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

WASHINGTON – Behavioral and mental health issues are the largest group of conditions that you see in your practice, but pediatric residency training does not adequately prepare you for this challenge, Dr. Julia A. McMillan said in a video roundtable at the annual meeting of the American Academy of Pediatrics.

Dr. John D. Duby, professor and chair of pediatrics at Wright State University, Dayton, Ohio, added, “as we think about the innovation and transformation in pediatric education, pediatricians alone can’t do this work. We need to think more about integrated models for training that bring in psychologists, licensed social workers, care coordinators, community health workers, maybe even child psychiatrists.”

Dr. McMillan, professor of pediatrics and associate dean for graduate medical education at the Johns Hopkins University, Baltimore, agreed, and said that training about behavioral and mental health issues needs to be reinforced throughout pediatric residency training, not just in a block rotation about mental health, but also during critical care or continuity clinic training.

Dr. Duby emphasized that although there are roadblocks to preparing pediatricians of the future to deal with children confronted with trauma or the most common mental health issues – attention-deficit/hyperactivity disorder, anxiety, depression, or disruptive behavior – the difficulty of handling these disorders in the pediatric medical home is not insurmountable. This really requires only about 10 skills, simple strategies that pediatricians can learn. One of these is assessing a patient’s readiness to change.

Dr. Michelle M. Macias, a professor of pediatrics and director of the division of developmental-behavioral pediatrics at the Medical University of South Carolina, Charleston, who also took part in the roundtable, added it is important to emphasize strength-based approaches, positive parenting, and preventive medicine to deal with behavioral and mental health issues in children.

For those already in practice, there also is help from the AAP. Dr. McMillan mentioned a 2009 article in Pediatrics (2009;124:410-21) written by the AAP Task Force on Mental Health and an online curriculum to aid residency continuity clinic preceptors in training residents to help children in their care with mental health issues.

WASHINGTON – Behavioral and mental health issues are the largest group of conditions that you see in your practice, but pediatric residency training does not adequately prepare you for this challenge, Dr. Julia A. McMillan said in a video roundtable at the annual meeting of the American Academy of Pediatrics.

Dr. John D. Duby, professor and chair of pediatrics at Wright State University, Dayton, Ohio, added, “as we think about the innovation and transformation in pediatric education, pediatricians alone can’t do this work. We need to think more about integrated models for training that bring in psychologists, licensed social workers, care coordinators, community health workers, maybe even child psychiatrists.”

Dr. McMillan, professor of pediatrics and associate dean for graduate medical education at the Johns Hopkins University, Baltimore, agreed, and said that training about behavioral and mental health issues needs to be reinforced throughout pediatric residency training, not just in a block rotation about mental health, but also during critical care or continuity clinic training.

Dr. Duby emphasized that although there are roadblocks to preparing pediatricians of the future to deal with children confronted with trauma or the most common mental health issues – attention-deficit/hyperactivity disorder, anxiety, depression, or disruptive behavior – the difficulty of handling these disorders in the pediatric medical home is not insurmountable. This really requires only about 10 skills, simple strategies that pediatricians can learn. One of these is assessing a patient’s readiness to change.

Dr. Michelle M. Macias, a professor of pediatrics and director of the division of developmental-behavioral pediatrics at the Medical University of South Carolina, Charleston, who also took part in the roundtable, added it is important to emphasize strength-based approaches, positive parenting, and preventive medicine to deal with behavioral and mental health issues in children.

For those already in practice, there also is help from the AAP. Dr. McMillan mentioned a 2009 article in Pediatrics (2009;124:410-21) written by the AAP Task Force on Mental Health and an online curriculum to aid residency continuity clinic preceptors in training residents to help children in their care with mental health issues.

WASHINGTON – Behavioral and mental health issues are the largest group of conditions that you see in your practice, but pediatric residency training does not adequately prepare you for this challenge, Dr. Julia A. McMillan said in a video roundtable at the annual meeting of the American Academy of Pediatrics.

Dr. John D. Duby, professor and chair of pediatrics at Wright State University, Dayton, Ohio, added, “as we think about the innovation and transformation in pediatric education, pediatricians alone can’t do this work. We need to think more about integrated models for training that bring in psychologists, licensed social workers, care coordinators, community health workers, maybe even child psychiatrists.”

Dr. McMillan, professor of pediatrics and associate dean for graduate medical education at the Johns Hopkins University, Baltimore, agreed, and said that training about behavioral and mental health issues needs to be reinforced throughout pediatric residency training, not just in a block rotation about mental health, but also during critical care or continuity clinic training.

Dr. Duby emphasized that although there are roadblocks to preparing pediatricians of the future to deal with children confronted with trauma or the most common mental health issues – attention-deficit/hyperactivity disorder, anxiety, depression, or disruptive behavior – the difficulty of handling these disorders in the pediatric medical home is not insurmountable. This really requires only about 10 skills, simple strategies that pediatricians can learn. One of these is assessing a patient’s readiness to change.

Dr. Michelle M. Macias, a professor of pediatrics and director of the division of developmental-behavioral pediatrics at the Medical University of South Carolina, Charleston, who also took part in the roundtable, added it is important to emphasize strength-based approaches, positive parenting, and preventive medicine to deal with behavioral and mental health issues in children.

For those already in practice, there also is help from the AAP. Dr. McMillan mentioned a 2009 article in Pediatrics (2009;124:410-21) written by the AAP Task Force on Mental Health and an online curriculum to aid residency continuity clinic preceptors in training residents to help children in their care with mental health issues.

WASHINGTON – Recommendations for universal lipid screening between 9 and 11 years and again between ages 17 and 21 – and selective screening of children with risk factors starting at age 2 years – may best be heeded by measuring nonfasting total cholesterol and high-density lipoprotein, pediatric cardiologist Dr. Sarah de Ferranti told a packed room at the annual meeting of the American Academy of Pediatrics.

The difference of the two values is the non-HDL cholesterol level (total cholesterol minus HDL) and represents the atherogenic portion of the lipid profile. It is a “valid” initial result, she assured pediatricians.

©Ugreen/thinkstockphotos.com

Non-HDL values of 145 mg/dL and over should then be further explored through a complete fasting lipid profile, said Dr. de Ferranti, who directs the preventive cardiology program at Boston Children’s Hospital.

While the nonfasting, non-HDL approach has been deemed acceptable for universal screening, national guidelines endorsed by the AAP recommend that selective testing of high-risk children be done with a fasting profile. “But I think people find that onerous,” Dr. de Ferranti said. “Doing a nonfasting test initially [in any pediatric case] is quite reasonable. It’s more convenient, and it may help us to better implement the guidelines and not lose families.”

In 2011, the National Heart, Lung, and Blood Institute (NHLBI) called on physicians not only to selectively screen children with risk factors for cardiovascular disease, but to screen their healthy 9- to 11- and 17- to 21-year-old patients, and to provide lifestyle therapy for patients who have high LDL cholesterol readings on follow-up testing, and then statin treatment for those who don’t respond.

Surveys have shown that fewer than half of pediatricians do routine screening, however, and that many are frustrated with the limitations of lifestyle interventions and at least somewhat uncomfortable with the concept of statin treatment.

The AAP’s own recommendations for lipid screening, issued in 2008, were confined to selective screening of children with risk factors such as obesity, diabetes, or hypertension, or a family history of heart attack, stroke, and high cholesterol. But in 2011, the academy endorsed the NHLBI’s Integrated Guidelines for Cardiovascular Risk Reduction in Childhood and Adolescence, embracing its additional call for screening healthy children during two windows of time.

Both guidelines – the AAP’s and the NHLBI’s – recommend statin treatment for patients whose LDL remains at 190 mg/dL or above after 6 months of lifestyle therapy, and for patients whose LDL is 160 mg/dL or above after lifestyle therapy when additional risk factors are present.

Dr. de Ferranti acknowledged gaps in research on the benefits of early treatment and said that, personally, she is “not sure that [universal screening] will definitely be the right approach for the future.”

She implored pediatricians, however, to remember when making practice decisions that universal screening “has attempted to address the fact that getting a family history [of cardiovascular disease] isn’t always helpful or reliable” for identifying children at high risk of cardiovascular disease, even those with familial hypercholesterolemia.

Familiar hypercholesterolemia is a disorder of LDL cholesterol processing estimated to affect 1 in 250 individuals. It’s usually “asymptomatic until individuals present in their young adulthood with a much higher risk of heart disease … or until they come to the ER as young adults,” said de Ferranti, assistant professor of medicine at Harvard Medical School, Boston.

Studies have shown that individuals aged 20-39 years who have the disorder are almost 90 times as likely to die from coronary heart disease as is the general population in that age group, she noted.

Available data on the impact of treating familiar hypercholesterolemia in childhood is “relatively scant” but “convincing,” she said. One randomized controlled study of statin treatment in children with the disorder used vascular thickness as a proxy for cardiovascular events. Children who took pravastatin for 2 years had a lower mean carotid intima media thickness, and lower LDL levels, compared with children assigned to placebo (JAMA 2004 Jul 21;292[3]:331-7).

Further follow-up of these children has suggested delayed atherosclerotic disease and prevention of cardiac events in the statin group, Dr. de Ferranti noted. And separate observational research shows a significant reduction in cardiovascular disease events in affected adults taking statins.

Not all pediatricians are convinced that screening is justified. A 2013 electronic survey of pediatric providers in Minnesota showed that while 77% supported the concept of lipid screening, 33% performed no screening, 50% screened selectively, and only 16% performed universal screening. (J. Pediatr. 2014 Mar;164[3]:572-6).

In a recent national survey of randomly selected, practicing AAP members, at least two-thirds indicated that they screen based on family history, high-risk conditions, and obesity. Fewer than half said they perform universal age-based screening.

Obtaining labs appears to be a major barrier, Dr. de Ferranti pointed out. Nearly half of the pediatricians who responded to the survey, which was presented at the 2015 annual meeting of the Pediatric Academic Societies, reported problems with patients not returning for a fasting test, she said.

Dr. de Ferranti and her colleagues at Boston Children’s Hospital recently led a quality improvement project to implement lipid screening in their center’s urban primary care practice. Provider adherence to recommended screening, which resembled the NHLBI recommendations, was high. Almost a quarter of the approximately 1,200 patients who received test orders, however, did not complete the ordered screening test, even though it entailed nonfasting non-HDL testing.

And patients screened based on their age alone (the universal screening component) had a low rate of abnormal findings: Only 2.7% were found to have non-HDL of 145 mg/dL or greater, which was surprising to Dr. de Ferranti given the high rate of obesity (45%) in the practice’s population.

“Age-only screening, at least from our data so far, is not very productive,” she said. Only one patient had a clinical picture consistent with familial hyperlipidemia, and this patient was identified based on risk factors and not age alone.

On the other hand, mild abnormalities (non-HDL of 120-145 mg/dL) – the kind that often prompt Dr. de Ferranti to advise lifestyle modification, including a low saturated fat intake of 12-15 g/day with no trans fat, high fiber, and high intake of fresh fruits and vegetables – were common across the board.

Asked about the safety of statins in children, Dr. de Ferranti said there appears to be a 1%-2% rate of side effects in the pediatric population. “My patients have done well,” she said. “Remember, initiation of statins (involves) a discussion – it’s not an emergency. We usually don’t decide in one visit.”

Low-dose statin therapy is an option starting at age 10 years, but Dr. de Ferranti said she sometimes will start “very high risk” patients earlier, between 8 and 10 years of age.

Many of the AAP survey participants believed that statins were appropriate for patients with confirmed high LDL unresponsive to lifestyle change; about 62% agreed with statin use for young children in such situations and almost 90% for older children. Significantly fewer started statin therapy themselves (about 8% for young children and 21% for older children). About half said they refer these patients to lipid specialists, but almost a third reported limited local access.

These low rates of statin treatment or referral for those with severe LDL elevations are concerning and “suggest a missed opportunity for cardiovascular risk reduction in these high-risk children,” Dr. de Ferranti said.

Pediatricians should soon receive more guidance on lipid screening from the U.S. Preventive Services Task Force. In 2007, the task force was unable to determine the balance between potential harms and benefits for routinely screening children and adolescents for dyslipidemia, and issued an “indeterminate” recommendation. It is now reviewing the evidence and is expected to release new guidelines in the near future, she said.

Dr. de Ferranti disclosed that she has current research funding from the Patient Centered Research Institute, the New England Congenital Cardiology Research Foundation, and the Pediatric Heart Network. She also receives royalties from UptoDate, an online clinical decision support resource.

WASHINGTON – Recommendations for universal lipid screening between 9 and 11 years and again between ages 17 and 21 – and selective screening of children with risk factors starting at age 2 years – may best be heeded by measuring nonfasting total cholesterol and high-density lipoprotein, pediatric cardiologist Dr. Sarah de Ferranti told a packed room at the annual meeting of the American Academy of Pediatrics.

The difference of the two values is the non-HDL cholesterol level (total cholesterol minus HDL) and represents the atherogenic portion of the lipid profile. It is a “valid” initial result, she assured pediatricians.

©Ugreen/thinkstockphotos.com

Non-HDL values of 145 mg/dL and over should then be further explored through a complete fasting lipid profile, said Dr. de Ferranti, who directs the preventive cardiology program at Boston Children’s Hospital.

While the nonfasting, non-HDL approach has been deemed acceptable for universal screening, national guidelines endorsed by the AAP recommend that selective testing of high-risk children be done with a fasting profile. “But I think people find that onerous,” Dr. de Ferranti said. “Doing a nonfasting test initially [in any pediatric case] is quite reasonable. It’s more convenient, and it may help us to better implement the guidelines and not lose families.”

In 2011, the National Heart, Lung, and Blood Institute (NHLBI) called on physicians not only to selectively screen children with risk factors for cardiovascular disease, but to screen their healthy 9- to 11- and 17- to 21-year-old patients, and to provide lifestyle therapy for patients who have high LDL cholesterol readings on follow-up testing, and then statin treatment for those who don’t respond.

Surveys have shown that fewer than half of pediatricians do routine screening, however, and that many are frustrated with the limitations of lifestyle interventions and at least somewhat uncomfortable with the concept of statin treatment.

The AAP’s own recommendations for lipid screening, issued in 2008, were confined to selective screening of children with risk factors such as obesity, diabetes, or hypertension, or a family history of heart attack, stroke, and high cholesterol. But in 2011, the academy endorsed the NHLBI’s Integrated Guidelines for Cardiovascular Risk Reduction in Childhood and Adolescence, embracing its additional call for screening healthy children during two windows of time.

Both guidelines – the AAP’s and the NHLBI’s – recommend statin treatment for patients whose LDL remains at 190 mg/dL or above after 6 months of lifestyle therapy, and for patients whose LDL is 160 mg/dL or above after lifestyle therapy when additional risk factors are present.

Dr. de Ferranti acknowledged gaps in research on the benefits of early treatment and said that, personally, she is “not sure that [universal screening] will definitely be the right approach for the future.”

She implored pediatricians, however, to remember when making practice decisions that universal screening “has attempted to address the fact that getting a family history [of cardiovascular disease] isn’t always helpful or reliable” for identifying children at high risk of cardiovascular disease, even those with familial hypercholesterolemia.

Familiar hypercholesterolemia is a disorder of LDL cholesterol processing estimated to affect 1 in 250 individuals. It’s usually “asymptomatic until individuals present in their young adulthood with a much higher risk of heart disease … or until they come to the ER as young adults,” said de Ferranti, assistant professor of medicine at Harvard Medical School, Boston.

Studies have shown that individuals aged 20-39 years who have the disorder are almost 90 times as likely to die from coronary heart disease as is the general population in that age group, she noted.

Available data on the impact of treating familiar hypercholesterolemia in childhood is “relatively scant” but “convincing,” she said. One randomized controlled study of statin treatment in children with the disorder used vascular thickness as a proxy for cardiovascular events. Children who took pravastatin for 2 years had a lower mean carotid intima media thickness, and lower LDL levels, compared with children assigned to placebo (JAMA 2004 Jul 21;292[3]:331-7).

Further follow-up of these children has suggested delayed atherosclerotic disease and prevention of cardiac events in the statin group, Dr. de Ferranti noted. And separate observational research shows a significant reduction in cardiovascular disease events in affected adults taking statins.

Not all pediatricians are convinced that screening is justified. A 2013 electronic survey of pediatric providers in Minnesota showed that while 77% supported the concept of lipid screening, 33% performed no screening, 50% screened selectively, and only 16% performed universal screening. (J. Pediatr. 2014 Mar;164[3]:572-6).

In a recent national survey of randomly selected, practicing AAP members, at least two-thirds indicated that they screen based on family history, high-risk conditions, and obesity. Fewer than half said they perform universal age-based screening.

Obtaining labs appears to be a major barrier, Dr. de Ferranti pointed out. Nearly half of the pediatricians who responded to the survey, which was presented at the 2015 annual meeting of the Pediatric Academic Societies, reported problems with patients not returning for a fasting test, she said.

Dr. de Ferranti and her colleagues at Boston Children’s Hospital recently led a quality improvement project to implement lipid screening in their center’s urban primary care practice. Provider adherence to recommended screening, which resembled the NHLBI recommendations, was high. Almost a quarter of the approximately 1,200 patients who received test orders, however, did not complete the ordered screening test, even though it entailed nonfasting non-HDL testing.

And patients screened based on their age alone (the universal screening component) had a low rate of abnormal findings: Only 2.7% were found to have non-HDL of 145 mg/dL or greater, which was surprising to Dr. de Ferranti given the high rate of obesity (45%) in the practice’s population.

“Age-only screening, at least from our data so far, is not very productive,” she said. Only one patient had a clinical picture consistent with familial hyperlipidemia, and this patient was identified based on risk factors and not age alone.

On the other hand, mild abnormalities (non-HDL of 120-145 mg/dL) – the kind that often prompt Dr. de Ferranti to advise lifestyle modification, including a low saturated fat intake of 12-15 g/day with no trans fat, high fiber, and high intake of fresh fruits and vegetables – were common across the board.

Asked about the safety of statins in children, Dr. de Ferranti said there appears to be a 1%-2% rate of side effects in the pediatric population. “My patients have done well,” she said. “Remember, initiation of statins (involves) a discussion – it’s not an emergency. We usually don’t decide in one visit.”

Low-dose statin therapy is an option starting at age 10 years, but Dr. de Ferranti said she sometimes will start “very high risk” patients earlier, between 8 and 10 years of age.

Many of the AAP survey participants believed that statins were appropriate for patients with confirmed high LDL unresponsive to lifestyle change; about 62% agreed with statin use for young children in such situations and almost 90% for older children. Significantly fewer started statin therapy themselves (about 8% for young children and 21% for older children). About half said they refer these patients to lipid specialists, but almost a third reported limited local access.

These low rates of statin treatment or referral for those with severe LDL elevations are concerning and “suggest a missed opportunity for cardiovascular risk reduction in these high-risk children,” Dr. de Ferranti said.

Pediatricians should soon receive more guidance on lipid screening from the U.S. Preventive Services Task Force. In 2007, the task force was unable to determine the balance between potential harms and benefits for routinely screening children and adolescents for dyslipidemia, and issued an “indeterminate” recommendation. It is now reviewing the evidence and is expected to release new guidelines in the near future, she said.

Dr. de Ferranti disclosed that she has current research funding from the Patient Centered Research Institute, the New England Congenital Cardiology Research Foundation, and the Pediatric Heart Network. She also receives royalties from UptoDate, an online clinical decision support resource.

WASHINGTON – Recommendations for universal lipid screening between 9 and 11 years and again between ages 17 and 21 – and selective screening of children with risk factors starting at age 2 years – may best be heeded by measuring nonfasting total cholesterol and high-density lipoprotein, pediatric cardiologist Dr. Sarah de Ferranti told a packed room at the annual meeting of the American Academy of Pediatrics.

The difference of the two values is the non-HDL cholesterol level (total cholesterol minus HDL) and represents the atherogenic portion of the lipid profile. It is a “valid” initial result, she assured pediatricians.

©Ugreen/thinkstockphotos.com

Non-HDL values of 145 mg/dL and over should then be further explored through a complete fasting lipid profile, said Dr. de Ferranti, who directs the preventive cardiology program at Boston Children’s Hospital.

While the nonfasting, non-HDL approach has been deemed acceptable for universal screening, national guidelines endorsed by the AAP recommend that selective testing of high-risk children be done with a fasting profile. “But I think people find that onerous,” Dr. de Ferranti said. “Doing a nonfasting test initially [in any pediatric case] is quite reasonable. It’s more convenient, and it may help us to better implement the guidelines and not lose families.”

In 2011, the National Heart, Lung, and Blood Institute (NHLBI) called on physicians not only to selectively screen children with risk factors for cardiovascular disease, but to screen their healthy 9- to 11- and 17- to 21-year-old patients, and to provide lifestyle therapy for patients who have high LDL cholesterol readings on follow-up testing, and then statin treatment for those who don’t respond.

Surveys have shown that fewer than half of pediatricians do routine screening, however, and that many are frustrated with the limitations of lifestyle interventions and at least somewhat uncomfortable with the concept of statin treatment.

The AAP’s own recommendations for lipid screening, issued in 2008, were confined to selective screening of children with risk factors such as obesity, diabetes, or hypertension, or a family history of heart attack, stroke, and high cholesterol. But in 2011, the academy endorsed the NHLBI’s Integrated Guidelines for Cardiovascular Risk Reduction in Childhood and Adolescence, embracing its additional call for screening healthy children during two windows of time.

Both guidelines – the AAP’s and the NHLBI’s – recommend statin treatment for patients whose LDL remains at 190 mg/dL or above after 6 months of lifestyle therapy, and for patients whose LDL is 160 mg/dL or above after lifestyle therapy when additional risk factors are present.

Dr. de Ferranti acknowledged gaps in research on the benefits of early treatment and said that, personally, she is “not sure that [universal screening] will definitely be the right approach for the future.”

She implored pediatricians, however, to remember when making practice decisions that universal screening “has attempted to address the fact that getting a family history [of cardiovascular disease] isn’t always helpful or reliable” for identifying children at high risk of cardiovascular disease, even those with familial hypercholesterolemia.

Familiar hypercholesterolemia is a disorder of LDL cholesterol processing estimated to affect 1 in 250 individuals. It’s usually “asymptomatic until individuals present in their young adulthood with a much higher risk of heart disease … or until they come to the ER as young adults,” said de Ferranti, assistant professor of medicine at Harvard Medical School, Boston.

Studies have shown that individuals aged 20-39 years who have the disorder are almost 90 times as likely to die from coronary heart disease as is the general population in that age group, she noted.

Available data on the impact of treating familiar hypercholesterolemia in childhood is “relatively scant” but “convincing,” she said. One randomized controlled study of statin treatment in children with the disorder used vascular thickness as a proxy for cardiovascular events. Children who took pravastatin for 2 years had a lower mean carotid intima media thickness, and lower LDL levels, compared with children assigned to placebo (JAMA 2004 Jul 21;292[3]:331-7).

Further follow-up of these children has suggested delayed atherosclerotic disease and prevention of cardiac events in the statin group, Dr. de Ferranti noted. And separate observational research shows a significant reduction in cardiovascular disease events in affected adults taking statins.

Not all pediatricians are convinced that screening is justified. A 2013 electronic survey of pediatric providers in Minnesota showed that while 77% supported the concept of lipid screening, 33% performed no screening, 50% screened selectively, and only 16% performed universal screening. (J. Pediatr. 2014 Mar;164[3]:572-6).

In a recent national survey of randomly selected, practicing AAP members, at least two-thirds indicated that they screen based on family history, high-risk conditions, and obesity. Fewer than half said they perform universal age-based screening.

Obtaining labs appears to be a major barrier, Dr. de Ferranti pointed out. Nearly half of the pediatricians who responded to the survey, which was presented at the 2015 annual meeting of the Pediatric Academic Societies, reported problems with patients not returning for a fasting test, she said.

Dr. de Ferranti and her colleagues at Boston Children’s Hospital recently led a quality improvement project to implement lipid screening in their center’s urban primary care practice. Provider adherence to recommended screening, which resembled the NHLBI recommendations, was high. Almost a quarter of the approximately 1,200 patients who received test orders, however, did not complete the ordered screening test, even though it entailed nonfasting non-HDL testing.

And patients screened based on their age alone (the universal screening component) had a low rate of abnormal findings: Only 2.7% were found to have non-HDL of 145 mg/dL or greater, which was surprising to Dr. de Ferranti given the high rate of obesity (45%) in the practice’s population.

“Age-only screening, at least from our data so far, is not very productive,” she said. Only one patient had a clinical picture consistent with familial hyperlipidemia, and this patient was identified based on risk factors and not age alone.

On the other hand, mild abnormalities (non-HDL of 120-145 mg/dL) – the kind that often prompt Dr. de Ferranti to advise lifestyle modification, including a low saturated fat intake of 12-15 g/day with no trans fat, high fiber, and high intake of fresh fruits and vegetables – were common across the board.

Asked about the safety of statins in children, Dr. de Ferranti said there appears to be a 1%-2% rate of side effects in the pediatric population. “My patients have done well,” she said. “Remember, initiation of statins (involves) a discussion – it’s not an emergency. We usually don’t decide in one visit.”

Low-dose statin therapy is an option starting at age 10 years, but Dr. de Ferranti said she sometimes will start “very high risk” patients earlier, between 8 and 10 years of age.

Many of the AAP survey participants believed that statins were appropriate for patients with confirmed high LDL unresponsive to lifestyle change; about 62% agreed with statin use for young children in such situations and almost 90% for older children. Significantly fewer started statin therapy themselves (about 8% for young children and 21% for older children). About half said they refer these patients to lipid specialists, but almost a third reported limited local access.

These low rates of statin treatment or referral for those with severe LDL elevations are concerning and “suggest a missed opportunity for cardiovascular risk reduction in these high-risk children,” Dr. de Ferranti said.

Pediatricians should soon receive more guidance on lipid screening from the U.S. Preventive Services Task Force. In 2007, the task force was unable to determine the balance between potential harms and benefits for routinely screening children and adolescents for dyslipidemia, and issued an “indeterminate” recommendation. It is now reviewing the evidence and is expected to release new guidelines in the near future, she said.

Dr. de Ferranti disclosed that she has current research funding from the Patient Centered Research Institute, the New England Congenital Cardiology Research Foundation, and the Pediatric Heart Network. She also receives royalties from UptoDate, an online clinical decision support resource.

WASHINGTON – Four experts explain what COQIPS, VIP, PEMCRC, and ALIIGN are all about.

These acronyms each concern pediatric quality improvement, and you can learn about them in part 2 of a video roundtable that took place at the annual meeting of the American Academy of Pediatrics.

Dr. Matt D. Garber, director of pediatric hospitalists and chief quality officer at Palmetto Health Children’s Hospital, Columbia, S.C., representing the AAP Quality Improvement Innovation Networks (QUIIN), explains how Value in Inpatient Pediatrics (VIP) quality collaboratives involving a number of hospitals take guidelines that impact patient care, such as bronchiolitis, and create quality measures and toolkits, and try to implement what the guidelines are recommending. There also is an outpatient arm involving pediatric practices.

Dr. Michael L. Rinke, a pediatric hospitalist who is medical director of quality at Children’s Hospital at Montefiore, New York, and cochair of the implementation committee of the AAP Council on Quality Improvement and Patient Safety (COQIPS), described how COQIPS will serve as a clearinghouse for toolkits so pediatricians “don’t have to reinvent the wheel” when they want to do quality improvement projects. He emphasized that these toolkits are a quality improvement project-in-a-box.

Dr. Anupam B. Kharbanda, director of research for emergency services at Children’s Minnesota, Minneapolis, and chairman, AAP pediatric emergency medicine collaborative research committee of the section on emergency medicine, emphasized these guidelines and toolkits “apply to your patients, to the average pediatrician who wants to get involved.”

Dr. Joel S. Tieder, a pediatric hospitalist and director of the maintenance of certification program at Seattle Children’s Hospital and vice-chair of the AAP COQIPS, added that maintenance of certification is a perfect opportunity to do a quality improvement project, and not just that, to improve quality for your patients. Dr. Tieder is the author of the ALIIGN proposal, which is all about evaluating and implementing guidelines.

*This article was updated 11/3/2015.

WASHINGTON – Four experts explain what COQIPS, VIP, PEMCRC, and ALIIGN are all about.

These acronyms each concern pediatric quality improvement, and you can learn about them in part 2 of a video roundtable that took place at the annual meeting of the American Academy of Pediatrics.

Dr. Matt D. Garber, director of pediatric hospitalists and chief quality officer at Palmetto Health Children’s Hospital, Columbia, S.C., representing the AAP Quality Improvement Innovation Networks (QUIIN), explains how Value in Inpatient Pediatrics (VIP) quality collaboratives involving a number of hospitals take guidelines that impact patient care, such as bronchiolitis, and create quality measures and toolkits, and try to implement what the guidelines are recommending. There also is an outpatient arm involving pediatric practices.

Dr. Michael L. Rinke, a pediatric hospitalist who is medical director of quality at Children’s Hospital at Montefiore, New York, and cochair of the implementation committee of the AAP Council on Quality Improvement and Patient Safety (COQIPS), described how COQIPS will serve as a clearinghouse for toolkits so pediatricians “don’t have to reinvent the wheel” when they want to do quality improvement projects. He emphasized that these toolkits are a quality improvement project-in-a-box.

Dr. Anupam B. Kharbanda, director of research for emergency services at Children’s Minnesota, Minneapolis, and chairman, AAP pediatric emergency medicine collaborative research committee of the section on emergency medicine, emphasized these guidelines and toolkits “apply to your patients, to the average pediatrician who wants to get involved.”

Dr. Joel S. Tieder, a pediatric hospitalist and director of the maintenance of certification program at Seattle Children’s Hospital and vice-chair of the AAP COQIPS, added that maintenance of certification is a perfect opportunity to do a quality improvement project, and not just that, to improve quality for your patients. Dr. Tieder is the author of the ALIIGN proposal, which is all about evaluating and implementing guidelines.

*This article was updated 11/3/2015.

WASHINGTON – Four experts explain what COQIPS, VIP, PEMCRC, and ALIIGN are all about.

These acronyms each concern pediatric quality improvement, and you can learn about them in part 2 of a video roundtable that took place at the annual meeting of the American Academy of Pediatrics.

Dr. Matt D. Garber, director of pediatric hospitalists and chief quality officer at Palmetto Health Children’s Hospital, Columbia, S.C., representing the AAP Quality Improvement Innovation Networks (QUIIN), explains how Value in Inpatient Pediatrics (VIP) quality collaboratives involving a number of hospitals take guidelines that impact patient care, such as bronchiolitis, and create quality measures and toolkits, and try to implement what the guidelines are recommending. There also is an outpatient arm involving pediatric practices.

Dr. Michael L. Rinke, a pediatric hospitalist who is medical director of quality at Children’s Hospital at Montefiore, New York, and cochair of the implementation committee of the AAP Council on Quality Improvement and Patient Safety (COQIPS), described how COQIPS will serve as a clearinghouse for toolkits so pediatricians “don’t have to reinvent the wheel” when they want to do quality improvement projects. He emphasized that these toolkits are a quality improvement project-in-a-box.

Dr. Anupam B. Kharbanda, director of research for emergency services at Children’s Minnesota, Minneapolis, and chairman, AAP pediatric emergency medicine collaborative research committee of the section on emergency medicine, emphasized these guidelines and toolkits “apply to your patients, to the average pediatrician who wants to get involved.”

Dr. Joel S. Tieder, a pediatric hospitalist and director of the maintenance of certification program at Seattle Children’s Hospital and vice-chair of the AAP COQIPS, added that maintenance of certification is a perfect opportunity to do a quality improvement project, and not just that, to improve quality for your patients. Dr. Tieder is the author of the ALIIGN proposal, which is all about evaluating and implementing guidelines.

*This article was updated 11/3/2015.

WASHINGTON – Pediatricians need to understand the different types of bullying, as well as its risk factors and consequences, according to Dr. Adiaha I.A. Spinks-Franklin, a developmental and behavioral pediatrician at Baylor College of Medicine in Houston.

Knowing how to address bullying and act as a community antibullying advocate is essential as well, Dr. Spinks-Franklin said at the annual meeting of the American Academy of Pediatrics.

Wavebreakmedia/Thinkstock.com

The first step to understanding the problem is understanding the lingo. Bullying is more than making fun of other people. It’s “aggressive behavior that is intentional, repeated over time, and involves an imbalance of power or strength,” Dr. Spinks-Franklin explained. That power imbalance can be physical, social, economic, or involve some power differential. Although the perpetrator is always called the bully, the victim also may be called a “target,” and some children are “bully-victims,” both perpetrators and targets. A third group is the bystanders or witnesses, who also can experience trauma from seeing bullying.

About a third of U.S. children experience bullying, which peaks in middle schools, but that does not mean it’s a normal, acceptable aspect of growing up, Dr. Spinks-Franklin said.

“A lot of teachers think bullying is a normal part of childhood and won’t say anything,” but speaking up can make a difference, Dr. Spinks-Franklin said. “If a child intervenes for another child, the bullying drops. And when an adult intervenes, the effect is even stronger.”

Types of bullying

Most people are familiar with physical bullying – hitting, punching, destruction of physical property or some other physical contact – and verbal bullying such as name-calling or harsh teasing aimed at humiliating the victim. Just as damaging are the other two types of bullying: social or relational bullying and cyberbullying. Boys tend to engage in cyberbullying, verbal bullying, and physical bullying more often than girls, but girls are social bullies more often than are boys.

Social bullying involves excluding someone, spreading rumors about them, or otherwise intentionally interfering with their relationships or their ability to build relationships. Cyberbullying can involve any digital technology, from social media to email to phone texting. With cell phones in the pockets of 75% of teens and an average of 71 texts buzzing those phones each day, according to 2011 and 2015 data, cyberbullying can be deeply intrusive.

Dr. Spinks-Franklin made special mention of a cultural practice called “the Dozens,” or, basically, “trash talk” among African-American children and teens.

“The Dozens is an old tradition of talking smack to your friend. It’s all about verbal comedic talk and coming up with the most incredible insults,” she explained. “There’s timing involved, there’s cadence involved, and you have to maintain emotional regulation or you lose. If you don’t have a good comeback, you lose.”

Examples include classic “Yo Mama” jokes traded back and forth, which she enthusiastically demonstrated to laughter among attendees. But her point was a serious one: If children are shouting insults back and forth and laughing in a group, that’s not verbal bullying. But if a group of children are all taunting a single child who’s not participating or seems distressed, that is verbal bullying.

Consequences of bullying

No one involved is immune to negative effects when bullying is involved, Dr. Spinks-Franklin explained. Victims of bullying have a higher risk of depression, anxiety, poor academic performance, and somatic complaints, particularly on Sunday evenings before they return to school for the week. They also have an increased risk of suicidal thoughts and attempts, which has given rise to the term “bullycide” – a suicide caused by the effects of bullying. On the more extreme end, victims of bullying are at higher risk for violent retaliation, such as attempting or executing mass killings, Dr. Spinks-Franklin said.

Bullies have a different set of risks, starting with a higher risk of alcohol or substance abuse and a greater likelihood to start having sex sooner than peers. Bullies are more likely to get into fights, drop out of school, and vandalize property. As adults, bullies are more likely to rack up traffic citations and criminal convictions and to abuse others, such as romantic partners and children.

Even bystanders who witness bullying suffer, with twice the rate of depression, compared with those who don’t witness bullying. Bystanders also have about a 65% greater odds of anxiety disorders and more than twice the odds of attempting suicide.

Bullying risk factors

Both victims and bullies have identifiable risk factors that are helpful for pediatricians to know about. As individuals, having behavioral problems or depression is a risk factor for being a bully.

“We used to think that bullies had inferior social skills, but some of the newer data tell us that bullies have superior social skills and are so good at manipulating that adults don’t know how they treat people they consider inferior,” Dr. Spinks-Franklin said. “So bullies can have poor social skills or superior social skills.”

Depression and poor social skills also are risk factors for victims, but a major risk factor is simply being an identifiable minority of any kind. A victim’s minority status could relate to religion, sex, race, ethnicity, immigration status, sexual orientation, economic status, hair color, height, or any number of other characteristics. “Whatever it is, you are different from the people around you,” Dr. Spinks-Franklin explained. One study found the three main reasons kids were bullied were their looks, their body shape, and their race.

Risk factors show up in families and environments too. Bullies are more likely to come from families with poor cohesiveness, little warmth, intolerance of different people, physical abuse, authoritarian parenting, and aggression. An absent father is a risk factor for bullies and victims alike. Victims’ mothers are more likely to be controlling, hostile, overprotective, restrictive, threatening, or coddling, and their fathers are more likely to be distant, critical, controlling, uncaring, or neglectful.

Domestic violence, neglect, uninvolved parents, and inconsistent discipline are among the major risk factors for bully-victims. Research also has identified media violence as a risk factor for increased aggression and antisocial behavior. Violent video game players are more likely to become middle-school bullies.

Communities also can be ripe for bullying if they are unsafe, violent, or disorganized. By contrast, safe and connected neighborhoods have a lower risk of bullying among residents. Similarly, classrooms with poor teacher-student relationships and negative peer relationships can be breeding grounds for bullying, as can unsupportive or punitive school environments or ones with misinformed teachers who do not intervene in bullying. Systemic social contributors to bullying include racism, homophobia, sexism, xenophobia, classism, religious intolerance, and ageism.

Addressing bullying

It’s possible to stop bullying, but it requires intentional, evidence-based intervention, particularly throughout entire schools.

“School-wide antibullying curricula on social skills has been found worldwide to greatly reduce bullying and discipline problems in schools,” Dr. Spinks-Franklin explained. Such programs require buy-in from parents and from teachers, who need training and need to intervene consistently and appropriately whenever bullying occurs.

By contrast, zero-tolerance policies are ineffective at preventing or stopping bullying. They may even worsen the problem by discouraging students from reporting bullying. Peer mediation and conflict resolution also send mixed messages to bullies and victims because bullying is an intentional act with an inherent power imbalance, not part of a shared disagreement. Group treatment for bullies also can backfire, leading to worse behaviors from association with other bullies.

Parents can reduce the likelihood that their children will be bullies or victims by using consistent discipline with clear rules and by remaining supportive and fair. If bullying does occur, parents should recognize the warning signs and start a conversation with their children to find out more. Parents can teach and model appropriate behavior and healthy social skills while also working with the school to develop antibullying programs.

Similarly, pediatricians should screen for bullying by asking just three simple questions:

1. Do you ever see kids picking on other kids? (bystander)

2. Do kids ever pick on you? (target/victim)

3. Do you ever pick on other kids? (bully)

Physicians can use the Centers for Disease Control and Prevention’s violence prevention website as a resource and become community advocates against bullies by publicly supporting community-based behavioral health services and raising awareness of bullying among parents, children, teachers, and school administrators. Pediatricians also can push for active local injury surveillance systems in local or state governments and contribute data to existing systems. Finally, pediatricians should familiarize themselves with the resources available to help victims and bullies and to stop or prevent bullying, both online and within their communities.

Dr. Spinks-Franklin said that she had no relevant financial disclosures.

WASHINGTON – Pediatricians need to understand the different types of bullying, as well as its risk factors and consequences, according to Dr. Adiaha I.A. Spinks-Franklin, a developmental and behavioral pediatrician at Baylor College of Medicine in Houston.

Knowing how to address bullying and act as a community antibullying advocate is essential as well, Dr. Spinks-Franklin said at the annual meeting of the American Academy of Pediatrics.

Wavebreakmedia/Thinkstock.com

The first step to understanding the problem is understanding the lingo. Bullying is more than making fun of other people. It’s “aggressive behavior that is intentional, repeated over time, and involves an imbalance of power or strength,” Dr. Spinks-Franklin explained. That power imbalance can be physical, social, economic, or involve some power differential. Although the perpetrator is always called the bully, the victim also may be called a “target,” and some children are “bully-victims,” both perpetrators and targets. A third group is the bystanders or witnesses, who also can experience trauma from seeing bullying.

About a third of U.S. children experience bullying, which peaks in middle schools, but that does not mean it’s a normal, acceptable aspect of growing up, Dr. Spinks-Franklin said.

“A lot of teachers think bullying is a normal part of childhood and won’t say anything,” but speaking up can make a difference, Dr. Spinks-Franklin said. “If a child intervenes for another child, the bullying drops. And when an adult intervenes, the effect is even stronger.”

Types of bullying

Most people are familiar with physical bullying – hitting, punching, destruction of physical property or some other physical contact – and verbal bullying such as name-calling or harsh teasing aimed at humiliating the victim. Just as damaging are the other two types of bullying: social or relational bullying and cyberbullying. Boys tend to engage in cyberbullying, verbal bullying, and physical bullying more often than girls, but girls are social bullies more often than are boys.

Social bullying involves excluding someone, spreading rumors about them, or otherwise intentionally interfering with their relationships or their ability to build relationships. Cyberbullying can involve any digital technology, from social media to email to phone texting. With cell phones in the pockets of 75% of teens and an average of 71 texts buzzing those phones each day, according to 2011 and 2015 data, cyberbullying can be deeply intrusive.

Dr. Spinks-Franklin made special mention of a cultural practice called “the Dozens,” or, basically, “trash talk” among African-American children and teens.

“The Dozens is an old tradition of talking smack to your friend. It’s all about verbal comedic talk and coming up with the most incredible insults,” she explained. “There’s timing involved, there’s cadence involved, and you have to maintain emotional regulation or you lose. If you don’t have a good comeback, you lose.”

Examples include classic “Yo Mama” jokes traded back and forth, which she enthusiastically demonstrated to laughter among attendees. But her point was a serious one: If children are shouting insults back and forth and laughing in a group, that’s not verbal bullying. But if a group of children are all taunting a single child who’s not participating or seems distressed, that is verbal bullying.

Consequences of bullying

No one involved is immune to negative effects when bullying is involved, Dr. Spinks-Franklin explained. Victims of bullying have a higher risk of depression, anxiety, poor academic performance, and somatic complaints, particularly on Sunday evenings before they return to school for the week. They also have an increased risk of suicidal thoughts and attempts, which has given rise to the term “bullycide” – a suicide caused by the effects of bullying. On the more extreme end, victims of bullying are at higher risk for violent retaliation, such as attempting or executing mass killings, Dr. Spinks-Franklin said.

Bullies have a different set of risks, starting with a higher risk of alcohol or substance abuse and a greater likelihood to start having sex sooner than peers. Bullies are more likely to get into fights, drop out of school, and vandalize property. As adults, bullies are more likely to rack up traffic citations and criminal convictions and to abuse others, such as romantic partners and children.

Even bystanders who witness bullying suffer, with twice the rate of depression, compared with those who don’t witness bullying. Bystanders also have about a 65% greater odds of anxiety disorders and more than twice the odds of attempting suicide.

Bullying risk factors

Both victims and bullies have identifiable risk factors that are helpful for pediatricians to know about. As individuals, having behavioral problems or depression is a risk factor for being a bully.

“We used to think that bullies had inferior social skills, but some of the newer data tell us that bullies have superior social skills and are so good at manipulating that adults don’t know how they treat people they consider inferior,” Dr. Spinks-Franklin said. “So bullies can have poor social skills or superior social skills.”

Depression and poor social skills also are risk factors for victims, but a major risk factor is simply being an identifiable minority of any kind. A victim’s minority status could relate to religion, sex, race, ethnicity, immigration status, sexual orientation, economic status, hair color, height, or any number of other characteristics. “Whatever it is, you are different from the people around you,” Dr. Spinks-Franklin explained. One study found the three main reasons kids were bullied were their looks, their body shape, and their race.

Risk factors show up in families and environments too. Bullies are more likely to come from families with poor cohesiveness, little warmth, intolerance of different people, physical abuse, authoritarian parenting, and aggression. An absent father is a risk factor for bullies and victims alike. Victims’ mothers are more likely to be controlling, hostile, overprotective, restrictive, threatening, or coddling, and their fathers are more likely to be distant, critical, controlling, uncaring, or neglectful.

Domestic violence, neglect, uninvolved parents, and inconsistent discipline are among the major risk factors for bully-victims. Research also has identified media violence as a risk factor for increased aggression and antisocial behavior. Violent video game players are more likely to become middle-school bullies.

Communities also can be ripe for bullying if they are unsafe, violent, or disorganized. By contrast, safe and connected neighborhoods have a lower risk of bullying among residents. Similarly, classrooms with poor teacher-student relationships and negative peer relationships can be breeding grounds for bullying, as can unsupportive or punitive school environments or ones with misinformed teachers who do not intervene in bullying. Systemic social contributors to bullying include racism, homophobia, sexism, xenophobia, classism, religious intolerance, and ageism.

Addressing bullying

It’s possible to stop bullying, but it requires intentional, evidence-based intervention, particularly throughout entire schools.

“School-wide antibullying curricula on social skills has been found worldwide to greatly reduce bullying and discipline problems in schools,” Dr. Spinks-Franklin explained. Such programs require buy-in from parents and from teachers, who need training and need to intervene consistently and appropriately whenever bullying occurs.

By contrast, zero-tolerance policies are ineffective at preventing or stopping bullying. They may even worsen the problem by discouraging students from reporting bullying. Peer mediation and conflict resolution also send mixed messages to bullies and victims because bullying is an intentional act with an inherent power imbalance, not part of a shared disagreement. Group treatment for bullies also can backfire, leading to worse behaviors from association with other bullies.

Parents can reduce the likelihood that their children will be bullies or victims by using consistent discipline with clear rules and by remaining supportive and fair. If bullying does occur, parents should recognize the warning signs and start a conversation with their children to find out more. Parents can teach and model appropriate behavior and healthy social skills while also working with the school to develop antibullying programs.

Similarly, pediatricians should screen for bullying by asking just three simple questions:

1. Do you ever see kids picking on other kids? (bystander)

2. Do kids ever pick on you? (target/victim)

3. Do you ever pick on other kids? (bully)

Physicians can use the Centers for Disease Control and Prevention’s violence prevention website as a resource and become community advocates against bullies by publicly supporting community-based behavioral health services and raising awareness of bullying among parents, children, teachers, and school administrators. Pediatricians also can push for active local injury surveillance systems in local or state governments and contribute data to existing systems. Finally, pediatricians should familiarize themselves with the resources available to help victims and bullies and to stop or prevent bullying, both online and within their communities.

Dr. Spinks-Franklin said that she had no relevant financial disclosures.

WASHINGTON – Pediatricians need to understand the different types of bullying, as well as its risk factors and consequences, according to Dr. Adiaha I.A. Spinks-Franklin, a developmental and behavioral pediatrician at Baylor College of Medicine in Houston.

Knowing how to address bullying and act as a community antibullying advocate is essential as well, Dr. Spinks-Franklin said at the annual meeting of the American Academy of Pediatrics.

Wavebreakmedia/Thinkstock.com

The first step to understanding the problem is understanding the lingo. Bullying is more than making fun of other people. It’s “aggressive behavior that is intentional, repeated over time, and involves an imbalance of power or strength,” Dr. Spinks-Franklin explained. That power imbalance can be physical, social, economic, or involve some power differential. Although the perpetrator is always called the bully, the victim also may be called a “target,” and some children are “bully-victims,” both perpetrators and targets. A third group is the bystanders or witnesses, who also can experience trauma from seeing bullying.

About a third of U.S. children experience bullying, which peaks in middle schools, but that does not mean it’s a normal, acceptable aspect of growing up, Dr. Spinks-Franklin said.

“A lot of teachers think bullying is a normal part of childhood and won’t say anything,” but speaking up can make a difference, Dr. Spinks-Franklin said. “If a child intervenes for another child, the bullying drops. And when an adult intervenes, the effect is even stronger.”

Types of bullying

Most people are familiar with physical bullying – hitting, punching, destruction of physical property or some other physical contact – and verbal bullying such as name-calling or harsh teasing aimed at humiliating the victim. Just as damaging are the other two types of bullying: social or relational bullying and cyberbullying. Boys tend to engage in cyberbullying, verbal bullying, and physical bullying more often than girls, but girls are social bullies more often than are boys.

Social bullying involves excluding someone, spreading rumors about them, or otherwise intentionally interfering with their relationships or their ability to build relationships. Cyberbullying can involve any digital technology, from social media to email to phone texting. With cell phones in the pockets of 75% of teens and an average of 71 texts buzzing those phones each day, according to 2011 and 2015 data, cyberbullying can be deeply intrusive.

Dr. Spinks-Franklin made special mention of a cultural practice called “the Dozens,” or, basically, “trash talk” among African-American children and teens.

“The Dozens is an old tradition of talking smack to your friend. It’s all about verbal comedic talk and coming up with the most incredible insults,” she explained. “There’s timing involved, there’s cadence involved, and you have to maintain emotional regulation or you lose. If you don’t have a good comeback, you lose.”

Examples include classic “Yo Mama” jokes traded back and forth, which she enthusiastically demonstrated to laughter among attendees. But her point was a serious one: If children are shouting insults back and forth and laughing in a group, that’s not verbal bullying. But if a group of children are all taunting a single child who’s not participating or seems distressed, that is verbal bullying.

Consequences of bullying

No one involved is immune to negative effects when bullying is involved, Dr. Spinks-Franklin explained. Victims of bullying have a higher risk of depression, anxiety, poor academic performance, and somatic complaints, particularly on Sunday evenings before they return to school for the week. They also have an increased risk of suicidal thoughts and attempts, which has given rise to the term “bullycide” – a suicide caused by the effects of bullying. On the more extreme end, victims of bullying are at higher risk for violent retaliation, such as attempting or executing mass killings, Dr. Spinks-Franklin said.

Bullies have a different set of risks, starting with a higher risk of alcohol or substance abuse and a greater likelihood to start having sex sooner than peers. Bullies are more likely to get into fights, drop out of school, and vandalize property. As adults, bullies are more likely to rack up traffic citations and criminal convictions and to abuse others, such as romantic partners and children.

Even bystanders who witness bullying suffer, with twice the rate of depression, compared with those who don’t witness bullying. Bystanders also have about a 65% greater odds of anxiety disorders and more than twice the odds of attempting suicide.

Bullying risk factors

Both victims and bullies have identifiable risk factors that are helpful for pediatricians to know about. As individuals, having behavioral problems or depression is a risk factor for being a bully.

“We used to think that bullies had inferior social skills, but some of the newer data tell us that bullies have superior social skills and are so good at manipulating that adults don’t know how they treat people they consider inferior,” Dr. Spinks-Franklin said. “So bullies can have poor social skills or superior social skills.”

Depression and poor social skills also are risk factors for victims, but a major risk factor is simply being an identifiable minority of any kind. A victim’s minority status could relate to religion, sex, race, ethnicity, immigration status, sexual orientation, economic status, hair color, height, or any number of other characteristics. “Whatever it is, you are different from the people around you,” Dr. Spinks-Franklin explained. One study found the three main reasons kids were bullied were their looks, their body shape, and their race.

Risk factors show up in families and environments too. Bullies are more likely to come from families with poor cohesiveness, little warmth, intolerance of different people, physical abuse, authoritarian parenting, and aggression. An absent father is a risk factor for bullies and victims alike. Victims’ mothers are more likely to be controlling, hostile, overprotective, restrictive, threatening, or coddling, and their fathers are more likely to be distant, critical, controlling, uncaring, or neglectful.

Domestic violence, neglect, uninvolved parents, and inconsistent discipline are among the major risk factors for bully-victims. Research also has identified media violence as a risk factor for increased aggression and antisocial behavior. Violent video game players are more likely to become middle-school bullies.

Communities also can be ripe for bullying if they are unsafe, violent, or disorganized. By contrast, safe and connected neighborhoods have a lower risk of bullying among residents. Similarly, classrooms with poor teacher-student relationships and negative peer relationships can be breeding grounds for bullying, as can unsupportive or punitive school environments or ones with misinformed teachers who do not intervene in bullying. Systemic social contributors to bullying include racism, homophobia, sexism, xenophobia, classism, religious intolerance, and ageism.

Addressing bullying

It’s possible to stop bullying, but it requires intentional, evidence-based intervention, particularly throughout entire schools.

“School-wide antibullying curricula on social skills has been found worldwide to greatly reduce bullying and discipline problems in schools,” Dr. Spinks-Franklin explained. Such programs require buy-in from parents and from teachers, who need training and need to intervene consistently and appropriately whenever bullying occurs.

By contrast, zero-tolerance policies are ineffective at preventing or stopping bullying. They may even worsen the problem by discouraging students from reporting bullying. Peer mediation and conflict resolution also send mixed messages to bullies and victims because bullying is an intentional act with an inherent power imbalance, not part of a shared disagreement. Group treatment for bullies also can backfire, leading to worse behaviors from association with other bullies.

Parents can reduce the likelihood that their children will be bullies or victims by using consistent discipline with clear rules and by remaining supportive and fair. If bullying does occur, parents should recognize the warning signs and start a conversation with their children to find out more. Parents can teach and model appropriate behavior and healthy social skills while also working with the school to develop antibullying programs.

Similarly, pediatricians should screen for bullying by asking just three simple questions:

1. Do you ever see kids picking on other kids? (bystander)

2. Do kids ever pick on you? (target/victim)

3. Do you ever pick on other kids? (bully)

Physicians can use the Centers for Disease Control and Prevention’s violence prevention website as a resource and become community advocates against bullies by publicly supporting community-based behavioral health services and raising awareness of bullying among parents, children, teachers, and school administrators. Pediatricians also can push for active local injury surveillance systems in local or state governments and contribute data to existing systems. Finally, pediatricians should familiarize themselves with the resources available to help victims and bullies and to stop or prevent bullying, both online and within their communities.

Dr. Spinks-Franklin said that she had no relevant financial disclosures.

WASHINGTON – Experts in pediatric quality improvement convened at the annual meeting of the American Academy of Pediatrics to discuss important next steps that must occur for quality improvement to advance.

In part 1 of a video roundtable, they described how networks are being formed to spur data sharing and determination of benchmarks in a variety of pediatric conditions, such as urinary tract infections and asthma. Dr. Matt D. Garber, director of pediatric hospitalists and chief quality officer at Palmetto Health Children’s Hospital, Columbia, S.C., representing the American Academy of Pediatrics Quality Improvement Innovation Networks (QUIIN), discussed how one such study on bronchiolitis guidelines enlisted the help of emergency physicians and inpatient physicians.

Dr. Anupam B. Kharbanda, director of research for emergency services at Children’s Minnesota, Minneapolis, and chairman, AAP pediatric emergency medicine collaborative research committee of the section on emergency medicine, questioned whether what third party payers want as benchmarks and what physicians, patients, and parents want in terms of quality of care are the same.

Dr. Joel S. Tieder, a pediatric hospitalist and director of the maintenance of certification program at Seattle Children’s Hospital and vice-chair of the AAP Council on Quality Improvement and Patient Safety (COQIPS), said, “With asthma, now we have a world where patient preferences matter, and they are hard to measure across this complicated health system.”

Dr. Michael L. Rinke, a pediatric hospitalist who is medical director of quality at Children’s Hospital at Montefiore in New York and cochair of the implementation committee of the AAP Council on Quality Improvement and Patient Safety (COQIPS), concurred.

WASHINGTON – Experts in pediatric quality improvement convened at the annual meeting of the American Academy of Pediatrics to discuss important next steps that must occur for quality improvement to advance.

In part 1 of a video roundtable, they described how networks are being formed to spur data sharing and determination of benchmarks in a variety of pediatric conditions, such as urinary tract infections and asthma. Dr. Matt D. Garber, director of pediatric hospitalists and chief quality officer at Palmetto Health Children’s Hospital, Columbia, S.C., representing the American Academy of Pediatrics Quality Improvement Innovation Networks (QUIIN), discussed how one such study on bronchiolitis guidelines enlisted the help of emergency physicians and inpatient physicians.

Dr. Anupam B. Kharbanda, director of research for emergency services at Children’s Minnesota, Minneapolis, and chairman, AAP pediatric emergency medicine collaborative research committee of the section on emergency medicine, questioned whether what third party payers want as benchmarks and what physicians, patients, and parents want in terms of quality of care are the same.

Dr. Joel S. Tieder, a pediatric hospitalist and director of the maintenance of certification program at Seattle Children’s Hospital and vice-chair of the AAP Council on Quality Improvement and Patient Safety (COQIPS), said, “With asthma, now we have a world where patient preferences matter, and they are hard to measure across this complicated health system.”

Dr. Michael L. Rinke, a pediatric hospitalist who is medical director of quality at Children’s Hospital at Montefiore in New York and cochair of the implementation committee of the AAP Council on Quality Improvement and Patient Safety (COQIPS), concurred.

WASHINGTON – Experts in pediatric quality improvement convened at the annual meeting of the American Academy of Pediatrics to discuss important next steps that must occur for quality improvement to advance.

In part 1 of a video roundtable, they described how networks are being formed to spur data sharing and determination of benchmarks in a variety of pediatric conditions, such as urinary tract infections and asthma. Dr. Matt D. Garber, director of pediatric hospitalists and chief quality officer at Palmetto Health Children’s Hospital, Columbia, S.C., representing the American Academy of Pediatrics Quality Improvement Innovation Networks (QUIIN), discussed how one such study on bronchiolitis guidelines enlisted the help of emergency physicians and inpatient physicians.

Dr. Anupam B. Kharbanda, director of research for emergency services at Children’s Minnesota, Minneapolis, and chairman, AAP pediatric emergency medicine collaborative research committee of the section on emergency medicine, questioned whether what third party payers want as benchmarks and what physicians, patients, and parents want in terms of quality of care are the same.

Dr. Joel S. Tieder, a pediatric hospitalist and director of the maintenance of certification program at Seattle Children’s Hospital and vice-chair of the AAP Council on Quality Improvement and Patient Safety (COQIPS), said, “With asthma, now we have a world where patient preferences matter, and they are hard to measure across this complicated health system.”

Dr. Michael L. Rinke, a pediatric hospitalist who is medical director of quality at Children’s Hospital at Montefiore in New York and cochair of the implementation committee of the AAP Council on Quality Improvement and Patient Safety (COQIPS), concurred.

WASHINGTON – Youth football coaches and officials should adopt a “zero tolerance” policy regarding dangerous, illegal head-first tackling, according to a policy statement from the American Academy of Pediatrics.

Dr. Gregory L. Landry, a pediatrician at the University of Wisconsin, Madison, presented the policy statement in a plenary session at the AAP annual meeting.

“In looking at the data, we could not find a case for banning tackling in youth football. The injury rate in youth football is relatively low, compared to the older boys and girls,” Dr. Landry, who coauthored the statement, said in a video interview. “We were a little bit worried that if we banned tackling at the youth level it would increase the injury rate when older kids learn how to tackle when they are bigger and more powerful.”

The policy also calls for the following:

• Players must decide whether the benefits of playing outweigh the risks of possible injury.

• Nontackling leagues should be expanded so athletes can choose to participate without the injury risks associated with tackling.

• Skilled athletic trainers should be available on the sidelines, as evidence shows they can reduce the number of injuries for players.

See the video interview with Dr. Landry below.

[email protected]

On Twitter @denisefulton

WASHINGTON – Youth football coaches and officials should adopt a “zero tolerance” policy regarding dangerous, illegal head-first tackling, according to a policy statement from the American Academy of Pediatrics.

Dr. Gregory L. Landry, a pediatrician at the University of Wisconsin, Madison, presented the policy statement in a plenary session at the AAP annual meeting.

“In looking at the data, we could not find a case for banning tackling in youth football. The injury rate in youth football is relatively low, compared to the older boys and girls,” Dr. Landry, who coauthored the statement, said in a video interview. “We were a little bit worried that if we banned tackling at the youth level it would increase the injury rate when older kids learn how to tackle when they are bigger and more powerful.”

The policy also calls for the following:

• Players must decide whether the benefits of playing outweigh the risks of possible injury.

• Nontackling leagues should be expanded so athletes can choose to participate without the injury risks associated with tackling.

• Skilled athletic trainers should be available on the sidelines, as evidence shows they can reduce the number of injuries for players.

See the video interview with Dr. Landry below.

[email protected]

On Twitter @denisefulton

WASHINGTON – Youth football coaches and officials should adopt a “zero tolerance” policy regarding dangerous, illegal head-first tackling, according to a policy statement from the American Academy of Pediatrics.

Dr. Gregory L. Landry, a pediatrician at the University of Wisconsin, Madison, presented the policy statement in a plenary session at the AAP annual meeting.

“In looking at the data, we could not find a case for banning tackling in youth football. The injury rate in youth football is relatively low, compared to the older boys and girls,” Dr. Landry, who coauthored the statement, said in a video interview. “We were a little bit worried that if we banned tackling at the youth level it would increase the injury rate when older kids learn how to tackle when they are bigger and more powerful.”

The policy also calls for the following:

• Players must decide whether the benefits of playing outweigh the risks of possible injury.

• Nontackling leagues should be expanded so athletes can choose to participate without the injury risks associated with tackling.

• Skilled athletic trainers should be available on the sidelines, as evidence shows they can reduce the number of injuries for players.

See the video interview with Dr. Landry below.

[email protected]

On Twitter @denisefulton

The two president-elect candidates for the American Academy of Pediatrics spoke Saturday about what they would do for the organization and how they would advocate for governmental policies benefiting children and pediatricians, during the first official day of the organization’s annual meeting in Washington.

AAP members can vote for Dr. Fernando Stein, FAAP, of Houston, or Dr. Lynda M. Young, FAAP, of Worcester, Mass., during the voting period from Oct. 23 through Nov. 24.

Dr. Stein spoke first, calling to mind the first meeting of pediatricians in 1929 that eventually led to the formation of the AAP and how different children’s needs and the demands on pediatricians are today.

“Our world has changed, pediatrics has changed, the needs of children have changed, our needs as pediatricians have changed, and if we are to be relevant to our mission, we as individuals and as fellows of the academy must change,” he said.

But Dr. Stein pointed out that pediatricians must now do more and more with less and less support from health systems each day, a status quo that is taking a toll on doctors.

“We chose our profession by our natural altruistic inclinations, and currently by self-report, more than 50% of us are burnt out, empathy exhausted, and compassion fatigued,” Dr. Stein said. “I believe that now is the time for the Academy to take a loud and clear and unmistakable position in defense of the pediatrician. It is no longer sufficient to prioritize children when the pediatrician is hurting,” he said to applause.

One challenge Dr. Stein said he would tackle is the process of maintaining certification, a system that he gleaned from local chapters “is thought to be more of an intermittent threat rather than a lifelong commitment to learning,” a description that provoked laughter and applause.

“We need to remove this as a toxic stress to the pediatrician,” he said, eliciting more laughter as he alluded to the previous day’s presentations on the toxic stress children experience. He pledged to ensure the Academy would amend current requirements for certification and maintenance of certification and to address the cost for both.

Dr. Stein also called for the Academy to build a technology platform for sharing data among members and mentioned his work as chairman of the Council on Sections and the Committee on Membership as helpful to this goal.

The most enthusiastically received message Dr. Stein delivered, however, related to the toll of gun violence in the United States. He cited injuries from all causes, suicide, and homicides as the first, third and fourth leading causes of death of youth aged 5-21 years, ranked above respiratory diseases, infections, and sepsis.

“The gun violence issue is by any definition an epidemic and a public health problem,” he said to applause. “The oversimplification of violence as a problem of social justice is unjustified.”

He noted that any other bacterial, viral, or other agent of infection that killed close to 100 people and injured hundreds more every day would unquestionably be called a public health problem demanding scientific research.

“As president of the AAP, I pledge to challenge the legislative efforts aimed at inhibiting pediatricians and scientific organizations from gathering potentially lifesaving information about firearms just as we did in the past with vaccines,” he said. “Is it not time to approach this with the same vigor of scientific inquiry we undertook for the prevention of communicable diseases?”

Next, Dr. Young opened and closed with the question “What do children need?” and spent her talk describing ways in which the answer is pediatricians themselves, remaining at the forefront of addressing the toxic challenges children face.

“Some days in our offices and our clinics, we’re not just physicians,” she said. “We’re nurses, we’re social workers, we’re pharmacists, we’re health insurance advisers, we’re nutritionists, we’re accountants, we’re teachers – all in the interest of trying to change for the better what children see and hear.”

She praised the advocacy efforts of many pediatricians in the room and described advocacy as a team sport to ensure children have access to care and appropriate essential health benefits, particularly if – and maybe when – children’s health insurance becomes part of health insurance exchanges instead of the Children’s Health Insurance Programs (CHIP).

“I spent a fair amount of time talking to legislators to prioritize children’s needs,” Dr. Young said. “I want funding to continue. No, I want funding to increase significantly for the programs that have proof of effectiveness for kids,” she continued to applause. She mentioned programs such as Women, Infants, and Children (WIC), early intervention and home visits for mothers and children.

“We need federal policy to address practice transformation: e-cigarette regulation, opioid abuse, vaccine refusal, gun control, drug pricing, graduate medical education reform,” Dr. Young said. “There are so many issues.”

She noted past legislative wins, including the Affordable Care Act – which garnered applause – for providing access to care and insurance to more people than ever before, and the CHIP Reauthorization Act, extending CHIP funding through 2017.

After describing challenges she’s heard pediatricians are facing in their practices, Dr. Young said some could become opportunities.

“For us to succeed in meeting children’s needs, we need to address our own concerns,” she said. “We need to ensure that we, primary care, specialty, subspecialty, whether you’re in a small independent practice or a large integrated system, have the resources and information to continue to provide the care for our most vulnerable population.”

Dr. Young suggested that offering virtual visits and partnering with telemedicine companies to maintain patients’ continuity of care might comprise one such opportunity, particularly if these services require payment to increase revenue since pediatricians have been providing after-hours care for free for years. She also suggested partnering with retail-based clinics, providing clinical knowledge and knowledge of the community.

“On the federal level, the Academy needs to remain a strong voice and continue to collaborate with other organized medical associations,” Dr. Young continued. “The Centers for Medicare & Medicaid respond to physician concerns, especially when presented by a unified front of physicians working together.”

She exhorted pediatricians never to forget how important they are to the children and families they care for.

“What do children need? They need us,” Dr. Young said to applause. “We pediatricians have a reputation for fairness, and we focus on the right priorities. Our children need us.”

The two president-elect candidates for the American Academy of Pediatrics spoke Saturday about what they would do for the organization and how they would advocate for governmental policies benefiting children and pediatricians, during the first official day of the organization’s annual meeting in Washington.

AAP members can vote for Dr. Fernando Stein, FAAP, of Houston, or Dr. Lynda M. Young, FAAP, of Worcester, Mass., during the voting period from Oct. 23 through Nov. 24.

Dr. Stein spoke first, calling to mind the first meeting of pediatricians in 1929 that eventually led to the formation of the AAP and how different children’s needs and the demands on pediatricians are today.

“Our world has changed, pediatrics has changed, the needs of children have changed, our needs as pediatricians have changed, and if we are to be relevant to our mission, we as individuals and as fellows of the academy must change,” he said.

But Dr. Stein pointed out that pediatricians must now do more and more with less and less support from health systems each day, a status quo that is taking a toll on doctors.

“We chose our profession by our natural altruistic inclinations, and currently by self-report, more than 50% of us are burnt out, empathy exhausted, and compassion fatigued,” Dr. Stein said. “I believe that now is the time for the Academy to take a loud and clear and unmistakable position in defense of the pediatrician. It is no longer sufficient to prioritize children when the pediatrician is hurting,” he said to applause.

One challenge Dr. Stein said he would tackle is the process of maintaining certification, a system that he gleaned from local chapters “is thought to be more of an intermittent threat rather than a lifelong commitment to learning,” a description that provoked laughter and applause.

“We need to remove this as a toxic stress to the pediatrician,” he said, eliciting more laughter as he alluded to the previous day’s presentations on the toxic stress children experience. He pledged to ensure the Academy would amend current requirements for certification and maintenance of certification and to address the cost for both.

Dr. Stein also called for the Academy to build a technology platform for sharing data among members and mentioned his work as chairman of the Council on Sections and the Committee on Membership as helpful to this goal.

The most enthusiastically received message Dr. Stein delivered, however, related to the toll of gun violence in the United States. He cited injuries from all causes, suicide, and homicides as the first, third and fourth leading causes of death of youth aged 5-21 years, ranked above respiratory diseases, infections, and sepsis.

“The gun violence issue is by any definition an epidemic and a public health problem,” he said to applause. “The oversimplification of violence as a problem of social justice is unjustified.”

He noted that any other bacterial, viral, or other agent of infection that killed close to 100 people and injured hundreds more every day would unquestionably be called a public health problem demanding scientific research.

“As president of the AAP, I pledge to challenge the legislative efforts aimed at inhibiting pediatricians and scientific organizations from gathering potentially lifesaving information about firearms just as we did in the past with vaccines,” he said. “Is it not time to approach this with the same vigor of scientific inquiry we undertook for the prevention of communicable diseases?”

Next, Dr. Young opened and closed with the question “What do children need?” and spent her talk describing ways in which the answer is pediatricians themselves, remaining at the forefront of addressing the toxic challenges children face.

“Some days in our offices and our clinics, we’re not just physicians,” she said. “We’re nurses, we’re social workers, we’re pharmacists, we’re health insurance advisers, we’re nutritionists, we’re accountants, we’re teachers – all in the interest of trying to change for the better what children see and hear.”

She praised the advocacy efforts of many pediatricians in the room and described advocacy as a team sport to ensure children have access to care and appropriate essential health benefits, particularly if – and maybe when – children’s health insurance becomes part of health insurance exchanges instead of the Children’s Health Insurance Programs (CHIP).

“I spent a fair amount of time talking to legislators to prioritize children’s needs,” Dr. Young said. “I want funding to continue. No, I want funding to increase significantly for the programs that have proof of effectiveness for kids,” she continued to applause. She mentioned programs such as Women, Infants, and Children (WIC), early intervention and home visits for mothers and children.

“We need federal policy to address practice transformation: e-cigarette regulation, opioid abuse, vaccine refusal, gun control, drug pricing, graduate medical education reform,” Dr. Young said. “There are so many issues.”

She noted past legislative wins, including the Affordable Care Act – which garnered applause – for providing access to care and insurance to more people than ever before, and the CHIP Reauthorization Act, extending CHIP funding through 2017.

After describing challenges she’s heard pediatricians are facing in their practices, Dr. Young said some could become opportunities.

“For us to succeed in meeting children’s needs, we need to address our own concerns,” she said. “We need to ensure that we, primary care, specialty, subspecialty, whether you’re in a small independent practice or a large integrated system, have the resources and information to continue to provide the care for our most vulnerable population.”

Dr. Young suggested that offering virtual visits and partnering with telemedicine companies to maintain patients’ continuity of care might comprise one such opportunity, particularly if these services require payment to increase revenue since pediatricians have been providing after-hours care for free for years. She also suggested partnering with retail-based clinics, providing clinical knowledge and knowledge of the community.

“On the federal level, the Academy needs to remain a strong voice and continue to collaborate with other organized medical associations,” Dr. Young continued. “The Centers for Medicare & Medicaid respond to physician concerns, especially when presented by a unified front of physicians working together.”

She exhorted pediatricians never to forget how important they are to the children and families they care for.

“What do children need? They need us,” Dr. Young said to applause. “We pediatricians have a reputation for fairness, and we focus on the right priorities. Our children need us.”

The two president-elect candidates for the American Academy of Pediatrics spoke Saturday about what they would do for the organization and how they would advocate for governmental policies benefiting children and pediatricians, during the first official day of the organization’s annual meeting in Washington.

AAP members can vote for Dr. Fernando Stein, FAAP, of Houston, or Dr. Lynda M. Young, FAAP, of Worcester, Mass., during the voting period from Oct. 23 through Nov. 24.

Dr. Stein spoke first, calling to mind the first meeting of pediatricians in 1929 that eventually led to the formation of the AAP and how different children’s needs and the demands on pediatricians are today.

“Our world has changed, pediatrics has changed, the needs of children have changed, our needs as pediatricians have changed, and if we are to be relevant to our mission, we as individuals and as fellows of the academy must change,” he said.

But Dr. Stein pointed out that pediatricians must now do more and more with less and less support from health systems each day, a status quo that is taking a toll on doctors.

“We chose our profession by our natural altruistic inclinations, and currently by self-report, more than 50% of us are burnt out, empathy exhausted, and compassion fatigued,” Dr. Stein said. “I believe that now is the time for the Academy to take a loud and clear and unmistakable position in defense of the pediatrician. It is no longer sufficient to prioritize children when the pediatrician is hurting,” he said to applause.

One challenge Dr. Stein said he would tackle is the process of maintaining certification, a system that he gleaned from local chapters “is thought to be more of an intermittent threat rather than a lifelong commitment to learning,” a description that provoked laughter and applause.

“We need to remove this as a toxic stress to the pediatrician,” he said, eliciting more laughter as he alluded to the previous day’s presentations on the toxic stress children experience. He pledged to ensure the Academy would amend current requirements for certification and maintenance of certification and to address the cost for both.

Dr. Stein also called for the Academy to build a technology platform for sharing data among members and mentioned his work as chairman of the Council on Sections and the Committee on Membership as helpful to this goal.

The most enthusiastically received message Dr. Stein delivered, however, related to the toll of gun violence in the United States. He cited injuries from all causes, suicide, and homicides as the first, third and fourth leading causes of death of youth aged 5-21 years, ranked above respiratory diseases, infections, and sepsis.

“The gun violence issue is by any definition an epidemic and a public health problem,” he said to applause. “The oversimplification of violence as a problem of social justice is unjustified.”

He noted that any other bacterial, viral, or other agent of infection that killed close to 100 people and injured hundreds more every day would unquestionably be called a public health problem demanding scientific research.

“As president of the AAP, I pledge to challenge the legislative efforts aimed at inhibiting pediatricians and scientific organizations from gathering potentially lifesaving information about firearms just as we did in the past with vaccines,” he said. “Is it not time to approach this with the same vigor of scientific inquiry we undertook for the prevention of communicable diseases?”

Next, Dr. Young opened and closed with the question “What do children need?” and spent her talk describing ways in which the answer is pediatricians themselves, remaining at the forefront of addressing the toxic challenges children face.

“Some days in our offices and our clinics, we’re not just physicians,” she said. “We’re nurses, we’re social workers, we’re pharmacists, we’re health insurance advisers, we’re nutritionists, we’re accountants, we’re teachers – all in the interest of trying to change for the better what children see and hear.”

She praised the advocacy efforts of many pediatricians in the room and described advocacy as a team sport to ensure children have access to care and appropriate essential health benefits, particularly if – and maybe when – children’s health insurance becomes part of health insurance exchanges instead of the Children’s Health Insurance Programs (CHIP).

“I spent a fair amount of time talking to legislators to prioritize children’s needs,” Dr. Young said. “I want funding to continue. No, I want funding to increase significantly for the programs that have proof of effectiveness for kids,” she continued to applause. She mentioned programs such as Women, Infants, and Children (WIC), early intervention and home visits for mothers and children.

“We need federal policy to address practice transformation: e-cigarette regulation, opioid abuse, vaccine refusal, gun control, drug pricing, graduate medical education reform,” Dr. Young said. “There are so many issues.”

She noted past legislative wins, including the Affordable Care Act – which garnered applause – for providing access to care and insurance to more people than ever before, and the CHIP Reauthorization Act, extending CHIP funding through 2017.

After describing challenges she’s heard pediatricians are facing in their practices, Dr. Young said some could become opportunities.

“For us to succeed in meeting children’s needs, we need to address our own concerns,” she said. “We need to ensure that we, primary care, specialty, subspecialty, whether you’re in a small independent practice or a large integrated system, have the resources and information to continue to provide the care for our most vulnerable population.”

Dr. Young suggested that offering virtual visits and partnering with telemedicine companies to maintain patients’ continuity of care might comprise one such opportunity, particularly if these services require payment to increase revenue since pediatricians have been providing after-hours care for free for years. She also suggested partnering with retail-based clinics, providing clinical knowledge and knowledge of the community.

“On the federal level, the Academy needs to remain a strong voice and continue to collaborate with other organized medical associations,” Dr. Young continued. “The Centers for Medicare & Medicaid respond to physician concerns, especially when presented by a unified front of physicians working together.”

She exhorted pediatricians never to forget how important they are to the children and families they care for.

“What do children need? They need us,” Dr. Young said to applause. “We pediatricians have a reputation for fairness, and we focus on the right priorities. Our children need us.”

Protecting oneself when parents refuse vaccinations for their children entails documenting all discussions – including a conversation about how parents should respond to illness or fever – as well as creating a system in the office to identify incompletely immunized patients for proper triage and care should the need arise, Dr. James P. Scibilia said at the annual meeting of the American Academy of Pediatrics.

Pediatricians should also document that parents have received a vaccine information sheet at each relevant visit and ensure that parents sign appropriate and unaltered “informed refusal” forms, preferably the AAP’s Refusal to Vaccinate form, each time vaccination is refused, said Dr. Scibilia, who is not an attorney but serves on the AAP Committee on Medical Liability and Risk Management.

©dina2001/thinkstockphotos.com

“If patients bring their own form, make sure you read it properly. I received one that had an AAP logo and looked like our form but had a different set of information,” he said.

Physicians may be at legal risk if parents claim in the wake of a bad outcome that they weren’t informed of the risk of nonvaccination; courts have favored the plaintiffs in at least a couple of reported cases thus far, he explained.

Documentation of repeated vaccine discussions – with chart notes indicating that “you’ve reemphasized the risks of not getting a vaccine,” for instance – is important. “Have some little phrase to integrate into your records so you can show that each time the patient came in, you readdressed the issue with them,” said Dr. Scibilia, of Heritage Valley Health System, Beaver, Pa.

“Then make sure you tell your parents that their [unvaccinated] child may require more aggressive evaluation when ill,” he said. “And make sure you have some kind of triage in your phone protocol system.”

Not properly triaging or caring for an unimmunized or underimmunized child may be legally risky, he explained. “If you have a 10-month-old child who hasn’t had their pneumococcal vaccine and develops a 104° fever, you’re going to treat that child differently than one who had the vaccine,” he said. “You need to have some way to identify kids who aren’t immunized and triage them properly.”

Less clear is a situation in which a child infected with a vaccine-preventable illness is seen in the office and infects another child while there. “There is no case law in the U.S. on this. It may happen at some point, but there is nothing right now that suggests you’re at special legal risk [in such a case],” said Dr. Scibilia.

Just as vaccine refusal has been a growing problem, so have requests for altered vaccine schedules. In a recent survey of pediatricians and family physicians, 93% of physicians reported that some parents had requested altered vaccine schedules within the prior month. A significant number of physicians agreed to spread out vaccines, either always or often (37%) or sometimes (37%).

In a minority of cases, physicians decided to dismiss families from their practice: 2% said they “always or often” dismissed patients, and 4% said they “sometimes” did (Pediatrics. 2015 Apr;135:666-77).

“As a group, it seems like pediatricians are following the AAP’s guidance in that we’re trying to convince parents [that vaccination is in their child’s best interest], but it seems that we’re willing to alter schedules in order to get kids vaccinated,” he said.

Whether to agree to alternative scheduling requests is a “philosophical question” for the individual physician to answer, with the understanding that “when you alter the established vaccine schedule, you’re putting yourself at some risk if a patient develops a vaccine-preventable illness during the time frame when you’ve altered the schedule,” he said.

If a physician-patient relationship must be severed, the termination should be done properly and formally in order to avoid possible claims of abandonment. This means providing written notification and documenting that the patient received the notification in a timely fashion, usually with a return receipt. The notification must include an offer to provide emergency care for a specified period of time, Dr. Scibilia said.

Protecting oneself when parents refuse vaccinations for their children entails documenting all discussions – including a conversation about how parents should respond to illness or fever – as well as creating a system in the office to identify incompletely immunized patients for proper triage and care should the need arise, Dr. James P. Scibilia said at the annual meeting of the American Academy of Pediatrics.

Pediatricians should also document that parents have received a vaccine information sheet at each relevant visit and ensure that parents sign appropriate and unaltered “informed refusal” forms, preferably the AAP’s Refusal to Vaccinate form, each time vaccination is refused, said Dr. Scibilia, who is not an attorney but serves on the AAP Committee on Medical Liability and Risk Management.

©dina2001/thinkstockphotos.com

“If patients bring their own form, make sure you read it properly. I received one that had an AAP logo and looked like our form but had a different set of information,” he said.

Physicians may be at legal risk if parents claim in the wake of a bad outcome that they weren’t informed of the risk of nonvaccination; courts have favored the plaintiffs in at least a couple of reported cases thus far, he explained.

Documentation of repeated vaccine discussions – with chart notes indicating that “you’ve reemphasized the risks of not getting a vaccine,” for instance – is important. “Have some little phrase to integrate into your records so you can show that each time the patient came in, you readdressed the issue with them,” said Dr. Scibilia, of Heritage Valley Health System, Beaver, Pa.

“Then make sure you tell your parents that their [unvaccinated] child may require more aggressive evaluation when ill,” he said. “And make sure you have some kind of triage in your phone protocol system.”

Not properly triaging or caring for an unimmunized or underimmunized child may be legally risky, he explained. “If you have a 10-month-old child who hasn’t had their pneumococcal vaccine and develops a 104° fever, you’re going to treat that child differently than one who had the vaccine,” he said. “You need to have some way to identify kids who aren’t immunized and triage them properly.”

Less clear is a situation in which a child infected with a vaccine-preventable illness is seen in the office and infects another child while there. “There is no case law in the U.S. on this. It may happen at some point, but there is nothing right now that suggests you’re at special legal risk [in such a case],” said Dr. Scibilia.

Just as vaccine refusal has been a growing problem, so have requests for altered vaccine schedules. In a recent survey of pediatricians and family physicians, 93% of physicians reported that some parents had requested altered vaccine schedules within the prior month. A significant number of physicians agreed to spread out vaccines, either always or often (37%) or sometimes (37%).

In a minority of cases, physicians decided to dismiss families from their practice: 2% said they “always or often” dismissed patients, and 4% said they “sometimes” did (Pediatrics. 2015 Apr;135:666-77).

“As a group, it seems like pediatricians are following the AAP’s guidance in that we’re trying to convince parents [that vaccination is in their child’s best interest], but it seems that we’re willing to alter schedules in order to get kids vaccinated,” he said.

Whether to agree to alternative scheduling requests is a “philosophical question” for the individual physician to answer, with the understanding that “when you alter the established vaccine schedule, you’re putting yourself at some risk if a patient develops a vaccine-preventable illness during the time frame when you’ve altered the schedule,” he said.

If a physician-patient relationship must be severed, the termination should be done properly and formally in order to avoid possible claims of abandonment. This means providing written notification and documenting that the patient received the notification in a timely fashion, usually with a return receipt. The notification must include an offer to provide emergency care for a specified period of time, Dr. Scibilia said.

Protecting oneself when parents refuse vaccinations for their children entails documenting all discussions – including a conversation about how parents should respond to illness or fever – as well as creating a system in the office to identify incompletely immunized patients for proper triage and care should the need arise, Dr. James P. Scibilia said at the annual meeting of the American Academy of Pediatrics.

Pediatricians should also document that parents have received a vaccine information sheet at each relevant visit and ensure that parents sign appropriate and unaltered “informed refusal” forms, preferably the AAP’s Refusal to Vaccinate form, each time vaccination is refused, said Dr. Scibilia, who is not an attorney but serves on the AAP Committee on Medical Liability and Risk Management.

©dina2001/thinkstockphotos.com

“If patients bring their own form, make sure you read it properly. I received one that had an AAP logo and looked like our form but had a different set of information,” he said.

Physicians may be at legal risk if parents claim in the wake of a bad outcome that they weren’t informed of the risk of nonvaccination; courts have favored the plaintiffs in at least a couple of reported cases thus far, he explained.

Documentation of repeated vaccine discussions – with chart notes indicating that “you’ve reemphasized the risks of not getting a vaccine,” for instance – is important. “Have some little phrase to integrate into your records so you can show that each time the patient came in, you readdressed the issue with them,” said Dr. Scibilia, of Heritage Valley Health System, Beaver, Pa.

“Then make sure you tell your parents that their [unvaccinated] child may require more aggressive evaluation when ill,” he said. “And make sure you have some kind of triage in your phone protocol system.”

Not properly triaging or caring for an unimmunized or underimmunized child may be legally risky, he explained. “If you have a 10-month-old child who hasn’t had their pneumococcal vaccine and develops a 104° fever, you’re going to treat that child differently than one who had the vaccine,” he said. “You need to have some way to identify kids who aren’t immunized and triage them properly.”

Less clear is a situation in which a child infected with a vaccine-preventable illness is seen in the office and infects another child while there. “There is no case law in the U.S. on this. It may happen at some point, but there is nothing right now that suggests you’re at special legal risk [in such a case],” said Dr. Scibilia.

Just as vaccine refusal has been a growing problem, so have requests for altered vaccine schedules. In a recent survey of pediatricians and family physicians, 93% of physicians reported that some parents had requested altered vaccine schedules within the prior month. A significant number of physicians agreed to spread out vaccines, either always or often (37%) or sometimes (37%).

In a minority of cases, physicians decided to dismiss families from their practice: 2% said they “always or often” dismissed patients, and 4% said they “sometimes” did (Pediatrics. 2015 Apr;135:666-77).

“As a group, it seems like pediatricians are following the AAP’s guidance in that we’re trying to convince parents [that vaccination is in their child’s best interest], but it seems that we’re willing to alter schedules in order to get kids vaccinated,” he said.

Whether to agree to alternative scheduling requests is a “philosophical question” for the individual physician to answer, with the understanding that “when you alter the established vaccine schedule, you’re putting yourself at some risk if a patient develops a vaccine-preventable illness during the time frame when you’ve altered the schedule,” he said.

If a physician-patient relationship must be severed, the termination should be done properly and formally in order to avoid possible claims of abandonment. This means providing written notification and documenting that the patient received the notification in a timely fashion, usually with a return receipt. The notification must include an offer to provide emergency care for a specified period of time, Dr. Scibilia said.