American Academy of Pediatrics (AAP): Practical Pediatrics

STEAMBOAT SPRINGS, COLO. – Klinefelter syndrome, the most common cause of hypergonadotrophic hypogonadism in boys, affects 1 in 660 males and is greatly underdiagnosed, according to Dr. Charlotte M. Boney.

"Seventy-five percent of guys with Klinefelter syndrome aren’t diagnosed until they are adults. We are missing the opportunity to diagnose Klinefelter when we could actually intervene in a timely way to promote normal pubertal development," said Dr. Boney, chief of the division of pediatric endocrinology and metabolism at Hasbro Children’s Hospital in Providence, R.I.

Neonates with Klinefelter syndrome look completely normal. But missed opportunities to make the diagnosis later in childhood abound. Among the most common red flags are cryptorchidism, which occurs in 25%-40% of affected boys; language delay, present in more than 40%; learning disabilities, present in more than 75%; and mood and behavior problems, such as attention-deficit/hyperactivity disorder, in more than 25%.

Problems fitting in socially with peers in preschool and kindergarten are also common in boys with Klinefelter syndrome.

"So if you see a boy with an undescended testis at 1 year of age, and that same boy later has language delay, and he’s a wreck in kindergarten, and then in third or fourth grade there are learning disabilities, think about Klinefelter syndrome. I’d like all of us to connect the dots a little better," Dr. Boney said at a meeting on practical pediatrics sponsored by the American Academy of Pediatrics.

She added that since well under 10% of boys should have undescended testes at age 1 year, if at that age she still can’t palpate testes, she’d obtain a karyotype study to rule out Klinefelter syndrome before sending the boy to the urologist to bring down the testes.

Klinefelter syndrome is characterized by delayed puberty, and endocrinologically by high serum FSH and LH and low testosterone levels for the child’s Tanner stage. The majority of affected boys will begin puberty, but it will then turn sluggish and stall.

"Seventy-five percent of guys with Klinefelter syndrome aren’t diagnosed until they are adults."

The diagnosis of Klinefelter syndrome is confirmed by karyotyping. Roughly 90% of individuals with Klinefelter syndrome are 47XXY, 10% are 47XXY/46XY, and less than 1% is 48XXY.

The treatment of Klinefelter syndrome is straightforward: testosterone replacement aimed at achieving normal pubertal development. The goals include a normal-trajectory pubertal growth spurt; normal male muscle mass, body fat distribution, and bone mineralization; induction of secondary sex characteristics; and a sense of psychosocial well-being.

If the boy didn’t virilize normally during puberty, treatment begins with intramuscular injections of a low-dose, long-acting testosterone ester, starting at 50 mg once every 3-4 weeks and working up over the course of a year to 200-300 mg every 2-3 weeks, Dr. Boney said.

Once the patient is in the Tanner 4 range and his serum testosterone climbs above 300 ng/dL, he can transition to maintenance therapy with transdermal testosterone patches. For the patient this is a most welcome event because the patches are self-administered and result in less-dramatic serum testosterone peaks and troughs than with intramuscular injections. Most patients prefer the Androderm patch, which can be placed on the arm, thigh, or back, rather than the Testoderm patch, which has to be stuck on the scrotum, she said.

Testosterone gels that are rubbed into the skin on a daily basis, such as AndroGel or Testim, are another option for replacement therapy. The gels result in impressively smooth serum hormone levels, but they are messy products.

"They have the consistency of ultrasound gel, and a lot of teenagers don’t like them," according to Dr. Boney.

Although a properly diagnosed and treated patient with Klinefelter syndrome will have completely normal sexual functioning, there is at present no way to forestall the death of the patient’s germ cells. In order to preserve the option of parenthood, many large centers are now offering patients with Klinefelter syndrome the option of testicular biopsy to harvest healthy sperm, then banking the sperm for assisted reproduction later in life. But the window for finding healthy sperm in these patients is quite narrow; the biopsy needs to be done when they are roughly 16-20 years old, so the conversation with the patient regarding this option must occur before many teens are emotionally mature, she said.

Dr. Boney reported having no relevant financial disclosures.

STEAMBOAT SPRINGS, COLO. – Klinefelter syndrome, the most common cause of hypergonadotrophic hypogonadism in boys, affects 1 in 660 males and is greatly underdiagnosed, according to Dr. Charlotte M. Boney.

"Seventy-five percent of guys with Klinefelter syndrome aren’t diagnosed until they are adults. We are missing the opportunity to diagnose Klinefelter when we could actually intervene in a timely way to promote normal pubertal development," said Dr. Boney, chief of the division of pediatric endocrinology and metabolism at Hasbro Children’s Hospital in Providence, R.I.

Neonates with Klinefelter syndrome look completely normal. But missed opportunities to make the diagnosis later in childhood abound. Among the most common red flags are cryptorchidism, which occurs in 25%-40% of affected boys; language delay, present in more than 40%; learning disabilities, present in more than 75%; and mood and behavior problems, such as attention-deficit/hyperactivity disorder, in more than 25%.

Problems fitting in socially with peers in preschool and kindergarten are also common in boys with Klinefelter syndrome.

"So if you see a boy with an undescended testis at 1 year of age, and that same boy later has language delay, and he’s a wreck in kindergarten, and then in third or fourth grade there are learning disabilities, think about Klinefelter syndrome. I’d like all of us to connect the dots a little better," Dr. Boney said at a meeting on practical pediatrics sponsored by the American Academy of Pediatrics.

She added that since well under 10% of boys should have undescended testes at age 1 year, if at that age she still can’t palpate testes, she’d obtain a karyotype study to rule out Klinefelter syndrome before sending the boy to the urologist to bring down the testes.

Klinefelter syndrome is characterized by delayed puberty, and endocrinologically by high serum FSH and LH and low testosterone levels for the child’s Tanner stage. The majority of affected boys will begin puberty, but it will then turn sluggish and stall.

"Seventy-five percent of guys with Klinefelter syndrome aren’t diagnosed until they are adults."

The diagnosis of Klinefelter syndrome is confirmed by karyotyping. Roughly 90% of individuals with Klinefelter syndrome are 47XXY, 10% are 47XXY/46XY, and less than 1% is 48XXY.

The treatment of Klinefelter syndrome is straightforward: testosterone replacement aimed at achieving normal pubertal development. The goals include a normal-trajectory pubertal growth spurt; normal male muscle mass, body fat distribution, and bone mineralization; induction of secondary sex characteristics; and a sense of psychosocial well-being.

If the boy didn’t virilize normally during puberty, treatment begins with intramuscular injections of a low-dose, long-acting testosterone ester, starting at 50 mg once every 3-4 weeks and working up over the course of a year to 200-300 mg every 2-3 weeks, Dr. Boney said.

Once the patient is in the Tanner 4 range and his serum testosterone climbs above 300 ng/dL, he can transition to maintenance therapy with transdermal testosterone patches. For the patient this is a most welcome event because the patches are self-administered and result in less-dramatic serum testosterone peaks and troughs than with intramuscular injections. Most patients prefer the Androderm patch, which can be placed on the arm, thigh, or back, rather than the Testoderm patch, which has to be stuck on the scrotum, she said.

Testosterone gels that are rubbed into the skin on a daily basis, such as AndroGel or Testim, are another option for replacement therapy. The gels result in impressively smooth serum hormone levels, but they are messy products.

"They have the consistency of ultrasound gel, and a lot of teenagers don’t like them," according to Dr. Boney.

Although a properly diagnosed and treated patient with Klinefelter syndrome will have completely normal sexual functioning, there is at present no way to forestall the death of the patient’s germ cells. In order to preserve the option of parenthood, many large centers are now offering patients with Klinefelter syndrome the option of testicular biopsy to harvest healthy sperm, then banking the sperm for assisted reproduction later in life. But the window for finding healthy sperm in these patients is quite narrow; the biopsy needs to be done when they are roughly 16-20 years old, so the conversation with the patient regarding this option must occur before many teens are emotionally mature, she said.

Dr. Boney reported having no relevant financial disclosures.

STEAMBOAT SPRINGS, COLO. – Klinefelter syndrome, the most common cause of hypergonadotrophic hypogonadism in boys, affects 1 in 660 males and is greatly underdiagnosed, according to Dr. Charlotte M. Boney.

"Seventy-five percent of guys with Klinefelter syndrome aren’t diagnosed until they are adults. We are missing the opportunity to diagnose Klinefelter when we could actually intervene in a timely way to promote normal pubertal development," said Dr. Boney, chief of the division of pediatric endocrinology and metabolism at Hasbro Children’s Hospital in Providence, R.I.

Neonates with Klinefelter syndrome look completely normal. But missed opportunities to make the diagnosis later in childhood abound. Among the most common red flags are cryptorchidism, which occurs in 25%-40% of affected boys; language delay, present in more than 40%; learning disabilities, present in more than 75%; and mood and behavior problems, such as attention-deficit/hyperactivity disorder, in more than 25%.

Problems fitting in socially with peers in preschool and kindergarten are also common in boys with Klinefelter syndrome.

"So if you see a boy with an undescended testis at 1 year of age, and that same boy later has language delay, and he’s a wreck in kindergarten, and then in third or fourth grade there are learning disabilities, think about Klinefelter syndrome. I’d like all of us to connect the dots a little better," Dr. Boney said at a meeting on practical pediatrics sponsored by the American Academy of Pediatrics.

She added that since well under 10% of boys should have undescended testes at age 1 year, if at that age she still can’t palpate testes, she’d obtain a karyotype study to rule out Klinefelter syndrome before sending the boy to the urologist to bring down the testes.

Klinefelter syndrome is characterized by delayed puberty, and endocrinologically by high serum FSH and LH and low testosterone levels for the child’s Tanner stage. The majority of affected boys will begin puberty, but it will then turn sluggish and stall.

"Seventy-five percent of guys with Klinefelter syndrome aren’t diagnosed until they are adults."

The diagnosis of Klinefelter syndrome is confirmed by karyotyping. Roughly 90% of individuals with Klinefelter syndrome are 47XXY, 10% are 47XXY/46XY, and less than 1% is 48XXY.

The treatment of Klinefelter syndrome is straightforward: testosterone replacement aimed at achieving normal pubertal development. The goals include a normal-trajectory pubertal growth spurt; normal male muscle mass, body fat distribution, and bone mineralization; induction of secondary sex characteristics; and a sense of psychosocial well-being.

If the boy didn’t virilize normally during puberty, treatment begins with intramuscular injections of a low-dose, long-acting testosterone ester, starting at 50 mg once every 3-4 weeks and working up over the course of a year to 200-300 mg every 2-3 weeks, Dr. Boney said.

Once the patient is in the Tanner 4 range and his serum testosterone climbs above 300 ng/dL, he can transition to maintenance therapy with transdermal testosterone patches. For the patient this is a most welcome event because the patches are self-administered and result in less-dramatic serum testosterone peaks and troughs than with intramuscular injections. Most patients prefer the Androderm patch, which can be placed on the arm, thigh, or back, rather than the Testoderm patch, which has to be stuck on the scrotum, she said.

Testosterone gels that are rubbed into the skin on a daily basis, such as AndroGel or Testim, are another option for replacement therapy. The gels result in impressively smooth serum hormone levels, but they are messy products.

"They have the consistency of ultrasound gel, and a lot of teenagers don’t like them," according to Dr. Boney.

Although a properly diagnosed and treated patient with Klinefelter syndrome will have completely normal sexual functioning, there is at present no way to forestall the death of the patient’s germ cells. In order to preserve the option of parenthood, many large centers are now offering patients with Klinefelter syndrome the option of testicular biopsy to harvest healthy sperm, then banking the sperm for assisted reproduction later in life. But the window for finding healthy sperm in these patients is quite narrow; the biopsy needs to be done when they are roughly 16-20 years old, so the conversation with the patient regarding this option must occur before many teens are emotionally mature, she said.

Dr. Boney reported having no relevant financial disclosures.

STEAMBOAT SPRINGS, COLO. – The thing parents need to understand about the age-based suitability ratings prominently displayed on video game packaging is they are bestowed by raters with no training in child development who are paid by an organization founded by the video game industry itself.

"What the ratings are telling us is not what’s good or bad for kids, it’s telling us what society will accept – what the industry can get away without getting people pissed off at them," Dr. Michael Rich said at a meeting on practical pediatrics, sponsored by the American Academy of Pediatrics.

mennovandijk/iStockphoto.com

The Entertainment Software Rating Board (ESRB) raters don’t even get to actually play the games before making their determinations. Instead, they are provided with a manufacturer-edited video sample of part of the game being played by someone else. In other words, they receive only part of the content, explained Dr. Rich, director of the center on media and child health at Children’s Hospital, Boston.

The video game industry’s ratings are based on the self-regulating rating system developed by the movie industry, with which Dr. Rich said he is intimately familiar. He began his career in adolescent medicine after a dozen years as a Hollywood filmmaker, a highlight of which was serving as the assistant director to the legendary Akira Kurosawa on the making of Kagemusha, which means "shadow warrior."

"We have a system in place to ensure a safe food supply so that when we walk down a grocery store aisle we can read labels and know what we’re putting in our kids’ bodies. Because of the way we approach media ratings, we’ve got no idea, really, what we’re putting into kids’ minds," he said.

The arbitrary age cutoffs used in the ESRB rating system are just plain silly, as not all 13-year-olds or 17-year-olds are developmentally equal, Dr. Rich noted. He said he favors instead a descriptive rating system that tells what happens in a video game.

"You really want to know whether you’re going to be killing hookers or building a farm," the pediatrician continued.

He said he recommends that parents disregard the ESRB ratings in favor of a more trustworthy rating system developed independently of the video game industry, such as Common Sense Media. Kids-in-Mind rates movies.

"While they are also fairly subjective, at least they’re coming from the position of a parent who cares, who’s seen it and rates it for you and tells you exactly what you’re going to find if you’re worried about violence or nudity or language," Dr. Rich said.

Patricia Vance, president of the ESRB, said, “The age ratings we assign serve as a reference point by which parents may make their own determination about a game’s suitability for their child, and the content descriptors give a clear and unmistakable warning about the type of material that contributed to that rating, and which a parent might reasonably want to know about. As a supplemental resource, we also offer ‘rating summaries’ via our website and a free mobile app. These provide brief but detailed descriptions of a game’s content, including specific examples.

We do not pretend to be perfect, nor do we believe that a rating can ever objectively represent the sensibilities of every single parent. But we do take seriously the obligation we have to provide them with trustworthy guidance about video game content," she said in a written statement.*

He reported that he had no relevant financial disclosures.

* Updated 2/29/2012 to include additional information.

STEAMBOAT SPRINGS, COLO. – The thing parents need to understand about the age-based suitability ratings prominently displayed on video game packaging is they are bestowed by raters with no training in child development who are paid by an organization founded by the video game industry itself.

"What the ratings are telling us is not what’s good or bad for kids, it’s telling us what society will accept – what the industry can get away without getting people pissed off at them," Dr. Michael Rich said at a meeting on practical pediatrics, sponsored by the American Academy of Pediatrics.

mennovandijk/iStockphoto.com

The Entertainment Software Rating Board (ESRB) raters don’t even get to actually play the games before making their determinations. Instead, they are provided with a manufacturer-edited video sample of part of the game being played by someone else. In other words, they receive only part of the content, explained Dr. Rich, director of the center on media and child health at Children’s Hospital, Boston.

The video game industry’s ratings are based on the self-regulating rating system developed by the movie industry, with which Dr. Rich said he is intimately familiar. He began his career in adolescent medicine after a dozen years as a Hollywood filmmaker, a highlight of which was serving as the assistant director to the legendary Akira Kurosawa on the making of Kagemusha, which means "shadow warrior."

"We have a system in place to ensure a safe food supply so that when we walk down a grocery store aisle we can read labels and know what we’re putting in our kids’ bodies. Because of the way we approach media ratings, we’ve got no idea, really, what we’re putting into kids’ minds," he said.

The arbitrary age cutoffs used in the ESRB rating system are just plain silly, as not all 13-year-olds or 17-year-olds are developmentally equal, Dr. Rich noted. He said he favors instead a descriptive rating system that tells what happens in a video game.

"You really want to know whether you’re going to be killing hookers or building a farm," the pediatrician continued.

He said he recommends that parents disregard the ESRB ratings in favor of a more trustworthy rating system developed independently of the video game industry, such as Common Sense Media. Kids-in-Mind rates movies.

"While they are also fairly subjective, at least they’re coming from the position of a parent who cares, who’s seen it and rates it for you and tells you exactly what you’re going to find if you’re worried about violence or nudity or language," Dr. Rich said.

Patricia Vance, president of the ESRB, said, “The age ratings we assign serve as a reference point by which parents may make their own determination about a game’s suitability for their child, and the content descriptors give a clear and unmistakable warning about the type of material that contributed to that rating, and which a parent might reasonably want to know about. As a supplemental resource, we also offer ‘rating summaries’ via our website and a free mobile app. These provide brief but detailed descriptions of a game’s content, including specific examples.

We do not pretend to be perfect, nor do we believe that a rating can ever objectively represent the sensibilities of every single parent. But we do take seriously the obligation we have to provide them with trustworthy guidance about video game content," she said in a written statement.*

He reported that he had no relevant financial disclosures.

* Updated 2/29/2012 to include additional information.

STEAMBOAT SPRINGS, COLO. – The thing parents need to understand about the age-based suitability ratings prominently displayed on video game packaging is they are bestowed by raters with no training in child development who are paid by an organization founded by the video game industry itself.

"What the ratings are telling us is not what’s good or bad for kids, it’s telling us what society will accept – what the industry can get away without getting people pissed off at them," Dr. Michael Rich said at a meeting on practical pediatrics, sponsored by the American Academy of Pediatrics.

mennovandijk/iStockphoto.com

The Entertainment Software Rating Board (ESRB) raters don’t even get to actually play the games before making their determinations. Instead, they are provided with a manufacturer-edited video sample of part of the game being played by someone else. In other words, they receive only part of the content, explained Dr. Rich, director of the center on media and child health at Children’s Hospital, Boston.

The video game industry’s ratings are based on the self-regulating rating system developed by the movie industry, with which Dr. Rich said he is intimately familiar. He began his career in adolescent medicine after a dozen years as a Hollywood filmmaker, a highlight of which was serving as the assistant director to the legendary Akira Kurosawa on the making of Kagemusha, which means "shadow warrior."

"We have a system in place to ensure a safe food supply so that when we walk down a grocery store aisle we can read labels and know what we’re putting in our kids’ bodies. Because of the way we approach media ratings, we’ve got no idea, really, what we’re putting into kids’ minds," he said.

The arbitrary age cutoffs used in the ESRB rating system are just plain silly, as not all 13-year-olds or 17-year-olds are developmentally equal, Dr. Rich noted. He said he favors instead a descriptive rating system that tells what happens in a video game.

"You really want to know whether you’re going to be killing hookers or building a farm," the pediatrician continued.

He said he recommends that parents disregard the ESRB ratings in favor of a more trustworthy rating system developed independently of the video game industry, such as Common Sense Media. Kids-in-Mind rates movies.

"While they are also fairly subjective, at least they’re coming from the position of a parent who cares, who’s seen it and rates it for you and tells you exactly what you’re going to find if you’re worried about violence or nudity or language," Dr. Rich said.

Patricia Vance, president of the ESRB, said, “The age ratings we assign serve as a reference point by which parents may make their own determination about a game’s suitability for their child, and the content descriptors give a clear and unmistakable warning about the type of material that contributed to that rating, and which a parent might reasonably want to know about. As a supplemental resource, we also offer ‘rating summaries’ via our website and a free mobile app. These provide brief but detailed descriptions of a game’s content, including specific examples.

We do not pretend to be perfect, nor do we believe that a rating can ever objectively represent the sensibilities of every single parent. But we do take seriously the obligation we have to provide them with trustworthy guidance about video game content," she said in a written statement.*

He reported that he had no relevant financial disclosures.

* Updated 2/29/2012 to include additional information.

STEAMBOAT SPRINGS, COLO. – The good news for pediatricians on the malpractice front is they get sued far less often than other specialists.

The bad news? When a pediatrician does have an indemnity payout, it’s a whopper, according to Dr. Steven M. Selbst, professor and vice chair of pediatrics at Jefferson Medical College, Philadelphia, and author of a textbook on preventing malpractice lawsuits in pediatric emergency medicine.

© BanksPhotos/iStockphoto

He pointed to the findings of a landmark study of medical malpractice which concluded that pediatricians had the highest average indemnity payouts out of any of the 25 specialties scrutinized. The mean payment in successful lawsuits involving pediatricians was $520,924, nearly twice the average of $274,887 for physicians overall, he said at a meeting on practical pediatrics sponsored by the American Academy of Pediatrics.

Indeed, the average indemnity payment for pediatricians was, surprisingly, substantially greater than for neurosurgeons or cardiothoracic surgeons, widely considered to be the highest-risk practitioners.

On the plus side, pediatricians had the second-lowest risk of being sued among all physician specialties. A mere 3.1% of pediatricians per year faced a malpractice claim, compared with 19.1% of all neurosurgeons, 18.9% of cardiothoracic surgeons, and 15.3% of general surgeons. Only psychiatrists had a lower annual risk of being sued than pediatricians, he said.

The study, funded by the RAND Institute for Civil Justice and the National Institute on Aging, encompassed one large insurance company’s malpractice lawsuit data for 1991-2005. It included nearly 41,000 insured physicians in all 50 states, among whom were 1,616 pediatricians. Each year, on average 7.4% of all physicians were the subject of a malpractice claim, and 1.6% of physicians had a claim resulting in a payout. In other words, 78% of malpractice claims did not result in payment to the claimant. The investigators calculated that by age 65 years, 75% of physicians in pediatrics and other low-risk specialties would face a malpractice claim, as would 99% of neurosurgeons and other high-risk practitioners (N. Engl. J. Med. 2011;365:629-36).

Dr. Selbst said that among the reasons lawsuit payouts are so large in pediatrics is that juries tend to be extremely sympathetic to plaintiffs injured in childhood. And, when damages are calculated in such cases, the tally will include potential lost income for the rest of that child’s life.

"We’re also at great risk because the statute of limitations is longer in pediatrics. For most other patients, it’s 2 years after the injury. But in pediatrics it can take a long time to recognize the injury. If a patient has developmental delay, it may not be recognized until they’re in school, so it could be 5-10 years later. And even if the family didn’t want to file a lawsuit, when the child becomes 18 years old he or she can file," explained Dr. Selbst.

"There are lawsuits out there dating from an injury at the time the child was a neonate, and he’s now 18 years old. So the statute of limitations in pediatrics can be 20 years. I think that’s a reminder that you have to keep your medical records, somehow, some way, pretty much forever, but at least for 21 years. You can be named in a lawsuit many, many years later," he emphasized.

Dr. Selbst reported having no financial conflicts.

STEAMBOAT SPRINGS, COLO. – The good news for pediatricians on the malpractice front is they get sued far less often than other specialists.

The bad news? When a pediatrician does have an indemnity payout, it’s a whopper, according to Dr. Steven M. Selbst, professor and vice chair of pediatrics at Jefferson Medical College, Philadelphia, and author of a textbook on preventing malpractice lawsuits in pediatric emergency medicine.

© BanksPhotos/iStockphoto

He pointed to the findings of a landmark study of medical malpractice which concluded that pediatricians had the highest average indemnity payouts out of any of the 25 specialties scrutinized. The mean payment in successful lawsuits involving pediatricians was $520,924, nearly twice the average of $274,887 for physicians overall, he said at a meeting on practical pediatrics sponsored by the American Academy of Pediatrics.

Indeed, the average indemnity payment for pediatricians was, surprisingly, substantially greater than for neurosurgeons or cardiothoracic surgeons, widely considered to be the highest-risk practitioners.

On the plus side, pediatricians had the second-lowest risk of being sued among all physician specialties. A mere 3.1% of pediatricians per year faced a malpractice claim, compared with 19.1% of all neurosurgeons, 18.9% of cardiothoracic surgeons, and 15.3% of general surgeons. Only psychiatrists had a lower annual risk of being sued than pediatricians, he said.

The study, funded by the RAND Institute for Civil Justice and the National Institute on Aging, encompassed one large insurance company’s malpractice lawsuit data for 1991-2005. It included nearly 41,000 insured physicians in all 50 states, among whom were 1,616 pediatricians. Each year, on average 7.4% of all physicians were the subject of a malpractice claim, and 1.6% of physicians had a claim resulting in a payout. In other words, 78% of malpractice claims did not result in payment to the claimant. The investigators calculated that by age 65 years, 75% of physicians in pediatrics and other low-risk specialties would face a malpractice claim, as would 99% of neurosurgeons and other high-risk practitioners (N. Engl. J. Med. 2011;365:629-36).

Dr. Selbst said that among the reasons lawsuit payouts are so large in pediatrics is that juries tend to be extremely sympathetic to plaintiffs injured in childhood. And, when damages are calculated in such cases, the tally will include potential lost income for the rest of that child’s life.

"We’re also at great risk because the statute of limitations is longer in pediatrics. For most other patients, it’s 2 years after the injury. But in pediatrics it can take a long time to recognize the injury. If a patient has developmental delay, it may not be recognized until they’re in school, so it could be 5-10 years later. And even if the family didn’t want to file a lawsuit, when the child becomes 18 years old he or she can file," explained Dr. Selbst.

"There are lawsuits out there dating from an injury at the time the child was a neonate, and he’s now 18 years old. So the statute of limitations in pediatrics can be 20 years. I think that’s a reminder that you have to keep your medical records, somehow, some way, pretty much forever, but at least for 21 years. You can be named in a lawsuit many, many years later," he emphasized.

Dr. Selbst reported having no financial conflicts.

STEAMBOAT SPRINGS, COLO. – The good news for pediatricians on the malpractice front is they get sued far less often than other specialists.

The bad news? When a pediatrician does have an indemnity payout, it’s a whopper, according to Dr. Steven M. Selbst, professor and vice chair of pediatrics at Jefferson Medical College, Philadelphia, and author of a textbook on preventing malpractice lawsuits in pediatric emergency medicine.

© BanksPhotos/iStockphoto

He pointed to the findings of a landmark study of medical malpractice which concluded that pediatricians had the highest average indemnity payouts out of any of the 25 specialties scrutinized. The mean payment in successful lawsuits involving pediatricians was $520,924, nearly twice the average of $274,887 for physicians overall, he said at a meeting on practical pediatrics sponsored by the American Academy of Pediatrics.

Indeed, the average indemnity payment for pediatricians was, surprisingly, substantially greater than for neurosurgeons or cardiothoracic surgeons, widely considered to be the highest-risk practitioners.

On the plus side, pediatricians had the second-lowest risk of being sued among all physician specialties. A mere 3.1% of pediatricians per year faced a malpractice claim, compared with 19.1% of all neurosurgeons, 18.9% of cardiothoracic surgeons, and 15.3% of general surgeons. Only psychiatrists had a lower annual risk of being sued than pediatricians, he said.

The study, funded by the RAND Institute for Civil Justice and the National Institute on Aging, encompassed one large insurance company’s malpractice lawsuit data for 1991-2005. It included nearly 41,000 insured physicians in all 50 states, among whom were 1,616 pediatricians. Each year, on average 7.4% of all physicians were the subject of a malpractice claim, and 1.6% of physicians had a claim resulting in a payout. In other words, 78% of malpractice claims did not result in payment to the claimant. The investigators calculated that by age 65 years, 75% of physicians in pediatrics and other low-risk specialties would face a malpractice claim, as would 99% of neurosurgeons and other high-risk practitioners (N. Engl. J. Med. 2011;365:629-36).

Dr. Selbst said that among the reasons lawsuit payouts are so large in pediatrics is that juries tend to be extremely sympathetic to plaintiffs injured in childhood. And, when damages are calculated in such cases, the tally will include potential lost income for the rest of that child’s life.

"We’re also at great risk because the statute of limitations is longer in pediatrics. For most other patients, it’s 2 years after the injury. But in pediatrics it can take a long time to recognize the injury. If a patient has developmental delay, it may not be recognized until they’re in school, so it could be 5-10 years later. And even if the family didn’t want to file a lawsuit, when the child becomes 18 years old he or she can file," explained Dr. Selbst.

"There are lawsuits out there dating from an injury at the time the child was a neonate, and he’s now 18 years old. So the statute of limitations in pediatrics can be 20 years. I think that’s a reminder that you have to keep your medical records, somehow, some way, pretty much forever, but at least for 21 years. You can be named in a lawsuit many, many years later," he emphasized.

Dr. Selbst reported having no financial conflicts.

STEAMBOAT SPRINGS, COLO. – When Dr. Michael Rich, a.k.a. "The Mediatrician," recently visited the University of Michigan, Ann Arbor, and met with a group who had won a grant to develop a protocol for teaching pediatric residents how to use e-mail with patients effectively, he had a simple word of advice: "Don’t."

"I said ‘Don’t do it’ because not only are there all kinds of problems with liability and not being able to read the situation well, but where’s the time going to come from? ... You can’t bill for e-mail with patients, you’re not doing an assessment. So why torture yourself by getting involved in all that?" said Dr. Rich, director of the Center on Media and Child Health at Children’s Hospital of Boston.

E-mail is several steps worse than the telephone as a tool for patient communication – and the telephone has plenty of shortcomings in its own right. "E-mail has lots and lots of problems. You don’t know what the assessment of the mom is. You can tell a lot more even on the telephone just from the tone of her voice. Think about the number of times you’ve gotten an e-mail from a friend, and you attributed a nuance to it that wasn’t there," Dr. Rich noted.

Regarding the telephone, another speaker, Dr. Steven M. Selbst, said that while pediatricians can’t manage a practice without giving advice over the phone, they need to understand there are inherent liability risks in doing so.

"A lot of taking a good history is guided by our physical exam, and obviously you can’t do a physical exam by telephone. Instructions given during telephone management are more likely to be misunderstood, and documentation for the medical record is difficult," observed Dr. Selbst, professor and vice chair of pediatrics at Jefferson Medical College, Philadelphia.

His own policy is not to give advice by phone. However, if it’s a life-threatening emergency, such as a poisoning, he’ll take the phone call and tell the family to get straightaway to the hospital.

Dr. Charlotte M. Boney took issue with Dr. Rich regarding e-mail with patients. She makes extensive use of it, albeit within a narrowly defined scope.

"Those of us who take care of a lot of patients with diabetes can all remember the cumbersome phone calls where they provided their blood sugar data. Things got better when they started faxing me their blood sugars. Now, we have lots of patients who send us their blood sugars by e-mail. I think it does have a place in patient care. The families really want to use it, and it’s more convenient than fax," commented Dr. Boney, chief of pediatric endocrinology and metabolism at Brown University in Providence, R.I.

Sure, Dr. Rich replied. "But these are patients you know and have trained well, and you’re asking for objective, measurable information," he pointed out.

As an example of how not to do e-mail, he mentioned that a physician he knows came back from a vacation and found a 5-day-old email from a patient expressing suicidality. The lesson? If you’re going to use e-mail with patients, there needs to be a built-in protocol for accessing and responding to e-mails in timely fashion from remote locations. There also should be an outgoing message stating when the physician won’t be able to respond.

Dr. Beth A. Vogt, a pediatric nephrologist at Case Western Reserve University in Cleveland, said she uses e-mail to manage her patients’ blood pressure.

"It’s an enormous time-saver compared to writing all the figures down. But I educate patients that they can’t e-mail a blood pressure of 180/110 mm Hg; that requires a phone call," she said.

Also, as a matter of hospital policy, Dr. Vogt had to get a signed parental consent authorizing e-mail communication with everyone in her office: her medical assistant, nurse, and secretary.

An audience show of hands indicated fewer than 10% now utilize e-mail as a means of communicating with their patients.

Dr. Rich and Dr. Selbst reported having no relevant financial conflicts.

STEAMBOAT SPRINGS, COLO. – When Dr. Michael Rich, a.k.a. "The Mediatrician," recently visited the University of Michigan, Ann Arbor, and met with a group who had won a grant to develop a protocol for teaching pediatric residents how to use e-mail with patients effectively, he had a simple word of advice: "Don’t."

"I said ‘Don’t do it’ because not only are there all kinds of problems with liability and not being able to read the situation well, but where’s the time going to come from? ... You can’t bill for e-mail with patients, you’re not doing an assessment. So why torture yourself by getting involved in all that?" said Dr. Rich, director of the Center on Media and Child Health at Children’s Hospital of Boston.

E-mail is several steps worse than the telephone as a tool for patient communication – and the telephone has plenty of shortcomings in its own right. "E-mail has lots and lots of problems. You don’t know what the assessment of the mom is. You can tell a lot more even on the telephone just from the tone of her voice. Think about the number of times you’ve gotten an e-mail from a friend, and you attributed a nuance to it that wasn’t there," Dr. Rich noted.

Regarding the telephone, another speaker, Dr. Steven M. Selbst, said that while pediatricians can’t manage a practice without giving advice over the phone, they need to understand there are inherent liability risks in doing so.

"A lot of taking a good history is guided by our physical exam, and obviously you can’t do a physical exam by telephone. Instructions given during telephone management are more likely to be misunderstood, and documentation for the medical record is difficult," observed Dr. Selbst, professor and vice chair of pediatrics at Jefferson Medical College, Philadelphia.

His own policy is not to give advice by phone. However, if it’s a life-threatening emergency, such as a poisoning, he’ll take the phone call and tell the family to get straightaway to the hospital.

Dr. Charlotte M. Boney took issue with Dr. Rich regarding e-mail with patients. She makes extensive use of it, albeit within a narrowly defined scope.

"Those of us who take care of a lot of patients with diabetes can all remember the cumbersome phone calls where they provided their blood sugar data. Things got better when they started faxing me their blood sugars. Now, we have lots of patients who send us their blood sugars by e-mail. I think it does have a place in patient care. The families really want to use it, and it’s more convenient than fax," commented Dr. Boney, chief of pediatric endocrinology and metabolism at Brown University in Providence, R.I.

Sure, Dr. Rich replied. "But these are patients you know and have trained well, and you’re asking for objective, measurable information," he pointed out.

As an example of how not to do e-mail, he mentioned that a physician he knows came back from a vacation and found a 5-day-old email from a patient expressing suicidality. The lesson? If you’re going to use e-mail with patients, there needs to be a built-in protocol for accessing and responding to e-mails in timely fashion from remote locations. There also should be an outgoing message stating when the physician won’t be able to respond.

Dr. Beth A. Vogt, a pediatric nephrologist at Case Western Reserve University in Cleveland, said she uses e-mail to manage her patients’ blood pressure.

"It’s an enormous time-saver compared to writing all the figures down. But I educate patients that they can’t e-mail a blood pressure of 180/110 mm Hg; that requires a phone call," she said.

Also, as a matter of hospital policy, Dr. Vogt had to get a signed parental consent authorizing e-mail communication with everyone in her office: her medical assistant, nurse, and secretary.

An audience show of hands indicated fewer than 10% now utilize e-mail as a means of communicating with their patients.

Dr. Rich and Dr. Selbst reported having no relevant financial conflicts.

STEAMBOAT SPRINGS, COLO. – When Dr. Michael Rich, a.k.a. "The Mediatrician," recently visited the University of Michigan, Ann Arbor, and met with a group who had won a grant to develop a protocol for teaching pediatric residents how to use e-mail with patients effectively, he had a simple word of advice: "Don’t."

"I said ‘Don’t do it’ because not only are there all kinds of problems with liability and not being able to read the situation well, but where’s the time going to come from? ... You can’t bill for e-mail with patients, you’re not doing an assessment. So why torture yourself by getting involved in all that?" said Dr. Rich, director of the Center on Media and Child Health at Children’s Hospital of Boston.

E-mail is several steps worse than the telephone as a tool for patient communication – and the telephone has plenty of shortcomings in its own right. "E-mail has lots and lots of problems. You don’t know what the assessment of the mom is. You can tell a lot more even on the telephone just from the tone of her voice. Think about the number of times you’ve gotten an e-mail from a friend, and you attributed a nuance to it that wasn’t there," Dr. Rich noted.

Regarding the telephone, another speaker, Dr. Steven M. Selbst, said that while pediatricians can’t manage a practice without giving advice over the phone, they need to understand there are inherent liability risks in doing so.

"A lot of taking a good history is guided by our physical exam, and obviously you can’t do a physical exam by telephone. Instructions given during telephone management are more likely to be misunderstood, and documentation for the medical record is difficult," observed Dr. Selbst, professor and vice chair of pediatrics at Jefferson Medical College, Philadelphia.

His own policy is not to give advice by phone. However, if it’s a life-threatening emergency, such as a poisoning, he’ll take the phone call and tell the family to get straightaway to the hospital.

Dr. Charlotte M. Boney took issue with Dr. Rich regarding e-mail with patients. She makes extensive use of it, albeit within a narrowly defined scope.

"Those of us who take care of a lot of patients with diabetes can all remember the cumbersome phone calls where they provided their blood sugar data. Things got better when they started faxing me their blood sugars. Now, we have lots of patients who send us their blood sugars by e-mail. I think it does have a place in patient care. The families really want to use it, and it’s more convenient than fax," commented Dr. Boney, chief of pediatric endocrinology and metabolism at Brown University in Providence, R.I.

Sure, Dr. Rich replied. "But these are patients you know and have trained well, and you’re asking for objective, measurable information," he pointed out.

As an example of how not to do e-mail, he mentioned that a physician he knows came back from a vacation and found a 5-day-old email from a patient expressing suicidality. The lesson? If you’re going to use e-mail with patients, there needs to be a built-in protocol for accessing and responding to e-mails in timely fashion from remote locations. There also should be an outgoing message stating when the physician won’t be able to respond.

Dr. Beth A. Vogt, a pediatric nephrologist at Case Western Reserve University in Cleveland, said she uses e-mail to manage her patients’ blood pressure.

"It’s an enormous time-saver compared to writing all the figures down. But I educate patients that they can’t e-mail a blood pressure of 180/110 mm Hg; that requires a phone call," she said.

Also, as a matter of hospital policy, Dr. Vogt had to get a signed parental consent authorizing e-mail communication with everyone in her office: her medical assistant, nurse, and secretary.

An audience show of hands indicated fewer than 10% now utilize e-mail as a means of communicating with their patients.

Dr. Rich and Dr. Selbst reported having no relevant financial conflicts.

STEAMBOAT SPRINGS, COLO.  – A surprisingly high percentage of primary care pediatricians don’t routinely use incision and drainage to treat simple boils in accordance with expert consensus clinical care guidelines, according to a national survey.

However, 55% of responding pediatricians indicated they were interested in obtaining further training in abscess management. And the good news for pediatricians lacking ready access to an expert is that a superb instructional training video is available on the Internet to subscribers of the New England Journal of Medicine, Dr. Penelope H. Dennehy said at the meeting.

The video was created by Dr. Michael T. Fitch and his colleagues at Wake Forest University, Winston-Salem, N.C. and has an accompanying instructional text. Dr. Dennehy is a professor of pediatrics and director of the division of pediatric infectious diseases at Brown University, Providence, R.I.

The Infectious Diseases Society of America (IDSA) guidelines for the treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections released last year (Clin. Infect. Dis. 2011;52:285-92) emphasize that the primary treatment of uncomplicated abscesses and boils is incision and drainage (I&D) alone. There is no need for aspiration and culture, because antibiotics are not warranted as part of initial treatment except in special circumstances. In most cases, I&D alone will be adequate.

Yet a national survey of 385 primary care pediatricians conducted by Dr. Alex R. Kemper and his coworkers at Duke University, Durham, N.C., found that only 59% of respondents would perform I&D in their office for a 3-year-old presenting with an uncomplicated boil or abscess. If the child was 6 months old, 46% would do so. For an 8- or 15-year-old, roughly 68% of pediatricians would treat the skin lesion with I&D (Clin. Pediatr. 2011;50:525-8).

About 10% of respondents indicated they would routinely aspirate the lesion with a needle and syringe.

When pediatricians who don’t use I&D to treat uncomplicated abscesses in their office were asked why not, 10% replied that no one in their practice could do the procedure. Another 34% reported that it’s too time consuming, and 24% indicated they considered reimbursement for I&D insufficient to justify using the treatment.

Fifty-six percent of the pediatricians named trimethoprim-sulfamethoxazole as their initial antibiotic of choice for empiric treatment of uncomplicated abscesses. Eleven percent named clindamycin, and 11% opted for a beta-lactam or cephalosporin. But 18% of pediatricians said they would go with various dual therapies, which is not recommended in the IDSA guidelines.

The guidelines recommend culturing and empiric antibiotics after I&D of an abscess in specific situations. These include the patient with signs and symptoms of systemic illness; immunosuppression; rapid local progression with associated cellulitis; or extensive disease, such as a large area of redness around the initial abscess. Culturing and antibiotics also are recommended in very young infants with a simple abscess, in patients with associated septic phlebitis, in those whose abscess can’t be drained completely, and in patients who haven’t responded adequately to I&D alone.

The IDSA guideline–recommended oral antibiotic options for empiric therapy include trimethoprim-sulfamethoxazole, doxycycline or minocycline for older children, or clindamycin, as long as the local community-acquired MRSA clindamycin resistance rate isn’t more than 10%.

The guidelines also include linezolid on the recommended list. However, Dr. Dennehy is opposed to using linezolid as initial therapy for an uncomplicated abscess or cellulitis.

"It’s a very expensive antibiotic. It’s probably pushed hard by some of the drug reps, but it has adverse effects, including hematologic toxicity. We reserve it in the infectious diseases community for infections where we want to transition off of IV vancomycin and need an oral alternative," she explained.

Neither the American Academy of Pediatrics nor any other organization recommends keeping a child with a MRSA skin infection out of school or day care.

"I get this question a lot. If you can cover the lesion and it’s not draining outside of the bandages, that child can go back to school or day care," Dr. Dennehy stressed.

In patients being treated empirically with an antibiotic, therapy should be adjusted once the etiologic organism and its drug susceptibility are known.

"About a third of the skin infections that look like MRSA are really MSSA [methicillin-sensitive S. aureus]. You can treat those orally with a first-generation cephalosporin, like cephalexin. You don’t need to continue on with something that’s directed at MRSA," according to Dr. Dennehy.

Clear discharge instructions are a key element in achieving treatment success. The family needs to understand the importance of hand washing after touching infected skin and the necessity to avoid sharing towels, linens, and other items that have contacted infected skin.

Dr. Dennehy reported having no relevant financial conflicts.

STEAMBOAT SPRINGS, COLO.  – A surprisingly high percentage of primary care pediatricians don’t routinely use incision and drainage to treat simple boils in accordance with expert consensus clinical care guidelines, according to a national survey.

However, 55% of responding pediatricians indicated they were interested in obtaining further training in abscess management. And the good news for pediatricians lacking ready access to an expert is that a superb instructional training video is available on the Internet to subscribers of the New England Journal of Medicine, Dr. Penelope H. Dennehy said at the meeting.

The video was created by Dr. Michael T. Fitch and his colleagues at Wake Forest University, Winston-Salem, N.C. and has an accompanying instructional text. Dr. Dennehy is a professor of pediatrics and director of the division of pediatric infectious diseases at Brown University, Providence, R.I.

The Infectious Diseases Society of America (IDSA) guidelines for the treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections released last year (Clin. Infect. Dis. 2011;52:285-92) emphasize that the primary treatment of uncomplicated abscesses and boils is incision and drainage (I&D) alone. There is no need for aspiration and culture, because antibiotics are not warranted as part of initial treatment except in special circumstances. In most cases, I&D alone will be adequate.

Yet a national survey of 385 primary care pediatricians conducted by Dr. Alex R. Kemper and his coworkers at Duke University, Durham, N.C., found that only 59% of respondents would perform I&D in their office for a 3-year-old presenting with an uncomplicated boil or abscess. If the child was 6 months old, 46% would do so. For an 8- or 15-year-old, roughly 68% of pediatricians would treat the skin lesion with I&D (Clin. Pediatr. 2011;50:525-8).

About 10% of respondents indicated they would routinely aspirate the lesion with a needle and syringe.

When pediatricians who don’t use I&D to treat uncomplicated abscesses in their office were asked why not, 10% replied that no one in their practice could do the procedure. Another 34% reported that it’s too time consuming, and 24% indicated they considered reimbursement for I&D insufficient to justify using the treatment.

Fifty-six percent of the pediatricians named trimethoprim-sulfamethoxazole as their initial antibiotic of choice for empiric treatment of uncomplicated abscesses. Eleven percent named clindamycin, and 11% opted for a beta-lactam or cephalosporin. But 18% of pediatricians said they would go with various dual therapies, which is not recommended in the IDSA guidelines.

The guidelines recommend culturing and empiric antibiotics after I&D of an abscess in specific situations. These include the patient with signs and symptoms of systemic illness; immunosuppression; rapid local progression with associated cellulitis; or extensive disease, such as a large area of redness around the initial abscess. Culturing and antibiotics also are recommended in very young infants with a simple abscess, in patients with associated septic phlebitis, in those whose abscess can’t be drained completely, and in patients who haven’t responded adequately to I&D alone.

The IDSA guideline–recommended oral antibiotic options for empiric therapy include trimethoprim-sulfamethoxazole, doxycycline or minocycline for older children, or clindamycin, as long as the local community-acquired MRSA clindamycin resistance rate isn’t more than 10%.

The guidelines also include linezolid on the recommended list. However, Dr. Dennehy is opposed to using linezolid as initial therapy for an uncomplicated abscess or cellulitis.

"It’s a very expensive antibiotic. It’s probably pushed hard by some of the drug reps, but it has adverse effects, including hematologic toxicity. We reserve it in the infectious diseases community for infections where we want to transition off of IV vancomycin and need an oral alternative," she explained.

Neither the American Academy of Pediatrics nor any other organization recommends keeping a child with a MRSA skin infection out of school or day care.

"I get this question a lot. If you can cover the lesion and it’s not draining outside of the bandages, that child can go back to school or day care," Dr. Dennehy stressed.

In patients being treated empirically with an antibiotic, therapy should be adjusted once the etiologic organism and its drug susceptibility are known.

"About a third of the skin infections that look like MRSA are really MSSA [methicillin-sensitive S. aureus]. You can treat those orally with a first-generation cephalosporin, like cephalexin. You don’t need to continue on with something that’s directed at MRSA," according to Dr. Dennehy.

Clear discharge instructions are a key element in achieving treatment success. The family needs to understand the importance of hand washing after touching infected skin and the necessity to avoid sharing towels, linens, and other items that have contacted infected skin.

Dr. Dennehy reported having no relevant financial conflicts.

STEAMBOAT SPRINGS, COLO.  – A surprisingly high percentage of primary care pediatricians don’t routinely use incision and drainage to treat simple boils in accordance with expert consensus clinical care guidelines, according to a national survey.

However, 55% of responding pediatricians indicated they were interested in obtaining further training in abscess management. And the good news for pediatricians lacking ready access to an expert is that a superb instructional training video is available on the Internet to subscribers of the New England Journal of Medicine, Dr. Penelope H. Dennehy said at the meeting.

The video was created by Dr. Michael T. Fitch and his colleagues at Wake Forest University, Winston-Salem, N.C. and has an accompanying instructional text. Dr. Dennehy is a professor of pediatrics and director of the division of pediatric infectious diseases at Brown University, Providence, R.I.

The Infectious Diseases Society of America (IDSA) guidelines for the treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections released last year (Clin. Infect. Dis. 2011;52:285-92) emphasize that the primary treatment of uncomplicated abscesses and boils is incision and drainage (I&D) alone. There is no need for aspiration and culture, because antibiotics are not warranted as part of initial treatment except in special circumstances. In most cases, I&D alone will be adequate.

Yet a national survey of 385 primary care pediatricians conducted by Dr. Alex R. Kemper and his coworkers at Duke University, Durham, N.C., found that only 59% of respondents would perform I&D in their office for a 3-year-old presenting with an uncomplicated boil or abscess. If the child was 6 months old, 46% would do so. For an 8- or 15-year-old, roughly 68% of pediatricians would treat the skin lesion with I&D (Clin. Pediatr. 2011;50:525-8).

About 10% of respondents indicated they would routinely aspirate the lesion with a needle and syringe.

When pediatricians who don’t use I&D to treat uncomplicated abscesses in their office were asked why not, 10% replied that no one in their practice could do the procedure. Another 34% reported that it’s too time consuming, and 24% indicated they considered reimbursement for I&D insufficient to justify using the treatment.

Fifty-six percent of the pediatricians named trimethoprim-sulfamethoxazole as their initial antibiotic of choice for empiric treatment of uncomplicated abscesses. Eleven percent named clindamycin, and 11% opted for a beta-lactam or cephalosporin. But 18% of pediatricians said they would go with various dual therapies, which is not recommended in the IDSA guidelines.

The guidelines recommend culturing and empiric antibiotics after I&D of an abscess in specific situations. These include the patient with signs and symptoms of systemic illness; immunosuppression; rapid local progression with associated cellulitis; or extensive disease, such as a large area of redness around the initial abscess. Culturing and antibiotics also are recommended in very young infants with a simple abscess, in patients with associated septic phlebitis, in those whose abscess can’t be drained completely, and in patients who haven’t responded adequately to I&D alone.

The IDSA guideline–recommended oral antibiotic options for empiric therapy include trimethoprim-sulfamethoxazole, doxycycline or minocycline for older children, or clindamycin, as long as the local community-acquired MRSA clindamycin resistance rate isn’t more than 10%.

The guidelines also include linezolid on the recommended list. However, Dr. Dennehy is opposed to using linezolid as initial therapy for an uncomplicated abscess or cellulitis.

"It’s a very expensive antibiotic. It’s probably pushed hard by some of the drug reps, but it has adverse effects, including hematologic toxicity. We reserve it in the infectious diseases community for infections where we want to transition off of IV vancomycin and need an oral alternative," she explained.

Neither the American Academy of Pediatrics nor any other organization recommends keeping a child with a MRSA skin infection out of school or day care.

"I get this question a lot. If you can cover the lesion and it’s not draining outside of the bandages, that child can go back to school or day care," Dr. Dennehy stressed.

In patients being treated empirically with an antibiotic, therapy should be adjusted once the etiologic organism and its drug susceptibility are known.

"About a third of the skin infections that look like MRSA are really MSSA [methicillin-sensitive S. aureus]. You can treat those orally with a first-generation cephalosporin, like cephalexin. You don’t need to continue on with something that’s directed at MRSA," according to Dr. Dennehy.

Clear discharge instructions are a key element in achieving treatment success. The family needs to understand the importance of hand washing after touching infected skin and the necessity to avoid sharing towels, linens, and other items that have contacted infected skin.

Dr. Dennehy reported having no relevant financial conflicts.

STEAMBOAT SPRINGS, COLO. – Primary care physicians commonly over-refer children for subspecialist nephrologic evaluation of proteinuria they could readily identify as nonpathologic in their own offices by simple testing, thereby sparing families considerable expense and anxiety.

All that’s needed to differentiate pathologic from nonpathologic causes of proteinuria is a properly obtained first morning voided urine specimen for dipstick testing and laboratory spot measurement of the urine protein/creatinine ratio, according to Dr. Beth A. Vogt, a pediatric nephrologist at Rainbow Babies and Children’s Hospital and Case Western Reserve University, Cleveland.

If the urinalysis shows no or only 1+ protein and a protein/creatinine ratio below 0.2, the patient and family can be reassured that there’s no problem. End of story. No need for the family to sweat out the weeks of delay likely required to see a pediatric nephrologist, she said at a meeting on practical pediatrics sponsored by the American Academy of Pediatrics.

Proteinuria is quite common in children. Roughly 10% of 8- to 15-year-olds will have proteinuria on a single screening dipstick sample. But upon repeat testing, this time using a first morning void sample rather than a urine specimen obtained during office hours, this figure drops from 10% to less than 1%.

This much smaller subgroup with persistent proteinuria should be presumed to have kidney disease until proven otherwise via nephrologic evaluation, she emphasized.

The urine protein/creatinine ratio is a simple quantitative test that’s ordered by checking off the spot protein and creatinine levels on a standard lab slip. This test has largely replaced the classic 24-hour urine collection.

"The 24-hour urine collection is a cumbersome, error-prone test that we’ve outgrown in pediatric nephrology. We don’t do this very much anymore. People tend to either over- or undercollect," Dr. Vogt explained.

The urine dipstick is a good, relatively cheap tool. But it’s important to recognize that false-positive results are common if the urine pH is more than about 8.0 or if the urine is concentrated, as is common because kids tend to drink less than they should.

"A 1+ proteinuria in a kid who has a urine specific gravity greater than 1.015 is really not an issue. If you recognize that it is normal, you can really save yourself a lot of trouble. Let it be," she advised.

The most common type of proteinuria is transient proteinuria accompanying a febrile illness, dehydration, urinary tract infection, or exercise. This is self-limited proteinuria that will resolve after the underlying condition resolves. If Dr. Vogt finds 1+ proteinuria under these circumstances, she typically doesn’t bother to retest later, as long as the patient has no history of renal disease or suggestive symptoms.

Orthostatic proteinuria is another common benign condition. Indeed, it is seen in 2%-5% of adolescents. For reasons as yet unknown, affected patients produce protein only in urine generated while they are in an upright position. Urine produced while they are supine is negative for protein, which is why testing a first morning voided specimen is so illuminating.

The family needs careful instruction in how to obtain an all-supine urine sample. The child should empty the bladder completely immediately before bedtime. The next morning the sample must be collected immediately after getting up.

Persistent proteinuria as evidenced by a positive first morning urinalysis indicates kidney disease. Among the more common causes are membranous nephropathy; polycystic kidney disease; renal scarring due to reflux nephropathy; renal dysplasia; and focal segmental glomerulosclerosis, which is on the rise as a result of the obesity epidemic.

In addition to arranging a referral to a nephrologist for the patient with persistent proteinuria, the primary care physician can help expedite matters by ordering a renal function panel, an antinuclear antibody test, C3 and C4, and a renal ultrasound. These are studies the pediatric nephrologist will want to have, Dr. Vogt said.

She reported having no relevant financial conflicts.

STEAMBOAT SPRINGS, COLO. – Primary care physicians commonly over-refer children for subspecialist nephrologic evaluation of proteinuria they could readily identify as nonpathologic in their own offices by simple testing, thereby sparing families considerable expense and anxiety.

All that’s needed to differentiate pathologic from nonpathologic causes of proteinuria is a properly obtained first morning voided urine specimen for dipstick testing and laboratory spot measurement of the urine protein/creatinine ratio, according to Dr. Beth A. Vogt, a pediatric nephrologist at Rainbow Babies and Children’s Hospital and Case Western Reserve University, Cleveland.

If the urinalysis shows no or only 1+ protein and a protein/creatinine ratio below 0.2, the patient and family can be reassured that there’s no problem. End of story. No need for the family to sweat out the weeks of delay likely required to see a pediatric nephrologist, she said at a meeting on practical pediatrics sponsored by the American Academy of Pediatrics.

Proteinuria is quite common in children. Roughly 10% of 8- to 15-year-olds will have proteinuria on a single screening dipstick sample. But upon repeat testing, this time using a first morning void sample rather than a urine specimen obtained during office hours, this figure drops from 10% to less than 1%.

This much smaller subgroup with persistent proteinuria should be presumed to have kidney disease until proven otherwise via nephrologic evaluation, she emphasized.

The urine protein/creatinine ratio is a simple quantitative test that’s ordered by checking off the spot protein and creatinine levels on a standard lab slip. This test has largely replaced the classic 24-hour urine collection.

"The 24-hour urine collection is a cumbersome, error-prone test that we’ve outgrown in pediatric nephrology. We don’t do this very much anymore. People tend to either over- or undercollect," Dr. Vogt explained.

The urine dipstick is a good, relatively cheap tool. But it’s important to recognize that false-positive results are common if the urine pH is more than about 8.0 or if the urine is concentrated, as is common because kids tend to drink less than they should.

"A 1+ proteinuria in a kid who has a urine specific gravity greater than 1.015 is really not an issue. If you recognize that it is normal, you can really save yourself a lot of trouble. Let it be," she advised.

The most common type of proteinuria is transient proteinuria accompanying a febrile illness, dehydration, urinary tract infection, or exercise. This is self-limited proteinuria that will resolve after the underlying condition resolves. If Dr. Vogt finds 1+ proteinuria under these circumstances, she typically doesn’t bother to retest later, as long as the patient has no history of renal disease or suggestive symptoms.

Orthostatic proteinuria is another common benign condition. Indeed, it is seen in 2%-5% of adolescents. For reasons as yet unknown, affected patients produce protein only in urine generated while they are in an upright position. Urine produced while they are supine is negative for protein, which is why testing a first morning voided specimen is so illuminating.

The family needs careful instruction in how to obtain an all-supine urine sample. The child should empty the bladder completely immediately before bedtime. The next morning the sample must be collected immediately after getting up.

Persistent proteinuria as evidenced by a positive first morning urinalysis indicates kidney disease. Among the more common causes are membranous nephropathy; polycystic kidney disease; renal scarring due to reflux nephropathy; renal dysplasia; and focal segmental glomerulosclerosis, which is on the rise as a result of the obesity epidemic.

In addition to arranging a referral to a nephrologist for the patient with persistent proteinuria, the primary care physician can help expedite matters by ordering a renal function panel, an antinuclear antibody test, C3 and C4, and a renal ultrasound. These are studies the pediatric nephrologist will want to have, Dr. Vogt said.

She reported having no relevant financial conflicts.

STEAMBOAT SPRINGS, COLO. – Primary care physicians commonly over-refer children for subspecialist nephrologic evaluation of proteinuria they could readily identify as nonpathologic in their own offices by simple testing, thereby sparing families considerable expense and anxiety.

All that’s needed to differentiate pathologic from nonpathologic causes of proteinuria is a properly obtained first morning voided urine specimen for dipstick testing and laboratory spot measurement of the urine protein/creatinine ratio, according to Dr. Beth A. Vogt, a pediatric nephrologist at Rainbow Babies and Children’s Hospital and Case Western Reserve University, Cleveland.

If the urinalysis shows no or only 1+ protein and a protein/creatinine ratio below 0.2, the patient and family can be reassured that there’s no problem. End of story. No need for the family to sweat out the weeks of delay likely required to see a pediatric nephrologist, she said at a meeting on practical pediatrics sponsored by the American Academy of Pediatrics.

Proteinuria is quite common in children. Roughly 10% of 8- to 15-year-olds will have proteinuria on a single screening dipstick sample. But upon repeat testing, this time using a first morning void sample rather than a urine specimen obtained during office hours, this figure drops from 10% to less than 1%.

This much smaller subgroup with persistent proteinuria should be presumed to have kidney disease until proven otherwise via nephrologic evaluation, she emphasized.

The urine protein/creatinine ratio is a simple quantitative test that’s ordered by checking off the spot protein and creatinine levels on a standard lab slip. This test has largely replaced the classic 24-hour urine collection.

"The 24-hour urine collection is a cumbersome, error-prone test that we’ve outgrown in pediatric nephrology. We don’t do this very much anymore. People tend to either over- or undercollect," Dr. Vogt explained.

The urine dipstick is a good, relatively cheap tool. But it’s important to recognize that false-positive results are common if the urine pH is more than about 8.0 or if the urine is concentrated, as is common because kids tend to drink less than they should.

"A 1+ proteinuria in a kid who has a urine specific gravity greater than 1.015 is really not an issue. If you recognize that it is normal, you can really save yourself a lot of trouble. Let it be," she advised.

The most common type of proteinuria is transient proteinuria accompanying a febrile illness, dehydration, urinary tract infection, or exercise. This is self-limited proteinuria that will resolve after the underlying condition resolves. If Dr. Vogt finds 1+ proteinuria under these circumstances, she typically doesn’t bother to retest later, as long as the patient has no history of renal disease or suggestive symptoms.

Orthostatic proteinuria is another common benign condition. Indeed, it is seen in 2%-5% of adolescents. For reasons as yet unknown, affected patients produce protein only in urine generated while they are in an upright position. Urine produced while they are supine is negative for protein, which is why testing a first morning voided specimen is so illuminating.

The family needs careful instruction in how to obtain an all-supine urine sample. The child should empty the bladder completely immediately before bedtime. The next morning the sample must be collected immediately after getting up.

Persistent proteinuria as evidenced by a positive first morning urinalysis indicates kidney disease. Among the more common causes are membranous nephropathy; polycystic kidney disease; renal scarring due to reflux nephropathy; renal dysplasia; and focal segmental glomerulosclerosis, which is on the rise as a result of the obesity epidemic.

In addition to arranging a referral to a nephrologist for the patient with persistent proteinuria, the primary care physician can help expedite matters by ordering a renal function panel, an antinuclear antibody test, C3 and C4, and a renal ultrasound. These are studies the pediatric nephrologist will want to have, Dr. Vogt said.

She reported having no relevant financial conflicts.

STEAMBOAT SPRINGS, COLO. – Internet/video game addiction disorder is a diagnosis that’s not to be found in the Fourth Diagnostic and Statistical Manual of Mental Disorders. Nor after considerable controversy will it make its way into DSM-5. But it is nonetheless a very real problem, according to Dr. Michael Rich, director of the Center on Media and Child Health at Children’s Hospital Boston.

Four elements are common to any addiction, whether it involves alcohol, heroin, or a behavior, such as gambling, sex, or shopping. These four components are excessive use that impedes other aspects of life, increasing tolerance in order to obtain the "high," withdrawal symptoms, and a willingness to sustain negative consequences in order to maintain the habit.

A survey of a national sample of more than 1,000 8- to 18-year-olds concluded that 8.6% of video gamers are pathological players, according to the criteria established for pathological gambling (Psychol. Sci. 2009;20:594-602). That’s consistent with study results from other countries.

In South Korea, a nation of 49 million where Internet addiction disorder (IAD) is a recognized diagnosis, 250,000 patients younger than age 18 are in treatment for this condition, said Dr. Rich, who is also director of the video intervention/prevention assessment program at the hospital and an adolescent medicine specialist at Harvard Medical School in Boston.

American children who meet the Korean criteria for IAD have higher levels of obsessive-compulsive behaviors; more depression, anxiety, and paranoid ideation; and lower scores for interpersonal sensitivity than do controls.

An intriguing but poorly understood interplay exists between IAD and attention-deficit/hyperactivity disorder (ADHD). The prevalence of IAD is significantly higher among American children with ADHD. Moreover, when youths with ADHD play video games, their ADHD symptoms subside. And when children who meet the criteria for IAD but don’t have ADHD are placed on methylphenidate (Ritalin) their IAD symptoms decrease, he said at the meeting.

Although the official American Psychiatric Association position is that there isn’t sufficient scientific data to support inclusion of IAD in the DSM-5, Dr. Rich said there has been a "huge" behind-the-scenes battle, with some addiction medicine specialists arguing against the entire concept of non–substance-based behavioral addictions. The skeptics may have carried the day by denying the IAD diagnosis inclusion in the forthcoming DSM-5, he said, but they haven’t done clinicians or patients any favors.

"I am seeing an increasing number of kids with not necessarily true addictions, but with problematic use ... of video games, where it’s getting in the way of their functioning in one way or another. I think we need to be there for them, but unless it’s recognized as a diagnosis it’s hard to build an infrastructure to care for them and access the services they need," the pediatrician said.

He works around this obstacle by using accepted diagnoses for which the young patients qualify.

"I’m often treating them with the diagnosis of insomnia when what’s really happening is they’re staying up all night playing World of Warcraft, or [I’m] treating them for generalized anxiety disorder because they’re playing a violent video game and they’re twitchy as a result. So, please, keep video game addiction in mind when you are assessing a kid for issues of sleeplessness, anxiety, irritability, poor school performance. Put it on the differential diagnosis list along with depression and anxiety and substance use," Dr. Rich urged.

World of Warcraft has close to 11 million subscribers.

Today, 92% of American youth aged 2-17 years play video games. Some 79% of games with an ‘E’ rating on the package (meaning they’re supposedly suitable for everyone aged 6 years and older) are violent. In all, 73% of 4th grade boys and 59% of girls list a violent video game as their favorite game.

Studies show that playing violent video games results in physiological arousal and increased aggressive thoughts, affect, and behavior in both boys and girls. Increasing amounts of game time are associated with significantly decreased prosocial and helping behaviors as well as worse school performance.

adamfilip/iStockphoto.com

Among children who list a violent game as their favorite, more than half report that their top choice is what’s known as an "online first-person shooter game." Examples include the Halo series and "Call of Duty: Modern Warfare 3," the single most lucrative entertainment product ever created, with $1 billion in sales in the first 16 days after its release.

"A first-person shooter game is one where you approach the world with a deadly weapon, and your job is to kill them before they kill you," Dr. Rich explained. "When you’re playing online, every character out there is another actual person somewhere in the world. Think about the implications of that."

Playing a violent video game, he stressed, is a very different experience from watching a violent movie.

"Unlike when you’re watching Arnold Schwarzenegger or Jean-Claude Van Damme do mayhem to people, in a video game you are directing the narrative. You are the person who is behind the gun," the pediatrician continued.

Video games are possibly the most effective educational technology ever invented. Players are immersed in an environment where they are rewarded for doing well and punished when they don’t. Either way, they get to keep doing it until their performance improves.

But what are the psychological effects of attaining mastery in a game such as the highly popular Grand Theft Auto, in which stealing cars is merely one of the crimes at which players learn to excel?

"Think about it: If you’re being rewarded for killing female hookers, that’s bound to teach you something over time," Dr. Rich observed.

In one study, 53% of parents say they limit their children’s video gaming time. However, when their kids are asked, only 11% report that this actually occurs, Dr. Rich said.

He offered the following tips that physicians can provide to parents in order to prevent problems from video games:

• Set a good example regarding parents’ own media use.

• Don’t rely upon the industry-sponsored game-rating system.

• Keep all of a child’s computer use in public areas of the home. "Don’t let them disappear into the bedroom to use a computer for hours and hours. That’s how World of Warcraft gets out of control," Dr. Rich advised.

• Offer engaging alternatives, like going outside to shoot baskets instead of playing an NBA basketball video game.

• Play every one of the video games in the house with the child. It’s the best way to learn about the actual game content, and it’s also an empowering experience for the child.

"I tell parents, ‘Your kid will clean your clock. There is no way that your thumbs will move fast enough. But it’s great for a kid – who’s spent his whole life being told what to do – to be the master and [to have] the parent be the student. It allows you to share an experience,’ " the physician said.

• Limit video game play to a period after all critical tasks – attending school, homework, physical activity, sleep, sit-down meals with the family – are completed.

Dr. Rich operates a website (www.askthemediatrician.com) on which he fields parents’ questions regarding media and their children. The site contains links to the Center on Media and Child Health, where physicians can obtain free downloads of handouts on media-related issues for their office.

He reported having no relevant financial conflicts.

STEAMBOAT SPRINGS, COLO. – Internet/video game addiction disorder is a diagnosis that’s not to be found in the Fourth Diagnostic and Statistical Manual of Mental Disorders. Nor after considerable controversy will it make its way into DSM-5. But it is nonetheless a very real problem, according to Dr. Michael Rich, director of the Center on Media and Child Health at Children’s Hospital Boston.

Four elements are common to any addiction, whether it involves alcohol, heroin, or a behavior, such as gambling, sex, or shopping. These four components are excessive use that impedes other aspects of life, increasing tolerance in order to obtain the "high," withdrawal symptoms, and a willingness to sustain negative consequences in order to maintain the habit.

A survey of a national sample of more than 1,000 8- to 18-year-olds concluded that 8.6% of video gamers are pathological players, according to the criteria established for pathological gambling (Psychol. Sci. 2009;20:594-602). That’s consistent with study results from other countries.

In South Korea, a nation of 49 million where Internet addiction disorder (IAD) is a recognized diagnosis, 250,000 patients younger than age 18 are in treatment for this condition, said Dr. Rich, who is also director of the video intervention/prevention assessment program at the hospital and an adolescent medicine specialist at Harvard Medical School in Boston.

American children who meet the Korean criteria for IAD have higher levels of obsessive-compulsive behaviors; more depression, anxiety, and paranoid ideation; and lower scores for interpersonal sensitivity than do controls.

An intriguing but poorly understood interplay exists between IAD and attention-deficit/hyperactivity disorder (ADHD). The prevalence of IAD is significantly higher among American children with ADHD. Moreover, when youths with ADHD play video games, their ADHD symptoms subside. And when children who meet the criteria for IAD but don’t have ADHD are placed on methylphenidate (Ritalin) their IAD symptoms decrease, he said at the meeting.

Although the official American Psychiatric Association position is that there isn’t sufficient scientific data to support inclusion of IAD in the DSM-5, Dr. Rich said there has been a "huge" behind-the-scenes battle, with some addiction medicine specialists arguing against the entire concept of non–substance-based behavioral addictions. The skeptics may have carried the day by denying the IAD diagnosis inclusion in the forthcoming DSM-5, he said, but they haven’t done clinicians or patients any favors.

"I am seeing an increasing number of kids with not necessarily true addictions, but with problematic use ... of video games, where it’s getting in the way of their functioning in one way or another. I think we need to be there for them, but unless it’s recognized as a diagnosis it’s hard to build an infrastructure to care for them and access the services they need," the pediatrician said.

He works around this obstacle by using accepted diagnoses for which the young patients qualify.

"I’m often treating them with the diagnosis of insomnia when what’s really happening is they’re staying up all night playing World of Warcraft, or [I’m] treating them for generalized anxiety disorder because they’re playing a violent video game and they’re twitchy as a result. So, please, keep video game addiction in mind when you are assessing a kid for issues of sleeplessness, anxiety, irritability, poor school performance. Put it on the differential diagnosis list along with depression and anxiety and substance use," Dr. Rich urged.

World of Warcraft has close to 11 million subscribers.

Today, 92% of American youth aged 2-17 years play video games. Some 79% of games with an ‘E’ rating on the package (meaning they’re supposedly suitable for everyone aged 6 years and older) are violent. In all, 73% of 4th grade boys and 59% of girls list a violent video game as their favorite game.

Studies show that playing violent video games results in physiological arousal and increased aggressive thoughts, affect, and behavior in both boys and girls. Increasing amounts of game time are associated with significantly decreased prosocial and helping behaviors as well as worse school performance.

adamfilip/iStockphoto.com

Among children who list a violent game as their favorite, more than half report that their top choice is what’s known as an "online first-person shooter game." Examples include the Halo series and "Call of Duty: Modern Warfare 3," the single most lucrative entertainment product ever created, with $1 billion in sales in the first 16 days after its release.

"A first-person shooter game is one where you approach the world with a deadly weapon, and your job is to kill them before they kill you," Dr. Rich explained. "When you’re playing online, every character out there is another actual person somewhere in the world. Think about the implications of that."

Playing a violent video game, he stressed, is a very different experience from watching a violent movie.

"Unlike when you’re watching Arnold Schwarzenegger or Jean-Claude Van Damme do mayhem to people, in a video game you are directing the narrative. You are the person who is behind the gun," the pediatrician continued.

Video games are possibly the most effective educational technology ever invented. Players are immersed in an environment where they are rewarded for doing well and punished when they don’t. Either way, they get to keep doing it until their performance improves.

But what are the psychological effects of attaining mastery in a game such as the highly popular Grand Theft Auto, in which stealing cars is merely one of the crimes at which players learn to excel?

"Think about it: If you’re being rewarded for killing female hookers, that’s bound to teach you something over time," Dr. Rich observed.

In one study, 53% of parents say they limit their children’s video gaming time. However, when their kids are asked, only 11% report that this actually occurs, Dr. Rich said.

He offered the following tips that physicians can provide to parents in order to prevent problems from video games:

• Set a good example regarding parents’ own media use.

• Don’t rely upon the industry-sponsored game-rating system.

• Keep all of a child’s computer use in public areas of the home. "Don’t let them disappear into the bedroom to use a computer for hours and hours. That’s how World of Warcraft gets out of control," Dr. Rich advised.

• Offer engaging alternatives, like going outside to shoot baskets instead of playing an NBA basketball video game.

• Play every one of the video games in the house with the child. It’s the best way to learn about the actual game content, and it’s also an empowering experience for the child.

"I tell parents, ‘Your kid will clean your clock. There is no way that your thumbs will move fast enough. But it’s great for a kid – who’s spent his whole life being told what to do – to be the master and [to have] the parent be the student. It allows you to share an experience,’ " the physician said.

• Limit video game play to a period after all critical tasks – attending school, homework, physical activity, sleep, sit-down meals with the family – are completed.

Dr. Rich operates a website (www.askthemediatrician.com) on which he fields parents’ questions regarding media and their children. The site contains links to the Center on Media and Child Health, where physicians can obtain free downloads of handouts on media-related issues for their office.

He reported having no relevant financial conflicts.

STEAMBOAT SPRINGS, COLO. – Internet/video game addiction disorder is a diagnosis that’s not to be found in the Fourth Diagnostic and Statistical Manual of Mental Disorders. Nor after considerable controversy will it make its way into DSM-5. But it is nonetheless a very real problem, according to Dr. Michael Rich, director of the Center on Media and Child Health at Children’s Hospital Boston.

Four elements are common to any addiction, whether it involves alcohol, heroin, or a behavior, such as gambling, sex, or shopping. These four components are excessive use that impedes other aspects of life, increasing tolerance in order to obtain the "high," withdrawal symptoms, and a willingness to sustain negative consequences in order to maintain the habit.

A survey of a national sample of more than 1,000 8- to 18-year-olds concluded that 8.6% of video gamers are pathological players, according to the criteria established for pathological gambling (Psychol. Sci. 2009;20:594-602). That’s consistent with study results from other countries.

In South Korea, a nation of 49 million where Internet addiction disorder (IAD) is a recognized diagnosis, 250,000 patients younger than age 18 are in treatment for this condition, said Dr. Rich, who is also director of the video intervention/prevention assessment program at the hospital and an adolescent medicine specialist at Harvard Medical School in Boston.

American children who meet the Korean criteria for IAD have higher levels of obsessive-compulsive behaviors; more depression, anxiety, and paranoid ideation; and lower scores for interpersonal sensitivity than do controls.

An intriguing but poorly understood interplay exists between IAD and attention-deficit/hyperactivity disorder (ADHD). The prevalence of IAD is significantly higher among American children with ADHD. Moreover, when youths with ADHD play video games, their ADHD symptoms subside. And when children who meet the criteria for IAD but don’t have ADHD are placed on methylphenidate (Ritalin) their IAD symptoms decrease, he said at the meeting.

Although the official American Psychiatric Association position is that there isn’t sufficient scientific data to support inclusion of IAD in the DSM-5, Dr. Rich said there has been a "huge" behind-the-scenes battle, with some addiction medicine specialists arguing against the entire concept of non–substance-based behavioral addictions. The skeptics may have carried the day by denying the IAD diagnosis inclusion in the forthcoming DSM-5, he said, but they haven’t done clinicians or patients any favors.

"I am seeing an increasing number of kids with not necessarily true addictions, but with problematic use ... of video games, where it’s getting in the way of their functioning in one way or another. I think we need to be there for them, but unless it’s recognized as a diagnosis it’s hard to build an infrastructure to care for them and access the services they need," the pediatrician said.

He works around this obstacle by using accepted diagnoses for which the young patients qualify.

"I’m often treating them with the diagnosis of insomnia when what’s really happening is they’re staying up all night playing World of Warcraft, or [I’m] treating them for generalized anxiety disorder because they’re playing a violent video game and they’re twitchy as a result. So, please, keep video game addiction in mind when you are assessing a kid for issues of sleeplessness, anxiety, irritability, poor school performance. Put it on the differential diagnosis list along with depression and anxiety and substance use," Dr. Rich urged.

World of Warcraft has close to 11 million subscribers.

Today, 92% of American youth aged 2-17 years play video games. Some 79% of games with an ‘E’ rating on the package (meaning they’re supposedly suitable for everyone aged 6 years and older) are violent. In all, 73% of 4th grade boys and 59% of girls list a violent video game as their favorite game.

Studies show that playing violent video games results in physiological arousal and increased aggressive thoughts, affect, and behavior in both boys and girls. Increasing amounts of game time are associated with significantly decreased prosocial and helping behaviors as well as worse school performance.

adamfilip/iStockphoto.com

Among children who list a violent game as their favorite, more than half report that their top choice is what’s known as an "online first-person shooter game." Examples include the Halo series and "Call of Duty: Modern Warfare 3," the single most lucrative entertainment product ever created, with $1 billion in sales in the first 16 days after its release.

"A first-person shooter game is one where you approach the world with a deadly weapon, and your job is to kill them before they kill you," Dr. Rich explained. "When you’re playing online, every character out there is another actual person somewhere in the world. Think about the implications of that."

Playing a violent video game, he stressed, is a very different experience from watching a violent movie.

"Unlike when you’re watching Arnold Schwarzenegger or Jean-Claude Van Damme do mayhem to people, in a video game you are directing the narrative. You are the person who is behind the gun," the pediatrician continued.

Video games are possibly the most effective educational technology ever invented. Players are immersed in an environment where they are rewarded for doing well and punished when they don’t. Either way, they get to keep doing it until their performance improves.

But what are the psychological effects of attaining mastery in a game such as the highly popular Grand Theft Auto, in which stealing cars is merely one of the crimes at which players learn to excel?

"Think about it: If you’re being rewarded for killing female hookers, that’s bound to teach you something over time," Dr. Rich observed.

In one study, 53% of parents say they limit their children’s video gaming time. However, when their kids are asked, only 11% report that this actually occurs, Dr. Rich said.

He offered the following tips that physicians can provide to parents in order to prevent problems from video games:

• Set a good example regarding parents’ own media use.

• Don’t rely upon the industry-sponsored game-rating system.

• Keep all of a child’s computer use in public areas of the home. "Don’t let them disappear into the bedroom to use a computer for hours and hours. That’s how World of Warcraft gets out of control," Dr. Rich advised.

• Offer engaging alternatives, like going outside to shoot baskets instead of playing an NBA basketball video game.

• Play every one of the video games in the house with the child. It’s the best way to learn about the actual game content, and it’s also an empowering experience for the child.

"I tell parents, ‘Your kid will clean your clock. There is no way that your thumbs will move fast enough. But it’s great for a kid – who’s spent his whole life being told what to do – to be the master and [to have] the parent be the student. It allows you to share an experience,’ " the physician said.

• Limit video game play to a period after all critical tasks – attending school, homework, physical activity, sleep, sit-down meals with the family – are completed.

Dr. Rich operates a website (www.askthemediatrician.com) on which he fields parents’ questions regarding media and their children. The site contains links to the Center on Media and Child Health, where physicians can obtain free downloads of handouts on media-related issues for their office.

He reported having no relevant financial conflicts.

STEAMBOAT SPRINGS, COLO. – Kidney stones, historically considered an adult malady, have become vastly more common among children during the past decade, in concert with the obesity epidemic.

Moreover, the clinical presentation of urolithiasis in children is often different than it is in adults. As a result, physicians are frequently caught off guard.

"The diagnosis of kidney stones is often not the first thing on the differential diagnosis list – or even on the list – for a child with abdominal pain," Dr. Beth A. Vogt observed at a meeting on practical pediatrics sponsored by the American Academy of Pediatrics.

The younger the child with a kidney stone, the more likely the clinical presentation will be nonspecific abdominal pain rather than the flank pain or renal colic typical in affected adults, according to Dr. Vogt, a pediatric nephrologist at Case Western Reserve University, Cleveland.

Thus, in the child with nonspecific abdominal pain, it’s important to add urolithiasis to the differential diagnosis list, which classically has included viral gastroenteritis, appendicitis, cholecystitis, intussusception, and food poisoning, she said.

Gross hematuria is present in 30%-40% of children who present with kidney stones. Dysuria is also common. In addition, asymptomatic kidney stones are frequently detected incidentally in children undergoing ultrasound or CT following traumatic injury.

The primary care physician’s role in pediatric urolithiasis is to make the diagnosis, begin acute management with hydration and pain control, hospitalize if necessary, and refer the patient to urology for intervention if the stone is so large it’s unlikely to pass.

Also, referral to a nephrologist is recommended after a first-ever stone has passed and the child has resumed normal activities. The nephrologist’s job is to figure out why the child is forming stones and to come up with a specific prevention plan (for example, a low-sodium diet in patients with hypercalciuria, or antibiotics in children with infection-related struvite stones), Dr. Vogt continued.

"In adults, the standard practice is to wait until they prove to be recurrent stone formers before doing a work-up. That’s not the case in children. Don’t wait until after a child has had several stones to refer to nephrology. We find something metabolically wrong in about 75% of the kids," she said.

The diagnosis of pediatric urolithiasis is suggested by the combination of abdominal or flank pain, hematuria on a urine dipstick test, and crystals in the urine upon microscopic examination. A couple of caveats, though: Recent studies indicate that up to 15% of kids with active stone disease have a negative urinalysis, so urolithiasis can’t be ruled out on the basis of a negative urine dipstick. Also, many children who don’t have kidney stone disease have crystals in their urine.

The best initial diagnostic imaging study is kidney ultrasound. It doesn’t involve radiation, which is an important advantage because some young patients will continue making stones and will therefore need to undergo imaging many times.

Ultrasound is very good at identifying stones in the renal parenchyma, but not ureteral stones or very small stones. So if the clinical picture and laboratory results suggest urolithiasis but the ultrasound is negative, it’s time to move on to CT without contrast, by far the most sensitive test. It is ordered by requesting a "CT stone protocol."

Acute management of stone disease entails oral or intravenous hydration to push the stone through the urinary tract. Pain medication is important. Tamsulosin (Flomax) is prescribed off label to induce ureteral relaxation and assist in the stone’s passage. It’s useful to have the patient use a urine-straining device to try to catch the stone for later analysis.

"The diagnosis of kidney stones is often not the first thing on the differential diagnosis list – or even on the list – for a child with abdominal pain."

Urologists consistently recommend a 4- to 6-week trial of spontaneous passage, provided the child doesn’t have a urinary tract infection, is able to hydrate orally, and obtains pain control with oral medications.

"When you tell that to parents, they say, ‘Are you kidding?’ That’s a long, long time. Parents don’t like it," Dr. Vogt said.

A stone larger than 10 mm is so unlikely to pass spontaneously that Dr. Vogt recommends going straight to urologic intervention. A stone less than 5 mm will usually pass spontaneously, even in a child.

Urologists will typically place a ureter-long stent in a patient with refractory nausea and vomiting or an infection. This allows urine to bypass an obstructive stone.

"It buys you time. It gets the patient out of the cycle of pain, vomiting, and renal colic," she explained.

A week or two later, the urologist will take out the stent and remove the stone, most often by ureteroscopy. This involves inserting the ureteroscope through the bladder and capturing the stone in a basket, sometimes after breaking it into fragments via laser lithotripsy.

Extracorporeal shock wave lithotripsy, in which several thousand shock waves are directed at the stone, is still widely performed in adults. It is less popular in children because of the theoretical risk of damaging nearby healthy tissues, which might then result in hypertension or diabetes.

Although the majority of cases of pediatric urolithiasis are managed on an outpatient basis, today roughly 1 in 1,000 pediatric hospitalizations is for kidney stones. The explanation for the increase in kidney stones in children over the past decade isn’t entirely clear. Increased consumption of salty, high-protein, processed foods and decreased water intake have been implicated.

General measures for prevention of stones in a stone-forming child include ample fluid intake – more than 2 L daily in teens – along with a healthy diet featuring liberal consumption of fruits and vegetables to increase excretion of stone-inhibiting citrate into the urine. Restriction of dietary calcium isn’t recommended, even in calcium stone formers.

"I usually tell patients to drink enough fluids that their urine looks very dilute. You don’t want dark yellow urine," Dr. Vogt said.

She reported having no financial conflicts.

STEAMBOAT SPRINGS, COLO. – Kidney stones, historically considered an adult malady, have become vastly more common among children during the past decade, in concert with the obesity epidemic.

Moreover, the clinical presentation of urolithiasis in children is often different than it is in adults. As a result, physicians are frequently caught off guard.

"The diagnosis of kidney stones is often not the first thing on the differential diagnosis list – or even on the list – for a child with abdominal pain," Dr. Beth A. Vogt observed at a meeting on practical pediatrics sponsored by the American Academy of Pediatrics.

The younger the child with a kidney stone, the more likely the clinical presentation will be nonspecific abdominal pain rather than the flank pain or renal colic typical in affected adults, according to Dr. Vogt, a pediatric nephrologist at Case Western Reserve University, Cleveland.

Thus, in the child with nonspecific abdominal pain, it’s important to add urolithiasis to the differential diagnosis list, which classically has included viral gastroenteritis, appendicitis, cholecystitis, intussusception, and food poisoning, she said.

Gross hematuria is present in 30%-40% of children who present with kidney stones. Dysuria is also common. In addition, asymptomatic kidney stones are frequently detected incidentally in children undergoing ultrasound or CT following traumatic injury.

The primary care physician’s role in pediatric urolithiasis is to make the diagnosis, begin acute management with hydration and pain control, hospitalize if necessary, and refer the patient to urology for intervention if the stone is so large it’s unlikely to pass.

Also, referral to a nephrologist is recommended after a first-ever stone has passed and the child has resumed normal activities. The nephrologist’s job is to figure out why the child is forming stones and to come up with a specific prevention plan (for example, a low-sodium diet in patients with hypercalciuria, or antibiotics in children with infection-related struvite stones), Dr. Vogt continued.

"In adults, the standard practice is to wait until they prove to be recurrent stone formers before doing a work-up. That’s not the case in children. Don’t wait until after a child has had several stones to refer to nephrology. We find something metabolically wrong in about 75% of the kids," she said.

The diagnosis of pediatric urolithiasis is suggested by the combination of abdominal or flank pain, hematuria on a urine dipstick test, and crystals in the urine upon microscopic examination. A couple of caveats, though: Recent studies indicate that up to 15% of kids with active stone disease have a negative urinalysis, so urolithiasis can’t be ruled out on the basis of a negative urine dipstick. Also, many children who don’t have kidney stone disease have crystals in their urine.

The best initial diagnostic imaging study is kidney ultrasound. It doesn’t involve radiation, which is an important advantage because some young patients will continue making stones and will therefore need to undergo imaging many times.

Ultrasound is very good at identifying stones in the renal parenchyma, but not ureteral stones or very small stones. So if the clinical picture and laboratory results suggest urolithiasis but the ultrasound is negative, it’s time to move on to CT without contrast, by far the most sensitive test. It is ordered by requesting a "CT stone protocol."

Acute management of stone disease entails oral or intravenous hydration to push the stone through the urinary tract. Pain medication is important. Tamsulosin (Flomax) is prescribed off label to induce ureteral relaxation and assist in the stone’s passage. It’s useful to have the patient use a urine-straining device to try to catch the stone for later analysis.

"The diagnosis of kidney stones is often not the first thing on the differential diagnosis list – or even on the list – for a child with abdominal pain."

Urologists consistently recommend a 4- to 6-week trial of spontaneous passage, provided the child doesn’t have a urinary tract infection, is able to hydrate orally, and obtains pain control with oral medications.

"When you tell that to parents, they say, ‘Are you kidding?’ That’s a long, long time. Parents don’t like it," Dr. Vogt said.

A stone larger than 10 mm is so unlikely to pass spontaneously that Dr. Vogt recommends going straight to urologic intervention. A stone less than 5 mm will usually pass spontaneously, even in a child.

Urologists will typically place a ureter-long stent in a patient with refractory nausea and vomiting or an infection. This allows urine to bypass an obstructive stone.

"It buys you time. It gets the patient out of the cycle of pain, vomiting, and renal colic," she explained.

A week or two later, the urologist will take out the stent and remove the stone, most often by ureteroscopy. This involves inserting the ureteroscope through the bladder and capturing the stone in a basket, sometimes after breaking it into fragments via laser lithotripsy.

Extracorporeal shock wave lithotripsy, in which several thousand shock waves are directed at the stone, is still widely performed in adults. It is less popular in children because of the theoretical risk of damaging nearby healthy tissues, which might then result in hypertension or diabetes.

Although the majority of cases of pediatric urolithiasis are managed on an outpatient basis, today roughly 1 in 1,000 pediatric hospitalizations is for kidney stones. The explanation for the increase in kidney stones in children over the past decade isn’t entirely clear. Increased consumption of salty, high-protein, processed foods and decreased water intake have been implicated.

General measures for prevention of stones in a stone-forming child include ample fluid intake – more than 2 L daily in teens – along with a healthy diet featuring liberal consumption of fruits and vegetables to increase excretion of stone-inhibiting citrate into the urine. Restriction of dietary calcium isn’t recommended, even in calcium stone formers.

"I usually tell patients to drink enough fluids that their urine looks very dilute. You don’t want dark yellow urine," Dr. Vogt said.

She reported having no financial conflicts.

STEAMBOAT SPRINGS, COLO. – Kidney stones, historically considered an adult malady, have become vastly more common among children during the past decade, in concert with the obesity epidemic.

Moreover, the clinical presentation of urolithiasis in children is often different than it is in adults. As a result, physicians are frequently caught off guard.

"The diagnosis of kidney stones is often not the first thing on the differential diagnosis list – or even on the list – for a child with abdominal pain," Dr. Beth A. Vogt observed at a meeting on practical pediatrics sponsored by the American Academy of Pediatrics.

The younger the child with a kidney stone, the more likely the clinical presentation will be nonspecific abdominal pain rather than the flank pain or renal colic typical in affected adults, according to Dr. Vogt, a pediatric nephrologist at Case Western Reserve University, Cleveland.

Thus, in the child with nonspecific abdominal pain, it’s important to add urolithiasis to the differential diagnosis list, which classically has included viral gastroenteritis, appendicitis, cholecystitis, intussusception, and food poisoning, she said.

Gross hematuria is present in 30%-40% of children who present with kidney stones. Dysuria is also common. In addition, asymptomatic kidney stones are frequently detected incidentally in children undergoing ultrasound or CT following traumatic injury.

The primary care physician’s role in pediatric urolithiasis is to make the diagnosis, begin acute management with hydration and pain control, hospitalize if necessary, and refer the patient to urology for intervention if the stone is so large it’s unlikely to pass.

Also, referral to a nephrologist is recommended after a first-ever stone has passed and the child has resumed normal activities. The nephrologist’s job is to figure out why the child is forming stones and to come up with a specific prevention plan (for example, a low-sodium diet in patients with hypercalciuria, or antibiotics in children with infection-related struvite stones), Dr. Vogt continued.

"In adults, the standard practice is to wait until they prove to be recurrent stone formers before doing a work-up. That’s not the case in children. Don’t wait until after a child has had several stones to refer to nephrology. We find something metabolically wrong in about 75% of the kids," she said.

The diagnosis of pediatric urolithiasis is suggested by the combination of abdominal or flank pain, hematuria on a urine dipstick test, and crystals in the urine upon microscopic examination. A couple of caveats, though: Recent studies indicate that up to 15% of kids with active stone disease have a negative urinalysis, so urolithiasis can’t be ruled out on the basis of a negative urine dipstick. Also, many children who don’t have kidney stone disease have crystals in their urine.

The best initial diagnostic imaging study is kidney ultrasound. It doesn’t involve radiation, which is an important advantage because some young patients will continue making stones and will therefore need to undergo imaging many times.

Ultrasound is very good at identifying stones in the renal parenchyma, but not ureteral stones or very small stones. So if the clinical picture and laboratory results suggest urolithiasis but the ultrasound is negative, it’s time to move on to CT without contrast, by far the most sensitive test. It is ordered by requesting a "CT stone protocol."

Acute management of stone disease entails oral or intravenous hydration to push the stone through the urinary tract. Pain medication is important. Tamsulosin (Flomax) is prescribed off label to induce ureteral relaxation and assist in the stone’s passage. It’s useful to have the patient use a urine-straining device to try to catch the stone for later analysis.

"The diagnosis of kidney stones is often not the first thing on the differential diagnosis list – or even on the list – for a child with abdominal pain."

Urologists consistently recommend a 4- to 6-week trial of spontaneous passage, provided the child doesn’t have a urinary tract infection, is able to hydrate orally, and obtains pain control with oral medications.

"When you tell that to parents, they say, ‘Are you kidding?’ That’s a long, long time. Parents don’t like it," Dr. Vogt said.

A stone larger than 10 mm is so unlikely to pass spontaneously that Dr. Vogt recommends going straight to urologic intervention. A stone less than 5 mm will usually pass spontaneously, even in a child.

Urologists will typically place a ureter-long stent in a patient with refractory nausea and vomiting or an infection. This allows urine to bypass an obstructive stone.

"It buys you time. It gets the patient out of the cycle of pain, vomiting, and renal colic," she explained.

A week or two later, the urologist will take out the stent and remove the stone, most often by ureteroscopy. This involves inserting the ureteroscope through the bladder and capturing the stone in a basket, sometimes after breaking it into fragments via laser lithotripsy.

Extracorporeal shock wave lithotripsy, in which several thousand shock waves are directed at the stone, is still widely performed in adults. It is less popular in children because of the theoretical risk of damaging nearby healthy tissues, which might then result in hypertension or diabetes.

Although the majority of cases of pediatric urolithiasis are managed on an outpatient basis, today roughly 1 in 1,000 pediatric hospitalizations is for kidney stones. The explanation for the increase in kidney stones in children over the past decade isn’t entirely clear. Increased consumption of salty, high-protein, processed foods and decreased water intake have been implicated.

General measures for prevention of stones in a stone-forming child include ample fluid intake – more than 2 L daily in teens – along with a healthy diet featuring liberal consumption of fruits and vegetables to increase excretion of stone-inhibiting citrate into the urine. Restriction of dietary calcium isn’t recommended, even in calcium stone formers.

"I usually tell patients to drink enough fluids that their urine looks very dilute. You don’t want dark yellow urine," Dr. Vogt said.

She reported having no financial conflicts.

STEAMBOAT SPRINGS, COLO. – Clindamycin is an effective and guideline-recommended treatment for methicillin-resistant Staphylococcus aureus infections that has one major shortcoming for use in children: The liquid pediatric formulation tastes and smells, well, awful.

"What we do instead of prescribing liquid clindamycin is we prescribe the capsule, crush it up, and put it into chocolate frosting. Usually you can get it into kids by doing that. It’s only going to be for 7-10 days. And it’s much better than trying to add flavors to liquid clindamycin," said Dr. Penelope H. Dennehy, professor and vice chair of pediatrics and director of the division of pediatric infectious diseases at Brown University in Providence, R.I.

© lisafxlisaf/iStockphoto.com

She hit upon the chocolate frosting solution well before MRSA grew into the enormous problem it is today.

"I run a TB clinic, and INH [isonicotinic acid hydrazide] also tastes yucky," Dr. Dennehy said at the meeting.

"We make all our residents taste all the antibiotics. And I have to say, liquid clindamycin is about the worst-tasting antibiotic I’ve ever come across," she added.

Clindamycin is not recommended for treatment of MRSA infections in communities where the organism’s clindamycin-resistance rate exceeds 10%, so it’s important to know the local resistance pattern.

Dr. Dennehy reported having no financial conflicts.

STEAMBOAT SPRINGS, COLO. – Clindamycin is an effective and guideline-recommended treatment for methicillin-resistant Staphylococcus aureus infections that has one major shortcoming for use in children: The liquid pediatric formulation tastes and smells, well, awful.

"What we do instead of prescribing liquid clindamycin is we prescribe the capsule, crush it up, and put it into chocolate frosting. Usually you can get it into kids by doing that. It’s only going to be for 7-10 days. And it’s much better than trying to add flavors to liquid clindamycin," said Dr. Penelope H. Dennehy, professor and vice chair of pediatrics and director of the division of pediatric infectious diseases at Brown University in Providence, R.I.

© lisafxlisaf/iStockphoto.com

She hit upon the chocolate frosting solution well before MRSA grew into the enormous problem it is today.

"I run a TB clinic, and INH [isonicotinic acid hydrazide] also tastes yucky," Dr. Dennehy said at the meeting.

"We make all our residents taste all the antibiotics. And I have to say, liquid clindamycin is about the worst-tasting antibiotic I’ve ever come across," she added.

Clindamycin is not recommended for treatment of MRSA infections in communities where the organism’s clindamycin-resistance rate exceeds 10%, so it’s important to know the local resistance pattern.

Dr. Dennehy reported having no financial conflicts.

STEAMBOAT SPRINGS, COLO. – Clindamycin is an effective and guideline-recommended treatment for methicillin-resistant Staphylococcus aureus infections that has one major shortcoming for use in children: The liquid pediatric formulation tastes and smells, well, awful.

"What we do instead of prescribing liquid clindamycin is we prescribe the capsule, crush it up, and put it into chocolate frosting. Usually you can get it into kids by doing that. It’s only going to be for 7-10 days. And it’s much better than trying to add flavors to liquid clindamycin," said Dr. Penelope H. Dennehy, professor and vice chair of pediatrics and director of the division of pediatric infectious diseases at Brown University in Providence, R.I.

© lisafxlisaf/iStockphoto.com

She hit upon the chocolate frosting solution well before MRSA grew into the enormous problem it is today.

"I run a TB clinic, and INH [isonicotinic acid hydrazide] also tastes yucky," Dr. Dennehy said at the meeting.

"We make all our residents taste all the antibiotics. And I have to say, liquid clindamycin is about the worst-tasting antibiotic I’ve ever come across," she added.

Clindamycin is not recommended for treatment of MRSA infections in communities where the organism’s clindamycin-resistance rate exceeds 10%, so it’s important to know the local resistance pattern.

Dr. Dennehy reported having no financial conflicts.