

Anorexia occurred more often among those with celiac disease than those without: a rate of 27 girls per 100,000 with celiac disease developed anorexia per year, compared with 18 of 100,000 without celiac disease, for a hazard ratio for an anorexia nervosa diagnosis of 1.46 (95% confidence interval, 1.08-1.98). In addition, girls whose celiac disease had not yet been identified had more than double the odds of developing anorexia before diagnosis than did those without celiac disease (odds ratio, 2.13).

Females with celiac disease therefore were more likely to have anorexia both before and after their celiac diagnosis, although the authors noted that surveillance bias may have made it more likely for either of the patients’ conditions to be identified after the first was. Another possible explanation is shared genetic risk factors, the authors wrote.

Dr. Kemper also offered possible reasons, including one related to the child behavior study.

“It could be that girls with celiac disease might develop anorexia because of the need to focus on their diet,” he said in an interview. “Celiac disease has been associated with psychological problems, and so that could contribute.”

Until further research can shed light on the reasons for the associations, physicians simply should be aware of the study’s clinical implications.

“Pediatricians should be aware of the bidirectional association between celiac disease and anorexia nervosa in teens and young adult women, and be prepared to evaluate for celiac disease or treat anorexia,” Dr. Kemper said.

He noted the need for more research to learn “what pediatricians can do to help to either prevent these problems from developing in the first place, or identify and treat celiac disease or anorexia nervosa early to prevent long-term complications.”

Dr. Kemper reported having no relevant financial disclosures and no external funding. Ketil Stordal, MD, PhD, of the anorexia study received funding from the OAK foundation in Switzerland, and Cynthia M. Bulik, PhD, from the same study received funding from the Swedish Research Council, and has consulted for and received a grant from Shire. The remaining authors of the anorexia study had no relevant financial disclosures. The behavioral study was funded by the National Institutes of Health, the Juvenile Diabetes Research Foundation and the Centers for Disease Control and Prevention. The authors from the behavioral study had no relevant financial disclosures.

[email protected]

The clinical challenges of celiac disease go beyond identifying the condition and helping families adjust to a child’s gluten-free diet. Behavioral problems and/or an eating disorder may predate celiac disease, according to Alex R. Kemper, MD, MPH, division chief of ambulatory pediatrics at Nationwide Children’s Hospital, Columbus, Ohio, and deputy editor of Pediatrics.

designer491/Thinkstock

Impact of undiagnosed celiac disease on behavior

At the 2017 annual meeting of the American Academy of Pediatrics and, in a later interview, Dr. Kemper discussed a study that explored how behavior and celiac disease might be interrelated, particularly among children whose families don’t yet know their child has the condition.

“It’s challenging to assess the psychological impact of celiac disease autoimmunity when families aren’t aware a child has it, because prospective studies are difficult to do and recall bias can distort findings,” he noted.

Link between celiac disease and anorexia nervosa

The eating disorders study Dr. Kemper discussed examined possible associations between celiac disease and anorexia nervosa (Pediatrics. 2017. doi: 10.1542/peds.2016-4367). Researchers compared 17,959 Swedish females diagnosed with celiac disease between 1969 and 2008, at a median 28 years old, to 89,379 controls matched by sex and age.

Anorexia occurred more often among those with celiac disease than those without: a rate of 27 girls per 100,000 with celiac disease developed anorexia per year, compared with 18 of 100,000 without celiac disease, for a hazard ratio for an anorexia nervosa diagnosis of 1.46 (95% confidence interval, 1.08-1.98). In addition, girls whose celiac disease had not yet been identified had more than double the odds of developing anorexia before diagnosis than did those without celiac disease (odds ratio, 2.13).

Females with celiac disease therefore were more likely to have anorexia both before and after their celiac diagnosis, although the authors noted that surveillance bias may have made it more likely for either of the patients’ conditions to be identified after the first was. Another possible explanation is shared genetic risk factors, the authors wrote.

Dr. Kemper also offered possible reasons, including one related to the child behavior study.

“It could be that girls with celiac disease might develop anorexia because of the need to focus on their diet,” he said in an interview. “Celiac disease has been associated with psychological problems, and so that could contribute.”

Until further research can shed light on the reasons for the associations, physicians simply should be aware of the study’s clinical implications.

“Pediatricians should be aware of the bidirectional association between celiac disease and anorexia nervosa in teens and young adult women, and be prepared to evaluate for celiac disease or treat anorexia,” Dr. Kemper said.

He noted the need for more research to learn “what pediatricians can do to help to either prevent these problems from developing in the first place, or identify and treat celiac disease or anorexia nervosa early to prevent long-term complications.”

Dr. Kemper reported having no relevant financial disclosures and no external funding. Ketil Stordal, MD, PhD, of the anorexia study received funding from the OAK foundation in Switzerland, and Cynthia M. Bulik, PhD, from the same study received funding from the Swedish Research Council, and has consulted for and received a grant from Shire. The remaining authors of the anorexia study had no relevant financial disclosures. The behavioral study was funded by the National Institutes of Health, the Juvenile Diabetes Research Foundation and the Centers for Disease Control and Prevention. The authors from the behavioral study had no relevant financial disclosures.

[email protected]

The clinical challenges of celiac disease go beyond identifying the condition and helping families adjust to a child’s gluten-free diet. Behavioral problems and/or an eating disorder may predate celiac disease, according to Alex R. Kemper, MD, MPH, division chief of ambulatory pediatrics at Nationwide Children’s Hospital, Columbus, Ohio, and deputy editor of Pediatrics.

designer491/Thinkstock

Impact of undiagnosed celiac disease on behavior

At the 2017 annual meeting of the American Academy of Pediatrics and, in a later interview, Dr. Kemper discussed a study that explored how behavior and celiac disease might be interrelated, particularly among children whose families don’t yet know their child has the condition.

“It’s challenging to assess the psychological impact of celiac disease autoimmunity when families aren’t aware a child has it, because prospective studies are difficult to do and recall bias can distort findings,” he noted.

Link between celiac disease and anorexia nervosa

The eating disorders study Dr. Kemper discussed examined possible associations between celiac disease and anorexia nervosa (Pediatrics. 2017. doi: 10.1542/peds.2016-4367). Researchers compared 17,959 Swedish females diagnosed with celiac disease between 1969 and 2008, at a median 28 years old, to 89,379 controls matched by sex and age.

Anorexia occurred more often among those with celiac disease than those without: a rate of 27 girls per 100,000 with celiac disease developed anorexia per year, compared with 18 of 100,000 without celiac disease, for a hazard ratio for an anorexia nervosa diagnosis of 1.46 (95% confidence interval, 1.08-1.98). In addition, girls whose celiac disease had not yet been identified had more than double the odds of developing anorexia before diagnosis than did those without celiac disease (odds ratio, 2.13).

Females with celiac disease therefore were more likely to have anorexia both before and after their celiac diagnosis, although the authors noted that surveillance bias may have made it more likely for either of the patients’ conditions to be identified after the first was. Another possible explanation is shared genetic risk factors, the authors wrote.

Dr. Kemper also offered possible reasons, including one related to the child behavior study.

“It could be that girls with celiac disease might develop anorexia because of the need to focus on their diet,” he said in an interview. “Celiac disease has been associated with psychological problems, and so that could contribute.”

Until further research can shed light on the reasons for the associations, physicians simply should be aware of the study’s clinical implications.

“Pediatricians should be aware of the bidirectional association between celiac disease and anorexia nervosa in teens and young adult women, and be prepared to evaluate for celiac disease or treat anorexia,” Dr. Kemper said.

He noted the need for more research to learn “what pediatricians can do to help to either prevent these problems from developing in the first place, or identify and treat celiac disease or anorexia nervosa early to prevent long-term complications.”

Dr. Kemper reported having no relevant financial disclosures and no external funding. Ketil Stordal, MD, PhD, of the anorexia study received funding from the OAK foundation in Switzerland, and Cynthia M. Bulik, PhD, from the same study received funding from the Swedish Research Council, and has consulted for and received a grant from Shire. The remaining authors of the anorexia study had no relevant financial disclosures. The behavioral study was funded by the National Institutes of Health, the Juvenile Diabetes Research Foundation and the Centers for Disease Control and Prevention. The authors from the behavioral study had no relevant financial disclosures.

[email protected]

CHICAGO – Screening mothers for postpartum depression is critical, because of the potential negative consequences for the child, according to Nerissa S. Bauer, MD, MPH.

Postpartum depression is the best known mood disorder related to pregnancy, but it’s not the only one. Perinatal mood and anxiety disorders exist along a spectrum, she told attendees at the American Academy of Pediatrics annual meeting. That spectrum includes prenatal depression, prenatal anxiety, “baby blues,” postpartum depression, posttraumatic stress disorder (PSTD), and postpartum anxiety with panic attacks and/or obsessive-compulsive disorder (OCD).

monkeybusinessimages/Thinkstock

Postpartum mood disorders

Postpartum depression (PPD), however, is serious and requires intervention. An estimated 10%-20% of new mothers experience PPD, but the numbers are much higher in at-risk communities. Up to 48% of mothers in low-income households and 40%-60% of adolescent mothers in low-income households experience it. Yet only about 15% of these higher-risk women seek treatment for PPD (Pediatrics. 2010 Nov;126[5]:1032-9).

PPD symptoms are similar to the usual symptoms of a depressive disorder: depressed mood, irritability, changes in sleep and/or appetite, fatigue, sleepiness, loss of interest in activities, inability to feel pleasure in everyday life, guilt, difficulty concentrating, indecisiveness, low energy, despair, and feelings of worthlessness. The biggest difference – and most important symptom – is that women with PPD may have thoughts about harming not only themselves but also their child. This symptom calls for immediate intervention and sometimes can be a sign of postpartum psychosis.

Postpartum psychosis is rare, occurring in about 1-3 out of 1,000 women, but its seriousness requires immediate medical attention, including hospitalization in most cases. The best established risk factor is preexisting bipolar disorder. Postpartum psychosis usually occurs in the first 4 weeks after delivery, with symptoms that include paranoia, severe mood shifts, hallucinations, delusions, and suicidal and/or homicidal thoughts.

Fathers also can experience depression after a baby’s birth: An estimated 6% of fathers develop paternal depression, but the numbers are triple that among fathers whose children are enrolled in Early Head Start programs, Dr. Bauer said. Paternal depression often co-occurs with postpartum maternal depression, particularly when poverty and substance abuse are contributing factors.

Fewer practitioners may be aware of postpartum anxiety disorders, even though they affect 9%-30% of women. These disorders include generalized anxiety disorder, OCD, and PTSD, either as a preexisting diagnosis or occurring after delivery. Women develop an intensive fear about their child’s well-being and worry that they aren’t able to parent adequately or effectively (Zero to Three. 2009 May:1-6).

Your role in screening mothers

It’s essential that you screen parents for depression, particularly mothers for PPD, because of the potential negative consequences for the child. Research has shown that children of mothers with PPD are at risk for failure to thrive, and have a greater likelihood of mental health conditions, developmental delays, lower IQ scores, sleep problems, and difficulties at school (Infant Behav Dev. 2011 Feb;34[1]:1-14). Further, mothers with PPD are less likely to breastfeed and more likely to stop breastfeeding early, studies have shown (Arch Pediatr Adolesc Med. 2006 Mar;160[3]:279-84).

The risk factors for PPD often occur together, with each additional one adding to the overall risk. As incidence estimates show, teens and those with low income are at higher risk, as are those with less education and any type of additional financial hardship. Other factors that increase women’s risk include interpersonal violence, a lack of social support, a history or family history of anxiety or depression, poor physical or mental health in general, and substance abuse (Depress Anxiety. 2017 Feb;34[2]:178-87).

Screening tools and procedures

Despite the risks to infants from maternal depression, less than half of pediatricians screen mothers for PPD, Dr. Bauer said. American Academy of Pediatrics surveys of 778 pediatricians in 2004 and 2013 found that the proportion of pediatricians screening or asking mothers about depression increased from 33% to 44% during that decade, driven partly by the “belief that family screening is in the scope of practice,” she explained. Physicians who asked about the child’s mood were more likely to ask mothers about their mood too, the surveys found (J Dev Behav Pediatr. 2016 Feb-Mar;37[2]:113-20).

Medical organizations differ in their screening recommendations, although all agree screening is important. The American College of Obstetricians and Gynecologists and the U.S. Preventive Services Task Force recommend screening mothers at least once in the perinatal period (Obstet Gynecol. 2015;125:1268–71; JAMA. 2016;315[4]:388-406). The AAP advocates a more aggressive approach, recommending screening at each of the 1, 2, 4, and 6-month child well-visits (“Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents,” 4th Edition [Elk Grove Village, Ill.: American Academy of Pediatrics Publishing, 2017]).

The two preferred screening tools for PPD are the Edinburgh Postpartum Depression Scale (EPDS) and the Patient Health Questionnaire (PHQ).

The former is fast and simple, requiring less than 5 minutes for mothers to answer 10 items about their symptoms in the previous 7 days. The EPDS has a maximum score of 30; anything above 12-13 should prompt further examination or referral. Women scoring a 10 should be reassessed 2 weeks later, unless they answer affirmatively to item 10 on suicidal ideation, in which case they should be referred immediately.

You also can use a shortened form of the EPDS as a first step, asking about the three EPDS items related to anxiety: “self-blame, feeling panicky, and [feeling] anxious or worried for no good reason,” Dr. Bauer said, explaining “the score should be multiplied by 10 and divided by 3, so the cutoff is greater than or equal to 10.”

The PHQ-9 asks about symptoms in the previous 2 weeks. Scores of 10-14 indicate minor depression or mild major depression, and scores of 15-19 indicate moderate depression. Mothers require intervention if they score at least 20, or in the case of teenage mothers, if they score at least 11 or have suicidal thoughts. Like the shortened EPDS-3, the PHQ has a shortened two-question option you can use as surveillance before fully screening mothers: 1. Have you felt down, depressed, or hopeless in the past 2 weeks? 2. Have you felt little interest or pleasure in doing things in the past 2 weeks?

If mothers have a positive screen, Dr. Bauer recommended that practices document it, according to protocols they’ve already set up.

“It’s not unlike domestic violence, maternal substance abuse, or parental smoking habits,” she said. “The score need not be noted, but [should] include details such as the name of the screener used, interpretation of the results, and when a referral was made.”

After making a referral to her ob.gyn. or a mental health professional, you can continue to help mothers by offering support and reassurance, reminding them that they are not alone and not to blame for depression, and that treatment can help them. Encourage parents to seek your advice and support as a pediatrician and use you as a resource to refer them to services that can help, such as lactation consultants and home-visiting programs.

Dr. Bauer offerred the following recommendations for clinical practice:

• Choose a validated screener for postpartum depression.
• Share the tool with everyone in your practice.
• Identify ways to integrate the screening tool into daily work flow.
• Collect data.
• Implement and assess how it went after a short time, using plan-do-study-act cycles.

Dr. Bauer advised consulting the following websites for information regarding postpartum depression:

• AAP Screening and Technical Assistance and Resource (STAR) Center. This AAP website recommends validated screening tools for maternal depression and has them available on the site ().
• Postpartum Support International (PSI). This website offers information and resources for women, family, and professionals (). PSI can also be reached by calling 800-944-4773.
• PSI Support Coordinator Network. This network can provide referrals for specialized support, such as for members of the military, for fathers, when there are legal concerns, or when psychosis is present, and serves all 50 states and 40 countries ().
• PostpartumDads. This website has recommendations for partners of women with postpartum depression, offering recommendations on how dads can help themselves and the mothers ().

Dr. Bauer said she had no relevant financial disclosures. She reported that her spouse is an employee of Anthem and holds Anthem stocks/bonds. No external funding was used for the presentation.

CHICAGO – Screening mothers for postpartum depression is critical, because of the potential negative consequences for the child, according to Nerissa S. Bauer, MD, MPH.

Postpartum depression is the best known mood disorder related to pregnancy, but it’s not the only one. Perinatal mood and anxiety disorders exist along a spectrum, she told attendees at the American Academy of Pediatrics annual meeting. That spectrum includes prenatal depression, prenatal anxiety, “baby blues,” postpartum depression, posttraumatic stress disorder (PSTD), and postpartum anxiety with panic attacks and/or obsessive-compulsive disorder (OCD).

monkeybusinessimages/Thinkstock

Postpartum mood disorders

Postpartum depression (PPD), however, is serious and requires intervention. An estimated 10%-20% of new mothers experience PPD, but the numbers are much higher in at-risk communities. Up to 48% of mothers in low-income households and 40%-60% of adolescent mothers in low-income households experience it. Yet only about 15% of these higher-risk women seek treatment for PPD (Pediatrics. 2010 Nov;126[5]:1032-9).

PPD symptoms are similar to the usual symptoms of a depressive disorder: depressed mood, irritability, changes in sleep and/or appetite, fatigue, sleepiness, loss of interest in activities, inability to feel pleasure in everyday life, guilt, difficulty concentrating, indecisiveness, low energy, despair, and feelings of worthlessness. The biggest difference – and most important symptom – is that women with PPD may have thoughts about harming not only themselves but also their child. This symptom calls for immediate intervention and sometimes can be a sign of postpartum psychosis.

Postpartum psychosis is rare, occurring in about 1-3 out of 1,000 women, but its seriousness requires immediate medical attention, including hospitalization in most cases. The best established risk factor is preexisting bipolar disorder. Postpartum psychosis usually occurs in the first 4 weeks after delivery, with symptoms that include paranoia, severe mood shifts, hallucinations, delusions, and suicidal and/or homicidal thoughts.

Fathers also can experience depression after a baby’s birth: An estimated 6% of fathers develop paternal depression, but the numbers are triple that among fathers whose children are enrolled in Early Head Start programs, Dr. Bauer said. Paternal depression often co-occurs with postpartum maternal depression, particularly when poverty and substance abuse are contributing factors.

Fewer practitioners may be aware of postpartum anxiety disorders, even though they affect 9%-30% of women. These disorders include generalized anxiety disorder, OCD, and PTSD, either as a preexisting diagnosis or occurring after delivery. Women develop an intensive fear about their child’s well-being and worry that they aren’t able to parent adequately or effectively (Zero to Three. 2009 May:1-6).

Your role in screening mothers

It’s essential that you screen parents for depression, particularly mothers for PPD, because of the potential negative consequences for the child. Research has shown that children of mothers with PPD are at risk for failure to thrive, and have a greater likelihood of mental health conditions, developmental delays, lower IQ scores, sleep problems, and difficulties at school (Infant Behav Dev. 2011 Feb;34[1]:1-14). Further, mothers with PPD are less likely to breastfeed and more likely to stop breastfeeding early, studies have shown (Arch Pediatr Adolesc Med. 2006 Mar;160[3]:279-84).

The risk factors for PPD often occur together, with each additional one adding to the overall risk. As incidence estimates show, teens and those with low income are at higher risk, as are those with less education and any type of additional financial hardship. Other factors that increase women’s risk include interpersonal violence, a lack of social support, a history or family history of anxiety or depression, poor physical or mental health in general, and substance abuse (Depress Anxiety. 2017 Feb;34[2]:178-87).

Screening tools and procedures

Despite the risks to infants from maternal depression, less than half of pediatricians screen mothers for PPD, Dr. Bauer said. American Academy of Pediatrics surveys of 778 pediatricians in 2004 and 2013 found that the proportion of pediatricians screening or asking mothers about depression increased from 33% to 44% during that decade, driven partly by the “belief that family screening is in the scope of practice,” she explained. Physicians who asked about the child’s mood were more likely to ask mothers about their mood too, the surveys found (J Dev Behav Pediatr. 2016 Feb-Mar;37[2]:113-20).

Medical organizations differ in their screening recommendations, although all agree screening is important. The American College of Obstetricians and Gynecologists and the U.S. Preventive Services Task Force recommend screening mothers at least once in the perinatal period (Obstet Gynecol. 2015;125:1268–71; JAMA. 2016;315[4]:388-406). The AAP advocates a more aggressive approach, recommending screening at each of the 1, 2, 4, and 6-month child well-visits (“Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents,” 4th Edition [Elk Grove Village, Ill.: American Academy of Pediatrics Publishing, 2017]).

The two preferred screening tools for PPD are the Edinburgh Postpartum Depression Scale (EPDS) and the Patient Health Questionnaire (PHQ).

The former is fast and simple, requiring less than 5 minutes for mothers to answer 10 items about their symptoms in the previous 7 days. The EPDS has a maximum score of 30; anything above 12-13 should prompt further examination or referral. Women scoring a 10 should be reassessed 2 weeks later, unless they answer affirmatively to item 10 on suicidal ideation, in which case they should be referred immediately.

You also can use a shortened form of the EPDS as a first step, asking about the three EPDS items related to anxiety: “self-blame, feeling panicky, and [feeling] anxious or worried for no good reason,” Dr. Bauer said, explaining “the score should be multiplied by 10 and divided by 3, so the cutoff is greater than or equal to 10.”

The PHQ-9 asks about symptoms in the previous 2 weeks. Scores of 10-14 indicate minor depression or mild major depression, and scores of 15-19 indicate moderate depression. Mothers require intervention if they score at least 20, or in the case of teenage mothers, if they score at least 11 or have suicidal thoughts. Like the shortened EPDS-3, the PHQ has a shortened two-question option you can use as surveillance before fully screening mothers: 1. Have you felt down, depressed, or hopeless in the past 2 weeks? 2. Have you felt little interest or pleasure in doing things in the past 2 weeks?

If mothers have a positive screen, Dr. Bauer recommended that practices document it, according to protocols they’ve already set up.

“It’s not unlike domestic violence, maternal substance abuse, or parental smoking habits,” she said. “The score need not be noted, but [should] include details such as the name of the screener used, interpretation of the results, and when a referral was made.”

After making a referral to her ob.gyn. or a mental health professional, you can continue to help mothers by offering support and reassurance, reminding them that they are not alone and not to blame for depression, and that treatment can help them. Encourage parents to seek your advice and support as a pediatrician and use you as a resource to refer them to services that can help, such as lactation consultants and home-visiting programs.

Dr. Bauer offerred the following recommendations for clinical practice:

• Choose a validated screener for postpartum depression.
• Share the tool with everyone in your practice.
• Identify ways to integrate the screening tool into daily work flow.
• Collect data.
• Implement and assess how it went after a short time, using plan-do-study-act cycles.

Dr. Bauer advised consulting the following websites for information regarding postpartum depression:

• AAP Screening and Technical Assistance and Resource (STAR) Center. This AAP website recommends validated screening tools for maternal depression and has them available on the site ().
• Postpartum Support International (PSI). This website offers information and resources for women, family, and professionals (). PSI can also be reached by calling 800-944-4773.
• PSI Support Coordinator Network. This network can provide referrals for specialized support, such as for members of the military, for fathers, when there are legal concerns, or when psychosis is present, and serves all 50 states and 40 countries ().
• PostpartumDads. This website has recommendations for partners of women with postpartum depression, offering recommendations on how dads can help themselves and the mothers ().

Dr. Bauer said she had no relevant financial disclosures. She reported that her spouse is an employee of Anthem and holds Anthem stocks/bonds. No external funding was used for the presentation.

CHICAGO – Screening mothers for postpartum depression is critical, because of the potential negative consequences for the child, according to Nerissa S. Bauer, MD, MPH.

Postpartum depression is the best known mood disorder related to pregnancy, but it’s not the only one. Perinatal mood and anxiety disorders exist along a spectrum, she told attendees at the American Academy of Pediatrics annual meeting. That spectrum includes prenatal depression, prenatal anxiety, “baby blues,” postpartum depression, posttraumatic stress disorder (PSTD), and postpartum anxiety with panic attacks and/or obsessive-compulsive disorder (OCD).

monkeybusinessimages/Thinkstock

Postpartum mood disorders

Postpartum depression (PPD), however, is serious and requires intervention. An estimated 10%-20% of new mothers experience PPD, but the numbers are much higher in at-risk communities. Up to 48% of mothers in low-income households and 40%-60% of adolescent mothers in low-income households experience it. Yet only about 15% of these higher-risk women seek treatment for PPD (Pediatrics. 2010 Nov;126[5]:1032-9).

PPD symptoms are similar to the usual symptoms of a depressive disorder: depressed mood, irritability, changes in sleep and/or appetite, fatigue, sleepiness, loss of interest in activities, inability to feel pleasure in everyday life, guilt, difficulty concentrating, indecisiveness, low energy, despair, and feelings of worthlessness. The biggest difference – and most important symptom – is that women with PPD may have thoughts about harming not only themselves but also their child. This symptom calls for immediate intervention and sometimes can be a sign of postpartum psychosis.

Postpartum psychosis is rare, occurring in about 1-3 out of 1,000 women, but its seriousness requires immediate medical attention, including hospitalization in most cases. The best established risk factor is preexisting bipolar disorder. Postpartum psychosis usually occurs in the first 4 weeks after delivery, with symptoms that include paranoia, severe mood shifts, hallucinations, delusions, and suicidal and/or homicidal thoughts.

Fathers also can experience depression after a baby’s birth: An estimated 6% of fathers develop paternal depression, but the numbers are triple that among fathers whose children are enrolled in Early Head Start programs, Dr. Bauer said. Paternal depression often co-occurs with postpartum maternal depression, particularly when poverty and substance abuse are contributing factors.

Fewer practitioners may be aware of postpartum anxiety disorders, even though they affect 9%-30% of women. These disorders include generalized anxiety disorder, OCD, and PTSD, either as a preexisting diagnosis or occurring after delivery. Women develop an intensive fear about their child’s well-being and worry that they aren’t able to parent adequately or effectively (Zero to Three. 2009 May:1-6).

Your role in screening mothers

It’s essential that you screen parents for depression, particularly mothers for PPD, because of the potential negative consequences for the child. Research has shown that children of mothers with PPD are at risk for failure to thrive, and have a greater likelihood of mental health conditions, developmental delays, lower IQ scores, sleep problems, and difficulties at school (Infant Behav Dev. 2011 Feb;34[1]:1-14). Further, mothers with PPD are less likely to breastfeed and more likely to stop breastfeeding early, studies have shown (Arch Pediatr Adolesc Med. 2006 Mar;160[3]:279-84).

The risk factors for PPD often occur together, with each additional one adding to the overall risk. As incidence estimates show, teens and those with low income are at higher risk, as are those with less education and any type of additional financial hardship. Other factors that increase women’s risk include interpersonal violence, a lack of social support, a history or family history of anxiety or depression, poor physical or mental health in general, and substance abuse (Depress Anxiety. 2017 Feb;34[2]:178-87).

Screening tools and procedures

Despite the risks to infants from maternal depression, less than half of pediatricians screen mothers for PPD, Dr. Bauer said. American Academy of Pediatrics surveys of 778 pediatricians in 2004 and 2013 found that the proportion of pediatricians screening or asking mothers about depression increased from 33% to 44% during that decade, driven partly by the “belief that family screening is in the scope of practice,” she explained. Physicians who asked about the child’s mood were more likely to ask mothers about their mood too, the surveys found (J Dev Behav Pediatr. 2016 Feb-Mar;37[2]:113-20).

Medical organizations differ in their screening recommendations, although all agree screening is important. The American College of Obstetricians and Gynecologists and the U.S. Preventive Services Task Force recommend screening mothers at least once in the perinatal period (Obstet Gynecol. 2015;125:1268–71; JAMA. 2016;315[4]:388-406). The AAP advocates a more aggressive approach, recommending screening at each of the 1, 2, 4, and 6-month child well-visits (“Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents,” 4th Edition [Elk Grove Village, Ill.: American Academy of Pediatrics Publishing, 2017]).

The two preferred screening tools for PPD are the Edinburgh Postpartum Depression Scale (EPDS) and the Patient Health Questionnaire (PHQ).

The former is fast and simple, requiring less than 5 minutes for mothers to answer 10 items about their symptoms in the previous 7 days. The EPDS has a maximum score of 30; anything above 12-13 should prompt further examination or referral. Women scoring a 10 should be reassessed 2 weeks later, unless they answer affirmatively to item 10 on suicidal ideation, in which case they should be referred immediately.

You also can use a shortened form of the EPDS as a first step, asking about the three EPDS items related to anxiety: “self-blame, feeling panicky, and [feeling] anxious or worried for no good reason,” Dr. Bauer said, explaining “the score should be multiplied by 10 and divided by 3, so the cutoff is greater than or equal to 10.”

The PHQ-9 asks about symptoms in the previous 2 weeks. Scores of 10-14 indicate minor depression or mild major depression, and scores of 15-19 indicate moderate depression. Mothers require intervention if they score at least 20, or in the case of teenage mothers, if they score at least 11 or have suicidal thoughts. Like the shortened EPDS-3, the PHQ has a shortened two-question option you can use as surveillance before fully screening mothers: 1. Have you felt down, depressed, or hopeless in the past 2 weeks? 2. Have you felt little interest or pleasure in doing things in the past 2 weeks?

If mothers have a positive screen, Dr. Bauer recommended that practices document it, according to protocols they’ve already set up.

“It’s not unlike domestic violence, maternal substance abuse, or parental smoking habits,” she said. “The score need not be noted, but [should] include details such as the name of the screener used, interpretation of the results, and when a referral was made.”

After making a referral to her ob.gyn. or a mental health professional, you can continue to help mothers by offering support and reassurance, reminding them that they are not alone and not to blame for depression, and that treatment can help them. Encourage parents to seek your advice and support as a pediatrician and use you as a resource to refer them to services that can help, such as lactation consultants and home-visiting programs.

Dr. Bauer offerred the following recommendations for clinical practice:

• Choose a validated screener for postpartum depression.
• Share the tool with everyone in your practice.
• Identify ways to integrate the screening tool into daily work flow.
• Collect data.
• Implement and assess how it went after a short time, using plan-do-study-act cycles.

Dr. Bauer advised consulting the following websites for information regarding postpartum depression:

• AAP Screening and Technical Assistance and Resource (STAR) Center. This AAP website recommends validated screening tools for maternal depression and has them available on the site ().
• Postpartum Support International (PSI). This website offers information and resources for women, family, and professionals (). PSI can also be reached by calling 800-944-4773.
• PSI Support Coordinator Network. This network can provide referrals for specialized support, such as for members of the military, for fathers, when there are legal concerns, or when psychosis is present, and serves all 50 states and 40 countries ().
• PostpartumDads. This website has recommendations for partners of women with postpartum depression, offering recommendations on how dads can help themselves and the mothers ().

Dr. Bauer said she had no relevant financial disclosures. She reported that her spouse is an employee of Anthem and holds Anthem stocks/bonds. No external funding was used for the presentation.