TBD Meeting (3199-19)

NEW ORLEANS – Weight-based harassment and bias is extremely prevalent throughout society and in doctors’ own offices, so be aware of ways to address it and support your patients regardless of weight.

Rebecca Puhl, PhD, a deputy director of the Rudd Center for Food Policy and Obesity at the University of Connecticut, Hartford, said that weight-based discrimination can occur whatever a person’s size or body shape, but it’s most often targeted at youth who are overweight or obese.

These children and teens commonly face teasing, harassment, cyberbullying, physical aggression, and social bullying from peers, coaches, teachers, and even parents, Dr. Puhl told attendees at the annual meeting of the American Academy of Pediatrics.

Common beliefs about overweight people – that they have little self discipline or poor eating and activity habits – only perpetuate stereotypes, she said. Common stereotypes are that people with obesity are noncompliant, lazy, sloppy, unsuccessful, unintelligent, dishonest, and awkward.

And health professionals of every type have been found to harbor these biases. In one study of more than 4,000 first-year medical students, well over half the respondents revealed explicit (74%) and implicit (67%) weight bias (Obesity. 2014 Apr;22[4]:1201-8). The study also found that explicit weight bias was stronger than explicit bias against blacks, Hispanics, LGBTQ people, and poor people.
 

Know the effects of weight stigma

Far from a minor issue, the discrimination that begins in childhood against those who are overweight can have a long-lasting impact on their future prospects and mental health. Being overweight is overwhelmingly cited as the most common reason for bullying (Pediatr Obes. 2016 Aug;11[4]:241-50). Dr. Puhl described to attendees how weight bias shifts throughout a lifetime, beginning as early as preschool. In childhood, the stereotypes about being overweight worsen, and the teasing and bullying increase. By adolescence, this treatment affects teens’ psychological, social, and physical well-being. It then translates in adulthood into reduced opportunities in employment and education, and poorer access and treatment in health care.

The mental distress caused by weight bullying often takes the form of depression, anxiety, and substance use, Dr. Puhl said, and children’s academic success can be hampered by bullying about their weight. One study found a higher risk of poor grades and school avoidance with each additional teasing incident (J Youth Adolesc. 2012 Jan;41[1]:27-40).

Weight stigma also can contribute to more weight gain, obesity, and lower physical activity levels. Maladaptive eating behaviors can result from weight stigmatization as well: binge eating, emotional eating, increased consumption in general, and other eating disorders. Severe binge eating is 80% more likely among teens who are bullied about their weight, Dr. Puhl said, and the risk increases with increased frequency and types of bullying.

Children who are teased about their weight often become less willing to engage in physical activity, she noted. They may skip gym class, feel less competent about physical activity, and end up enjoying sports participation less.

Further, sexual- and gender-minority youth report high rates of weight-related teasing from friends and family regardless of their body mass index (BMI) percentile, Dr. Puhl emphasized. Researchers have found bullying about weight in this population linked to dieting, difficulty sleeping, high stress levels, binge drinking, smoking, and marijuana use.
 

Know how to combat weight bias

Dr. Puhl described strategies for reducing weight bias based on clinical practice recommendations in the American Academy of Pediatrics’ policy statement entitled “Stigma Experienced by Children and Adolescents With Obesity” (Pediatrics. 2017 Dec;140[6]:e20173034).

Be aware. Consider how personal assumptions and attitudes about weight can affect your body language, tone of voice, facial expression, gestures, eye contact (or lack thereof), and spatial distance from the patient.

Recognizing the biological, genetic, and environmental causes of obesity can reduce stigma and improve understanding of the complexity of obesity etiology. It’s also important that you help parents understand this complexity and the negative impact of weight stigma.

Consider language and word choice. “Carefully consider language that might unintentionally communicate bias, blame, or negative judgment,” Dr. Puhl told attendees. “Use language that is supportive and empowering.”

Terms such as “unhealthy weight” and “high BMI” are less stigmatizing than “fat” and “morbidly obese” to parents, she said, and research has found nearly a quarter of parents would avoid future doctor appointments if their child’s doctor used stigmatizing terms to discuss weight (Pediatrics. 2011 Oct;128[4]:e786-93).

Teens themselves may have diverse preferences for the language used. Start by asking: “Could we talk about your weight today?” and then follow up by directly asking, “what words would you feel most comfortable with as we talk about your weight?”

Person-first language – such as “person with obesity” instead of “obese person” also is important to reducing stigma, she said.

It’s normal for you to feel uneasy about bringing up weight with patients, so Dr. Puhl recommended you practice dialogue out loud.

“Acknowledge your strengths,” she said. “You already have the skills and experience of engaging in difficult conversations with patients and families on a range of other health issues,” so apply that in this context as well.

Screen for negative experiences that could indicate weight-based bullying. These could include teasing and bullying, low self-esteem, poor school performance, depression, and anxiety.

“Remember that weight-based victimization can occur at diverse body sizes, not just in youth with obesity,” Dr. Puhl said. If you discover your patient is experiencing weight-related bullying, determine whether they have a support system in place and whether a mental health referral is appropriate. Provide or refer for behavior change counseling with motivational interviewing and patient-centered, empathic approaches. Parents should be aware of the issue and should contact the child’s teachers and school administration to help address it.

But before you do that, keep in mind that it’s not just peers doing the bullying. According to a study of teens with obesity enrolled in a national weight-loss camp, 37% of teen participants in 2012 said that their parents bully them (Pediatrics. 2013 Jan;131[1]:e1-9).

You should assess whether family interactions or the parents’ own history with weight is involved. If parents make disparaging comments about their child’s weight, “use this as an opportunity to model appropriate language and educate parents about weight bias,” Dr. Puhl said.

It’s also important to realize that parents themselves often are frustrated, so critical comments about their language or approach can backfire, she warned. Instead, help parents understand how to create a home setting that encourages healthy food choices, praises children for healthy decision making, and models positive health behaviors. It is key for them to focus on improving their children’s health behaviors rather than focusing on weight.

And before you contact the school, remember teachers also are common perpetrators of weight stigma, Dr. Puhl noted. She gave as an example a study in which investigators assessed 133 teachers’ perceptions of middle or high school students’ abilities based on photos that had been digitally altered to show each girl both as average weight or as overweight. Each photo was associated with an essay specifically chosen because it was neither particularly good nor bad (Brit J Educ Psychol. 2019 Oct 26. doi: 10.1111/bjep.12322). The teachers judged the essays believed to be submitted by overweight girls to be “similar in structural quality,” but they gave the overweight girls lower grades than the average-weight girls. They also indicated that they considered the overweight girls “put forth more effort, needed more remedial assistance, and had lower overall grades in school.” The teachers also rated other teachers’ weight bias to be at a low level, and their own weight bias to be “significantly lower” than the others.

Assess your clinical environment. Be aware of your clinical environment and whether it meets the needs of youth with diverse body sizes. That includes having a range of sturdy armless seating options and adequately sized doorways, hallways, and restrooms. You also should have beds, wheelchairs, and exam tables with adequate weight capacity. Also check that you have supplies, such as robes or blood pressure cuffs, on hand for a variety of body sizes.

NEW ORLEANS – Weight-based harassment and bias is extremely prevalent throughout society and in doctors’ own offices, so be aware of ways to address it and support your patients regardless of weight.

Rebecca Puhl, PhD, a deputy director of the Rudd Center for Food Policy and Obesity at the University of Connecticut, Hartford, said that weight-based discrimination can occur whatever a person’s size or body shape, but it’s most often targeted at youth who are overweight or obese.

These children and teens commonly face teasing, harassment, cyberbullying, physical aggression, and social bullying from peers, coaches, teachers, and even parents, Dr. Puhl told attendees at the annual meeting of the American Academy of Pediatrics.

Common beliefs about overweight people – that they have little self discipline or poor eating and activity habits – only perpetuate stereotypes, she said. Common stereotypes are that people with obesity are noncompliant, lazy, sloppy, unsuccessful, unintelligent, dishonest, and awkward.

And health professionals of every type have been found to harbor these biases. In one study of more than 4,000 first-year medical students, well over half the respondents revealed explicit (74%) and implicit (67%) weight bias (Obesity. 2014 Apr;22[4]:1201-8). The study also found that explicit weight bias was stronger than explicit bias against blacks, Hispanics, LGBTQ people, and poor people.
 

Know the effects of weight stigma

Far from a minor issue, the discrimination that begins in childhood against those who are overweight can have a long-lasting impact on their future prospects and mental health. Being overweight is overwhelmingly cited as the most common reason for bullying (Pediatr Obes. 2016 Aug;11[4]:241-50). Dr. Puhl described to attendees how weight bias shifts throughout a lifetime, beginning as early as preschool. In childhood, the stereotypes about being overweight worsen, and the teasing and bullying increase. By adolescence, this treatment affects teens’ psychological, social, and physical well-being. It then translates in adulthood into reduced opportunities in employment and education, and poorer access and treatment in health care.

The mental distress caused by weight bullying often takes the form of depression, anxiety, and substance use, Dr. Puhl said, and children’s academic success can be hampered by bullying about their weight. One study found a higher risk of poor grades and school avoidance with each additional teasing incident (J Youth Adolesc. 2012 Jan;41[1]:27-40).

Weight stigma also can contribute to more weight gain, obesity, and lower physical activity levels. Maladaptive eating behaviors can result from weight stigmatization as well: binge eating, emotional eating, increased consumption in general, and other eating disorders. Severe binge eating is 80% more likely among teens who are bullied about their weight, Dr. Puhl said, and the risk increases with increased frequency and types of bullying.

Children who are teased about their weight often become less willing to engage in physical activity, she noted. They may skip gym class, feel less competent about physical activity, and end up enjoying sports participation less.

Further, sexual- and gender-minority youth report high rates of weight-related teasing from friends and family regardless of their body mass index (BMI) percentile, Dr. Puhl emphasized. Researchers have found bullying about weight in this population linked to dieting, difficulty sleeping, high stress levels, binge drinking, smoking, and marijuana use.
 

Know how to combat weight bias

Dr. Puhl described strategies for reducing weight bias based on clinical practice recommendations in the American Academy of Pediatrics’ policy statement entitled “Stigma Experienced by Children and Adolescents With Obesity” (Pediatrics. 2017 Dec;140[6]:e20173034).

Be aware. Consider how personal assumptions and attitudes about weight can affect your body language, tone of voice, facial expression, gestures, eye contact (or lack thereof), and spatial distance from the patient.

Recognizing the biological, genetic, and environmental causes of obesity can reduce stigma and improve understanding of the complexity of obesity etiology. It’s also important that you help parents understand this complexity and the negative impact of weight stigma.

Consider language and word choice. “Carefully consider language that might unintentionally communicate bias, blame, or negative judgment,” Dr. Puhl told attendees. “Use language that is supportive and empowering.”

Terms such as “unhealthy weight” and “high BMI” are less stigmatizing than “fat” and “morbidly obese” to parents, she said, and research has found nearly a quarter of parents would avoid future doctor appointments if their child’s doctor used stigmatizing terms to discuss weight (Pediatrics. 2011 Oct;128[4]:e786-93).

Teens themselves may have diverse preferences for the language used. Start by asking: “Could we talk about your weight today?” and then follow up by directly asking, “what words would you feel most comfortable with as we talk about your weight?”

Person-first language – such as “person with obesity” instead of “obese person” also is important to reducing stigma, she said.

It’s normal for you to feel uneasy about bringing up weight with patients, so Dr. Puhl recommended you practice dialogue out loud.

“Acknowledge your strengths,” she said. “You already have the skills and experience of engaging in difficult conversations with patients and families on a range of other health issues,” so apply that in this context as well.

Screen for negative experiences that could indicate weight-based bullying. These could include teasing and bullying, low self-esteem, poor school performance, depression, and anxiety.

“Remember that weight-based victimization can occur at diverse body sizes, not just in youth with obesity,” Dr. Puhl said. If you discover your patient is experiencing weight-related bullying, determine whether they have a support system in place and whether a mental health referral is appropriate. Provide or refer for behavior change counseling with motivational interviewing and patient-centered, empathic approaches. Parents should be aware of the issue and should contact the child’s teachers and school administration to help address it.

But before you do that, keep in mind that it’s not just peers doing the bullying. According to a study of teens with obesity enrolled in a national weight-loss camp, 37% of teen participants in 2012 said that their parents bully them (Pediatrics. 2013 Jan;131[1]:e1-9).

You should assess whether family interactions or the parents’ own history with weight is involved. If parents make disparaging comments about their child’s weight, “use this as an opportunity to model appropriate language and educate parents about weight bias,” Dr. Puhl said.

It’s also important to realize that parents themselves often are frustrated, so critical comments about their language or approach can backfire, she warned. Instead, help parents understand how to create a home setting that encourages healthy food choices, praises children for healthy decision making, and models positive health behaviors. It is key for them to focus on improving their children’s health behaviors rather than focusing on weight.

And before you contact the school, remember teachers also are common perpetrators of weight stigma, Dr. Puhl noted. She gave as an example a study in which investigators assessed 133 teachers’ perceptions of middle or high school students’ abilities based on photos that had been digitally altered to show each girl both as average weight or as overweight. Each photo was associated with an essay specifically chosen because it was neither particularly good nor bad (Brit J Educ Psychol. 2019 Oct 26. doi: 10.1111/bjep.12322). The teachers judged the essays believed to be submitted by overweight girls to be “similar in structural quality,” but they gave the overweight girls lower grades than the average-weight girls. They also indicated that they considered the overweight girls “put forth more effort, needed more remedial assistance, and had lower overall grades in school.” The teachers also rated other teachers’ weight bias to be at a low level, and their own weight bias to be “significantly lower” than the others.

Assess your clinical environment. Be aware of your clinical environment and whether it meets the needs of youth with diverse body sizes. That includes having a range of sturdy armless seating options and adequately sized doorways, hallways, and restrooms. You also should have beds, wheelchairs, and exam tables with adequate weight capacity. Also check that you have supplies, such as robes or blood pressure cuffs, on hand for a variety of body sizes.

NEW ORLEANS – Weight-based harassment and bias is extremely prevalent throughout society and in doctors’ own offices, so be aware of ways to address it and support your patients regardless of weight.

Rebecca Puhl, PhD, a deputy director of the Rudd Center for Food Policy and Obesity at the University of Connecticut, Hartford, said that weight-based discrimination can occur whatever a person’s size or body shape, but it’s most often targeted at youth who are overweight or obese.

These children and teens commonly face teasing, harassment, cyberbullying, physical aggression, and social bullying from peers, coaches, teachers, and even parents, Dr. Puhl told attendees at the annual meeting of the American Academy of Pediatrics.

Common beliefs about overweight people – that they have little self discipline or poor eating and activity habits – only perpetuate stereotypes, she said. Common stereotypes are that people with obesity are noncompliant, lazy, sloppy, unsuccessful, unintelligent, dishonest, and awkward.

And health professionals of every type have been found to harbor these biases. In one study of more than 4,000 first-year medical students, well over half the respondents revealed explicit (74%) and implicit (67%) weight bias (Obesity. 2014 Apr;22[4]:1201-8). The study also found that explicit weight bias was stronger than explicit bias against blacks, Hispanics, LGBTQ people, and poor people.
 

Know the effects of weight stigma

Far from a minor issue, the discrimination that begins in childhood against those who are overweight can have a long-lasting impact on their future prospects and mental health. Being overweight is overwhelmingly cited as the most common reason for bullying (Pediatr Obes. 2016 Aug;11[4]:241-50). Dr. Puhl described to attendees how weight bias shifts throughout a lifetime, beginning as early as preschool. In childhood, the stereotypes about being overweight worsen, and the teasing and bullying increase. By adolescence, this treatment affects teens’ psychological, social, and physical well-being. It then translates in adulthood into reduced opportunities in employment and education, and poorer access and treatment in health care.

The mental distress caused by weight bullying often takes the form of depression, anxiety, and substance use, Dr. Puhl said, and children’s academic success can be hampered by bullying about their weight. One study found a higher risk of poor grades and school avoidance with each additional teasing incident (J Youth Adolesc. 2012 Jan;41[1]:27-40).

Weight stigma also can contribute to more weight gain, obesity, and lower physical activity levels. Maladaptive eating behaviors can result from weight stigmatization as well: binge eating, emotional eating, increased consumption in general, and other eating disorders. Severe binge eating is 80% more likely among teens who are bullied about their weight, Dr. Puhl said, and the risk increases with increased frequency and types of bullying.

Children who are teased about their weight often become less willing to engage in physical activity, she noted. They may skip gym class, feel less competent about physical activity, and end up enjoying sports participation less.

Further, sexual- and gender-minority youth report high rates of weight-related teasing from friends and family regardless of their body mass index (BMI) percentile, Dr. Puhl emphasized. Researchers have found bullying about weight in this population linked to dieting, difficulty sleeping, high stress levels, binge drinking, smoking, and marijuana use.
 

Know how to combat weight bias

Dr. Puhl described strategies for reducing weight bias based on clinical practice recommendations in the American Academy of Pediatrics’ policy statement entitled “Stigma Experienced by Children and Adolescents With Obesity” (Pediatrics. 2017 Dec;140[6]:e20173034).

Be aware. Consider how personal assumptions and attitudes about weight can affect your body language, tone of voice, facial expression, gestures, eye contact (or lack thereof), and spatial distance from the patient.

Recognizing the biological, genetic, and environmental causes of obesity can reduce stigma and improve understanding of the complexity of obesity etiology. It’s also important that you help parents understand this complexity and the negative impact of weight stigma.

Consider language and word choice. “Carefully consider language that might unintentionally communicate bias, blame, or negative judgment,” Dr. Puhl told attendees. “Use language that is supportive and empowering.”

Terms such as “unhealthy weight” and “high BMI” are less stigmatizing than “fat” and “morbidly obese” to parents, she said, and research has found nearly a quarter of parents would avoid future doctor appointments if their child’s doctor used stigmatizing terms to discuss weight (Pediatrics. 2011 Oct;128[4]:e786-93).

Teens themselves may have diverse preferences for the language used. Start by asking: “Could we talk about your weight today?” and then follow up by directly asking, “what words would you feel most comfortable with as we talk about your weight?”

Person-first language – such as “person with obesity” instead of “obese person” also is important to reducing stigma, she said.

It’s normal for you to feel uneasy about bringing up weight with patients, so Dr. Puhl recommended you practice dialogue out loud.

“Acknowledge your strengths,” she said. “You already have the skills and experience of engaging in difficult conversations with patients and families on a range of other health issues,” so apply that in this context as well.

Screen for negative experiences that could indicate weight-based bullying. These could include teasing and bullying, low self-esteem, poor school performance, depression, and anxiety.

“Remember that weight-based victimization can occur at diverse body sizes, not just in youth with obesity,” Dr. Puhl said. If you discover your patient is experiencing weight-related bullying, determine whether they have a support system in place and whether a mental health referral is appropriate. Provide or refer for behavior change counseling with motivational interviewing and patient-centered, empathic approaches. Parents should be aware of the issue and should contact the child’s teachers and school administration to help address it.

But before you do that, keep in mind that it’s not just peers doing the bullying. According to a study of teens with obesity enrolled in a national weight-loss camp, 37% of teen participants in 2012 said that their parents bully them (Pediatrics. 2013 Jan;131[1]:e1-9).

You should assess whether family interactions or the parents’ own history with weight is involved. If parents make disparaging comments about their child’s weight, “use this as an opportunity to model appropriate language and educate parents about weight bias,” Dr. Puhl said.

It’s also important to realize that parents themselves often are frustrated, so critical comments about their language or approach can backfire, she warned. Instead, help parents understand how to create a home setting that encourages healthy food choices, praises children for healthy decision making, and models positive health behaviors. It is key for them to focus on improving their children’s health behaviors rather than focusing on weight.

And before you contact the school, remember teachers also are common perpetrators of weight stigma, Dr. Puhl noted. She gave as an example a study in which investigators assessed 133 teachers’ perceptions of middle or high school students’ abilities based on photos that had been digitally altered to show each girl both as average weight or as overweight. Each photo was associated with an essay specifically chosen because it was neither particularly good nor bad (Brit J Educ Psychol. 2019 Oct 26. doi: 10.1111/bjep.12322). The teachers judged the essays believed to be submitted by overweight girls to be “similar in structural quality,” but they gave the overweight girls lower grades than the average-weight girls. They also indicated that they considered the overweight girls “put forth more effort, needed more remedial assistance, and had lower overall grades in school.” The teachers also rated other teachers’ weight bias to be at a low level, and their own weight bias to be “significantly lower” than the others.

Assess your clinical environment. Be aware of your clinical environment and whether it meets the needs of youth with diverse body sizes. That includes having a range of sturdy armless seating options and adequately sized doorways, hallways, and restrooms. You also should have beds, wheelchairs, and exam tables with adequate weight capacity. Also check that you have supplies, such as robes or blood pressure cuffs, on hand for a variety of body sizes.

NEW ORLEANS – A variety of reasons can contribute to the failure of stimulants to treat ADHD in children, such as comorbidities, missed diagnoses, inadequate medication dosage, side effects, major life changes, and other factors in the home or school environments, said Alison Schonwald, MD, of Harvard Medical School, Boston.

gpointstudio/Thinkstock

Stimulant medications indicated for ADHD usually work in 70%-75% of school-age children, but that leaves one in four children whose condition can be more challenging to treat, she said.

“Look around you,” Dr. Schonwald told a packed room at the annual meeting of the American Academy of Pediatrics. “You’re not the only one struggling with this topic.” She sprinkled her presentation with case studies of patients with ADHD for whom stimulants weren’t working, examples that the audience clearly found familiar.

The three steps you already know to do with treatment-resistant children sound simple: assess the child for factors linked to their poor response; develop a new treatment plan; and use Food and Drug Administration-approved nonstimulant medications, including off-label options, in a new plan.

But in the office, the process can be anything but simple when you must consider school and family environments, comorbidities, and other factors potentially complicating the child’s ability to function well.
 

Comorbidities

To start, Dr. Schonwald provided a chart of common coexisting problems in children with ADHD that included the recommended assessment and intervention:

• Mood and self-esteem issues call for the depression section of the patient health questionnaire (PHQ9) and Moods and Feelings questionnaire (MFQ), followed by interventions such as individual and peer group therapy and exercise.
• Anxiety can be assessed with the Screen for Child Anxiety Related Disorders (SCARED) and Spence Children’s Anxiety Scale, then treated similarly to mood and self-esteem issues.
• Bullying or trauma require taking a history during an interview, and treatment with individual and peer group therapy.
• Substance abuse should be assessed with the CRAFFT screening tool (Car, Relax, Alone, Forget, Friends, Trouble) and Screening to Brief Intervention (S2BI) Tool, then treated according to best practices.
• Executive function, low cognitive abilities, and poor adaptive skills require a review of the child’s Individualized Education Program (IEP) testing, followed by personalized school and home interventions.
• Poor social skills, assessed in an interview, also require personalized interventions at home and in school.

Doctors also may need to consider other common comorbidities in children with ADHD, such as bipolar disorder, depression, learning disabilities, oppositional defiant disorder, and tic disorders.

Tic disorders typically have an onset around 7 years old and peak in midadolescence, declining in late teen years. An estimated 35%-90% of children with Tourette syndrome have ADHD, Dr. Schonwald said (Dev Med Child Neurol. 2006 Jul;48[7]:616-21).
 

Managing treatment with stimulants

A common dosage amount for stimulants is 2.5-5 mg, but that dose may be too low for children, Dr. Schonwald said. She recommended increasing it until an effect is seen and stopping at the effective dose level the child can tolerate. The maximum recommended by the FDA is 60 mg/day for short-acting stimulants and 72 mg/day for extended-release ones, but some research has shown dosage can go even higher without causing toxic effects (J Child Adolesc Psychopharmacol. 2010 Feb;20[1]:49-54).

Dr. Schonwald also suggested trying both methylphenidate and amphetamine medication, while recognizing the latter tends to have more stimulant-related side effects.

Adherence is another consideration because multiple studies show high rates of noncompliance or discontinuation, such as up to 19% discontinuation for long-acting and 38% for short-acting stimulants (J Clin Psychiatry. 2015 Nov;76(11):e1459-68; Postgrad Med. 2012 May;124(3):139-48). A study of a school cohort in Philadelphia found only about one in five children were adherent (J Am Acad Child Adolesc Psychiatry. 2011 May;50[5]:480-9).

One potential solution to adherence challenges are pill reminder smartphone apps, such as Medisafe Medication Management, Pill Reminder-All in One, MyTherapy: Medication Reminder, and CareZone.

Dr. Schonwald noted several factors that can influence children’s response to stimulants. Among children with comorbid intellectual disability, for example, the response rate is lower than the average 75% of children without the disability, hovering around 40%-50% (Res Dev Disabil. 2018 Dec;83:217-32). Those who get more sleep tend to have improved attention, compared with children with less sleep (Atten Defic Hyperact Disord. 2017 Mar;9[1]:31-38).

She also offered strategies to manage problematic adverse effects from stimulants. Those experiencing weight loss can take their stimulant after breakfast, drink whole milk, and consider taking drug holidays.

To reduce stomachaches, children should take their medication with food, and you should look at whether the child is taking the lowest effective dose they can and whether anxiety may be involved. Similarly, children with headaches should take stimulants with food, and you should look at the dosage and ask whether the patient is getting adequate sleep.

Strategies to address difficulty falling asleep can include taking the stimulant earlier in the day or switching to a shorter-acting form, dexmethylphenidate, or another stimulant. If they’re having trouble staying asleep, inquire about sleep hygiene, and look for associations with other factors that might explain why the child is experiencing new problems with staying asleep. If these strategies are unsuccessful, you can consider prescribing melatonin or clonidine.
 

Alternatives to stimulants

Several medications besides stimulants are available to prescribe to children with ADHD if they aren’t responding adequately to stimulants, Dr. Schonwald said.

Atomoxetine performed better than placebo in treatment studies, with similar weight loss effects, albeit the lowest mean effect size in clinician ratings (Lancet Psychiatry. 2018 Sep;5[9]:727-38). Dr. Schonwald recommended starting atomoxetine in children under 40 kg at 0.5 mg/kg for 4 days, then increasing to 1.2 mg/kg/day. For children over 40 kg, the dose can start at 40 mg. Maximum dose can range from 1.4 to 1.8 mg/kg or 100 mg/day.

About 7% of white children and 2% of African American children are poor metabolizers of atomoxetine, and the drug has interactions with dextromethorphan, fluoxetine, and paroxetine, she noted. Side effects can include abdominal pain, dry mouth, fatigue, mood swings, nausea, and vomiting.

Two alpha-adrenergics that you can consider are clonidine and guanfacine. Clonidine, a hypotensive drug given at a dose of 0.05-0.2 mg up to three times a day, is helpful for hyperactivity and impulsivity rather than attention difficulties. Side effects can include depression, headache, rebound hypertension, and sedation, and it’s only FDA approved for ages 12 years and older.

An extended release version of clonidine (Kapvay) is approved for monotherapy or adjunctive therapy for ADHD; it led to improvements in ADHD–Rating Scale-IV scores as soon as the second week in an 8-week randomized controlled trial. Mild to moderate somnolence was the most common adverse event, and changes on electrocardiograms were minor (J Am Acad Child Adolesc Psychiatry. 2011 Feb;50[2]:171-9).

Guanfacine, also a hypotensive drug, given at a dose of 0.5-2 mg up to three times a day, has fewer data about its use for ADHD but appears to treat attention problems more effectively than hyperactivity. Also approved only for ages 12 years and older, guanfacine is less sedating, and its side effects can include agitation, headache , and insomnia. An extended-release version of guanfacine (brand name Intuniv) showed statistically significant reductions in ADHD Rating Scale-IV scores in a 9-week, double-blind, randomized, controlled trial. Side effects including fatigue, sedation, and somnolence occurred in the first 2 weeks but generally resolved, and participants returned to baseline during dose maintenance and tapering (J Am Acad Child Adolesc Psychiatry. 2009 Feb;48[2]:155-65).

Intuniv doses should start at 1 mg/day and increase no more than 1 mg/week, Dr. Schonwald said, until reaching a maintenance dose of 1-4 mg once daily, depending on the patient’s clinical response and tolerability. Children also must be able to swallow the pill whole.
 

Treating preschoolers

Preschool children are particularly difficult to diagnose given their normal range of temperament and development, Dr. Schonwald said. Their symptoms could be resulting from another diagnosis or from circumstances in the environment.

You should consider potential comorbidities and whether the child’s symptoms are situational or pervasive. About 55% of preschoolers have at least one comorbidity, she said (Infants & Young Children. 2006 Apr-Jun;19[2]:109-122.)

That said, stimulants usually are effective in very young children whose primary concern is ADHD. In a randomized controlled trial of 303 preschoolers, significantly more children experienced reduced ADHD symptoms with methylphenidate than with placebo. The trial’s “data suggest that preschoolers with ADHD need to start with low methylphenidate doses. Treatment may best begin using methylphenidate–immediate release at 2.5 mg twice daily, and then be increased to 7.5 mg three times a day during the course of 1 week. The mean optimal total daily [methylphenidate] dose for preschoolers was 14.2 plus or minus 8.1 mg/day” (J Am Acad Child Adolesc Psychiatry. 2006 Nov;45[11]:1284-93).

In treating preschoolers, if the patient’s symptoms appear to get worse after starting a stimulant, you can consider a medication change. If symptoms are much worse, consider a lower dose or a different stimulant class, or whether the diagnosis is appropriate.

Five common components of poor behavior in preschoolers with ADHD include agitation, anxiety, explosively, hyperactivity, and impulsivity. If these issues are occurring throughout the day, consider reducing the dose or switching drug classes.

If it’s only occurring in the morning, Dr. Schonwald said, optimize the morning structure and consider giving the medication earlier in the morning or adding a short-acting booster. If it’s occurring in late afternoon, consider a booster and reducing high-demand activities for the child.

If a preschooler experiences some benefit from the stimulant but still has problems, adjunctive atomoxetine or an alpha adrenergic may help. Those medications also are recommended if the child has no benefit with the stimulant or cannot tolerate the lowest therapeutic dose.

Dr. Schonwald said she had no relevant financial disclosures.

NEW ORLEANS – A variety of reasons can contribute to the failure of stimulants to treat ADHD in children, such as comorbidities, missed diagnoses, inadequate medication dosage, side effects, major life changes, and other factors in the home or school environments, said Alison Schonwald, MD, of Harvard Medical School, Boston.

gpointstudio/Thinkstock

Stimulant medications indicated for ADHD usually work in 70%-75% of school-age children, but that leaves one in four children whose condition can be more challenging to treat, she said.

“Look around you,” Dr. Schonwald told a packed room at the annual meeting of the American Academy of Pediatrics. “You’re not the only one struggling with this topic.” She sprinkled her presentation with case studies of patients with ADHD for whom stimulants weren’t working, examples that the audience clearly found familiar.

The three steps you already know to do with treatment-resistant children sound simple: assess the child for factors linked to their poor response; develop a new treatment plan; and use Food and Drug Administration-approved nonstimulant medications, including off-label options, in a new plan.

But in the office, the process can be anything but simple when you must consider school and family environments, comorbidities, and other factors potentially complicating the child’s ability to function well.
 

Comorbidities

To start, Dr. Schonwald provided a chart of common coexisting problems in children with ADHD that included the recommended assessment and intervention:

• Mood and self-esteem issues call for the depression section of the patient health questionnaire (PHQ9) and Moods and Feelings questionnaire (MFQ), followed by interventions such as individual and peer group therapy and exercise.
• Anxiety can be assessed with the Screen for Child Anxiety Related Disorders (SCARED) and Spence Children’s Anxiety Scale, then treated similarly to mood and self-esteem issues.
• Bullying or trauma require taking a history during an interview, and treatment with individual and peer group therapy.
• Substance abuse should be assessed with the CRAFFT screening tool (Car, Relax, Alone, Forget, Friends, Trouble) and Screening to Brief Intervention (S2BI) Tool, then treated according to best practices.
• Executive function, low cognitive abilities, and poor adaptive skills require a review of the child’s Individualized Education Program (IEP) testing, followed by personalized school and home interventions.
• Poor social skills, assessed in an interview, also require personalized interventions at home and in school.

Doctors also may need to consider other common comorbidities in children with ADHD, such as bipolar disorder, depression, learning disabilities, oppositional defiant disorder, and tic disorders.

Tic disorders typically have an onset around 7 years old and peak in midadolescence, declining in late teen years. An estimated 35%-90% of children with Tourette syndrome have ADHD, Dr. Schonwald said (Dev Med Child Neurol. 2006 Jul;48[7]:616-21).
 

Managing treatment with stimulants

A common dosage amount for stimulants is 2.5-5 mg, but that dose may be too low for children, Dr. Schonwald said. She recommended increasing it until an effect is seen and stopping at the effective dose level the child can tolerate. The maximum recommended by the FDA is 60 mg/day for short-acting stimulants and 72 mg/day for extended-release ones, but some research has shown dosage can go even higher without causing toxic effects (J Child Adolesc Psychopharmacol. 2010 Feb;20[1]:49-54).

Dr. Schonwald also suggested trying both methylphenidate and amphetamine medication, while recognizing the latter tends to have more stimulant-related side effects.

Adherence is another consideration because multiple studies show high rates of noncompliance or discontinuation, such as up to 19% discontinuation for long-acting and 38% for short-acting stimulants (J Clin Psychiatry. 2015 Nov;76(11):e1459-68; Postgrad Med. 2012 May;124(3):139-48). A study of a school cohort in Philadelphia found only about one in five children were adherent (J Am Acad Child Adolesc Psychiatry. 2011 May;50[5]:480-9).

One potential solution to adherence challenges are pill reminder smartphone apps, such as Medisafe Medication Management, Pill Reminder-All in One, MyTherapy: Medication Reminder, and CareZone.

Dr. Schonwald noted several factors that can influence children’s response to stimulants. Among children with comorbid intellectual disability, for example, the response rate is lower than the average 75% of children without the disability, hovering around 40%-50% (Res Dev Disabil. 2018 Dec;83:217-32). Those who get more sleep tend to have improved attention, compared with children with less sleep (Atten Defic Hyperact Disord. 2017 Mar;9[1]:31-38).

She also offered strategies to manage problematic adverse effects from stimulants. Those experiencing weight loss can take their stimulant after breakfast, drink whole milk, and consider taking drug holidays.

To reduce stomachaches, children should take their medication with food, and you should look at whether the child is taking the lowest effective dose they can and whether anxiety may be involved. Similarly, children with headaches should take stimulants with food, and you should look at the dosage and ask whether the patient is getting adequate sleep.

Strategies to address difficulty falling asleep can include taking the stimulant earlier in the day or switching to a shorter-acting form, dexmethylphenidate, or another stimulant. If they’re having trouble staying asleep, inquire about sleep hygiene, and look for associations with other factors that might explain why the child is experiencing new problems with staying asleep. If these strategies are unsuccessful, you can consider prescribing melatonin or clonidine.
 

Alternatives to stimulants

Several medications besides stimulants are available to prescribe to children with ADHD if they aren’t responding adequately to stimulants, Dr. Schonwald said.

Atomoxetine performed better than placebo in treatment studies, with similar weight loss effects, albeit the lowest mean effect size in clinician ratings (Lancet Psychiatry. 2018 Sep;5[9]:727-38). Dr. Schonwald recommended starting atomoxetine in children under 40 kg at 0.5 mg/kg for 4 days, then increasing to 1.2 mg/kg/day. For children over 40 kg, the dose can start at 40 mg. Maximum dose can range from 1.4 to 1.8 mg/kg or 100 mg/day.

About 7% of white children and 2% of African American children are poor metabolizers of atomoxetine, and the drug has interactions with dextromethorphan, fluoxetine, and paroxetine, she noted. Side effects can include abdominal pain, dry mouth, fatigue, mood swings, nausea, and vomiting.

Two alpha-adrenergics that you can consider are clonidine and guanfacine. Clonidine, a hypotensive drug given at a dose of 0.05-0.2 mg up to three times a day, is helpful for hyperactivity and impulsivity rather than attention difficulties. Side effects can include depression, headache, rebound hypertension, and sedation, and it’s only FDA approved for ages 12 years and older.

An extended release version of clonidine (Kapvay) is approved for monotherapy or adjunctive therapy for ADHD; it led to improvements in ADHD–Rating Scale-IV scores as soon as the second week in an 8-week randomized controlled trial. Mild to moderate somnolence was the most common adverse event, and changes on electrocardiograms were minor (J Am Acad Child Adolesc Psychiatry. 2011 Feb;50[2]:171-9).

Guanfacine, also a hypotensive drug, given at a dose of 0.5-2 mg up to three times a day, has fewer data about its use for ADHD but appears to treat attention problems more effectively than hyperactivity. Also approved only for ages 12 years and older, guanfacine is less sedating, and its side effects can include agitation, headache , and insomnia. An extended-release version of guanfacine (brand name Intuniv) showed statistically significant reductions in ADHD Rating Scale-IV scores in a 9-week, double-blind, randomized, controlled trial. Side effects including fatigue, sedation, and somnolence occurred in the first 2 weeks but generally resolved, and participants returned to baseline during dose maintenance and tapering (J Am Acad Child Adolesc Psychiatry. 2009 Feb;48[2]:155-65).

Intuniv doses should start at 1 mg/day and increase no more than 1 mg/week, Dr. Schonwald said, until reaching a maintenance dose of 1-4 mg once daily, depending on the patient’s clinical response and tolerability. Children also must be able to swallow the pill whole.
 

Treating preschoolers

Preschool children are particularly difficult to diagnose given their normal range of temperament and development, Dr. Schonwald said. Their symptoms could be resulting from another diagnosis or from circumstances in the environment.

You should consider potential comorbidities and whether the child’s symptoms are situational or pervasive. About 55% of preschoolers have at least one comorbidity, she said (Infants & Young Children. 2006 Apr-Jun;19[2]:109-122.)

That said, stimulants usually are effective in very young children whose primary concern is ADHD. In a randomized controlled trial of 303 preschoolers, significantly more children experienced reduced ADHD symptoms with methylphenidate than with placebo. The trial’s “data suggest that preschoolers with ADHD need to start with low methylphenidate doses. Treatment may best begin using methylphenidate–immediate release at 2.5 mg twice daily, and then be increased to 7.5 mg three times a day during the course of 1 week. The mean optimal total daily [methylphenidate] dose for preschoolers was 14.2 plus or minus 8.1 mg/day” (J Am Acad Child Adolesc Psychiatry. 2006 Nov;45[11]:1284-93).

In treating preschoolers, if the patient’s symptoms appear to get worse after starting a stimulant, you can consider a medication change. If symptoms are much worse, consider a lower dose or a different stimulant class, or whether the diagnosis is appropriate.

Five common components of poor behavior in preschoolers with ADHD include agitation, anxiety, explosively, hyperactivity, and impulsivity. If these issues are occurring throughout the day, consider reducing the dose or switching drug classes.

If it’s only occurring in the morning, Dr. Schonwald said, optimize the morning structure and consider giving the medication earlier in the morning or adding a short-acting booster. If it’s occurring in late afternoon, consider a booster and reducing high-demand activities for the child.

If a preschooler experiences some benefit from the stimulant but still has problems, adjunctive atomoxetine or an alpha adrenergic may help. Those medications also are recommended if the child has no benefit with the stimulant or cannot tolerate the lowest therapeutic dose.

Dr. Schonwald said she had no relevant financial disclosures.

NEW ORLEANS – A variety of reasons can contribute to the failure of stimulants to treat ADHD in children, such as comorbidities, missed diagnoses, inadequate medication dosage, side effects, major life changes, and other factors in the home or school environments, said Alison Schonwald, MD, of Harvard Medical School, Boston.

gpointstudio/Thinkstock

Stimulant medications indicated for ADHD usually work in 70%-75% of school-age children, but that leaves one in four children whose condition can be more challenging to treat, she said.

“Look around you,” Dr. Schonwald told a packed room at the annual meeting of the American Academy of Pediatrics. “You’re not the only one struggling with this topic.” She sprinkled her presentation with case studies of patients with ADHD for whom stimulants weren’t working, examples that the audience clearly found familiar.

The three steps you already know to do with treatment-resistant children sound simple: assess the child for factors linked to their poor response; develop a new treatment plan; and use Food and Drug Administration-approved nonstimulant medications, including off-label options, in a new plan.

But in the office, the process can be anything but simple when you must consider school and family environments, comorbidities, and other factors potentially complicating the child’s ability to function well.
 

Comorbidities

To start, Dr. Schonwald provided a chart of common coexisting problems in children with ADHD that included the recommended assessment and intervention:

• Mood and self-esteem issues call for the depression section of the patient health questionnaire (PHQ9) and Moods and Feelings questionnaire (MFQ), followed by interventions such as individual and peer group therapy and exercise.
• Anxiety can be assessed with the Screen for Child Anxiety Related Disorders (SCARED) and Spence Children’s Anxiety Scale, then treated similarly to mood and self-esteem issues.
• Bullying or trauma require taking a history during an interview, and treatment with individual and peer group therapy.
• Substance abuse should be assessed with the CRAFFT screening tool (Car, Relax, Alone, Forget, Friends, Trouble) and Screening to Brief Intervention (S2BI) Tool, then treated according to best practices.
• Executive function, low cognitive abilities, and poor adaptive skills require a review of the child’s Individualized Education Program (IEP) testing, followed by personalized school and home interventions.
• Poor social skills, assessed in an interview, also require personalized interventions at home and in school.

Doctors also may need to consider other common comorbidities in children with ADHD, such as bipolar disorder, depression, learning disabilities, oppositional defiant disorder, and tic disorders.

Tic disorders typically have an onset around 7 years old and peak in midadolescence, declining in late teen years. An estimated 35%-90% of children with Tourette syndrome have ADHD, Dr. Schonwald said (Dev Med Child Neurol. 2006 Jul;48[7]:616-21).
 

Managing treatment with stimulants

A common dosage amount for stimulants is 2.5-5 mg, but that dose may be too low for children, Dr. Schonwald said. She recommended increasing it until an effect is seen and stopping at the effective dose level the child can tolerate. The maximum recommended by the FDA is 60 mg/day for short-acting stimulants and 72 mg/day for extended-release ones, but some research has shown dosage can go even higher without causing toxic effects (J Child Adolesc Psychopharmacol. 2010 Feb;20[1]:49-54).

Dr. Schonwald also suggested trying both methylphenidate and amphetamine medication, while recognizing the latter tends to have more stimulant-related side effects.

Adherence is another consideration because multiple studies show high rates of noncompliance or discontinuation, such as up to 19% discontinuation for long-acting and 38% for short-acting stimulants (J Clin Psychiatry. 2015 Nov;76(11):e1459-68; Postgrad Med. 2012 May;124(3):139-48). A study of a school cohort in Philadelphia found only about one in five children were adherent (J Am Acad Child Adolesc Psychiatry. 2011 May;50[5]:480-9).

One potential solution to adherence challenges are pill reminder smartphone apps, such as Medisafe Medication Management, Pill Reminder-All in One, MyTherapy: Medication Reminder, and CareZone.

Dr. Schonwald noted several factors that can influence children’s response to stimulants. Among children with comorbid intellectual disability, for example, the response rate is lower than the average 75% of children without the disability, hovering around 40%-50% (Res Dev Disabil. 2018 Dec;83:217-32). Those who get more sleep tend to have improved attention, compared with children with less sleep (Atten Defic Hyperact Disord. 2017 Mar;9[1]:31-38).

She also offered strategies to manage problematic adverse effects from stimulants. Those experiencing weight loss can take their stimulant after breakfast, drink whole milk, and consider taking drug holidays.

To reduce stomachaches, children should take their medication with food, and you should look at whether the child is taking the lowest effective dose they can and whether anxiety may be involved. Similarly, children with headaches should take stimulants with food, and you should look at the dosage and ask whether the patient is getting adequate sleep.

Strategies to address difficulty falling asleep can include taking the stimulant earlier in the day or switching to a shorter-acting form, dexmethylphenidate, or another stimulant. If they’re having trouble staying asleep, inquire about sleep hygiene, and look for associations with other factors that might explain why the child is experiencing new problems with staying asleep. If these strategies are unsuccessful, you can consider prescribing melatonin or clonidine.
 

Alternatives to stimulants

Several medications besides stimulants are available to prescribe to children with ADHD if they aren’t responding adequately to stimulants, Dr. Schonwald said.

Atomoxetine performed better than placebo in treatment studies, with similar weight loss effects, albeit the lowest mean effect size in clinician ratings (Lancet Psychiatry. 2018 Sep;5[9]:727-38). Dr. Schonwald recommended starting atomoxetine in children under 40 kg at 0.5 mg/kg for 4 days, then increasing to 1.2 mg/kg/day. For children over 40 kg, the dose can start at 40 mg. Maximum dose can range from 1.4 to 1.8 mg/kg or 100 mg/day.

About 7% of white children and 2% of African American children are poor metabolizers of atomoxetine, and the drug has interactions with dextromethorphan, fluoxetine, and paroxetine, she noted. Side effects can include abdominal pain, dry mouth, fatigue, mood swings, nausea, and vomiting.

Two alpha-adrenergics that you can consider are clonidine and guanfacine. Clonidine, a hypotensive drug given at a dose of 0.05-0.2 mg up to three times a day, is helpful for hyperactivity and impulsivity rather than attention difficulties. Side effects can include depression, headache, rebound hypertension, and sedation, and it’s only FDA approved for ages 12 years and older.

An extended release version of clonidine (Kapvay) is approved for monotherapy or adjunctive therapy for ADHD; it led to improvements in ADHD–Rating Scale-IV scores as soon as the second week in an 8-week randomized controlled trial. Mild to moderate somnolence was the most common adverse event, and changes on electrocardiograms were minor (J Am Acad Child Adolesc Psychiatry. 2011 Feb;50[2]:171-9).

Guanfacine, also a hypotensive drug, given at a dose of 0.5-2 mg up to three times a day, has fewer data about its use for ADHD but appears to treat attention problems more effectively than hyperactivity. Also approved only for ages 12 years and older, guanfacine is less sedating, and its side effects can include agitation, headache , and insomnia. An extended-release version of guanfacine (brand name Intuniv) showed statistically significant reductions in ADHD Rating Scale-IV scores in a 9-week, double-blind, randomized, controlled trial. Side effects including fatigue, sedation, and somnolence occurred in the first 2 weeks but generally resolved, and participants returned to baseline during dose maintenance and tapering (J Am Acad Child Adolesc Psychiatry. 2009 Feb;48[2]:155-65).

Intuniv doses should start at 1 mg/day and increase no more than 1 mg/week, Dr. Schonwald said, until reaching a maintenance dose of 1-4 mg once daily, depending on the patient’s clinical response and tolerability. Children also must be able to swallow the pill whole.
 

Treating preschoolers

Preschool children are particularly difficult to diagnose given their normal range of temperament and development, Dr. Schonwald said. Their symptoms could be resulting from another diagnosis or from circumstances in the environment.

You should consider potential comorbidities and whether the child’s symptoms are situational or pervasive. About 55% of preschoolers have at least one comorbidity, she said (Infants & Young Children. 2006 Apr-Jun;19[2]:109-122.)

That said, stimulants usually are effective in very young children whose primary concern is ADHD. In a randomized controlled trial of 303 preschoolers, significantly more children experienced reduced ADHD symptoms with methylphenidate than with placebo. The trial’s “data suggest that preschoolers with ADHD need to start with low methylphenidate doses. Treatment may best begin using methylphenidate–immediate release at 2.5 mg twice daily, and then be increased to 7.5 mg three times a day during the course of 1 week. The mean optimal total daily [methylphenidate] dose for preschoolers was 14.2 plus or minus 8.1 mg/day” (J Am Acad Child Adolesc Psychiatry. 2006 Nov;45[11]:1284-93).

In treating preschoolers, if the patient’s symptoms appear to get worse after starting a stimulant, you can consider a medication change. If symptoms are much worse, consider a lower dose or a different stimulant class, or whether the diagnosis is appropriate.

Five common components of poor behavior in preschoolers with ADHD include agitation, anxiety, explosively, hyperactivity, and impulsivity. If these issues are occurring throughout the day, consider reducing the dose or switching drug classes.

If it’s only occurring in the morning, Dr. Schonwald said, optimize the morning structure and consider giving the medication earlier in the morning or adding a short-acting booster. If it’s occurring in late afternoon, consider a booster and reducing high-demand activities for the child.

If a preschooler experiences some benefit from the stimulant but still has problems, adjunctive atomoxetine or an alpha adrenergic may help. Those medications also are recommended if the child has no benefit with the stimulant or cannot tolerate the lowest therapeutic dose.

Dr. Schonwald said she had no relevant financial disclosures.

NEW ORLEANS – With more than 10% of children receiving complementary or alternative medicine (CAM), you should be familiar with what does and doesn’t work when it comes to using supplements for various medical issues, said Cora Breuner, MD, a professor of pediatrics at the University of Washington, Seattle, and attending physician at Seattle Children’s Hospital.

Dr. Breuner presented an overview of more than a dozen popular supplements with their uses and evidence at the American Academy of Pediatrics annual meeting. Most of the evidence comes from studies in adults, not children, and the evidence overall is sometimes scant, but it can guide physicians in discussing options with parents interested in CAM.
 

Butterbur

This root primarily is used to treat migraines via anti-inflammatory effects. The ideal dose is 50-75 mg daily in 2-3 divided doses for children aged 8-9 years and 100-150 mg daily in 2-3 divided doses for those aged 10 and older (Headache. 2005 Mar;45:196-203; Eur J Pain. 2008;12:301-13; Neurology. 2012 Apr 24;78[17]:1346-53).

Adverse effects are mostly gastrointestinal, such as diarrhea and stomach upset, and dermal/allergic reactions, such as itchy eyes, asthma, and itching.
 

Caffeine

Caffeine is the most popular drug of choice for reducing drowsiness and increasing alertness and has the strongest evidence base, including for improving sports and work performance (J Strength Cond Res. 2010 Jan;24[1]:257-65). Regular caffeine use can lead to dependence, however, and it can cause anxiety, nervousness, irritability, insomnia, peptic ulcers, palpitations, gastroesophageal reflux disease (GERD), and tremors. Withdrawal can involve headaches, irritability, and anxiety.

Cannabidiol

Marijuana has more than 80 cannabinoids, and a nonpsychoactive one, cannabidiol, makes up about 40% of cannabis extracts, Dr. Breuner said. It’s been used as an anticonvulsant and to combat anxiety, psychosis, nausea and rheumatoid arthritis pain. In a study using a rat model for arthritis, inflammation and pain-related behaviors decreased in rats that received cannabidiol (Eur J Pain. 2016 Jul;20[6]:936-48).

A human dose would be about 160-300 mg daily, but side effects can include dry mouth, hypotension, lightheadedness, psychomotor slowing, sedation, and sleepiness.
 

Coenzyme Q10

This antioxidant is fat-soluble and has a chemical structure similar to vitamin K. It has been used in people with autism, chronic fatigue syndrome, fatigue from chemotherapy, Lyme disease, and muscular dystrophy, but the evidence focuses on fibromyalgia. One study of patients with fibromyalgia found that a 300-mg daily dose for 40 days reduced pain by 52%-56%, fatigue by 47%, morning tiredness by 56%, and tender points by 44%, compared with baseline (Antioxid Redox Signal. 2013;19[12]:1356-61.)

In another, 200 mg of coenzyme Q10 with 200 mg ginkgo daily for 3 months resulted in improvement of quality of life measures, including physical fitness levels, emotional feelings, social activities, overall health, and pain (J Int Med Res. 2002;30:195-9).

Potential adverse effects of coenzyme Q10 include nausea, vomiting, diarrhea, appetite suppression, and heartburn, albeit typically in less than 1% of patients.
 

Echinacea

magicflute002/Thinkstock

Echinacea actually is approved in Germany for supportive therapy in treating upper respiratory tract infections, urogenital infections, and wound healing, Dr. Breuner said. Hypothesized mechanisms of action include stimulation of the alternate complement pathway, immune-modulating effects, activating nonspecific T cells, inhibiting viral replication, and enhancing phagocytosis.

However, in clinical studies, echinacea did not reduce the duration or severity of upper respiratory tract infections or the occurrence or severity of infection, compared with placebo (JAMA. 2003 Dec 3;290[21]:2824-30; N Engl J Med. 2005 Jul 28;353[4]:341-8); this was tested in children aged 2-11 years in the first study, and the mean age of the subjects in the second study was 21 years. A 2014 Cochrane review found no overall benefits for treating common colds but noted the possibility of “a weak benefit from some echinacea products” based on individual trials with consistently positive, yet nonsignificant, trends, albeit with “questionable clinical relevance” (Cochrane Database Syst Rev. 2014 Feb 20;[2]:CD000530).

People with autoimmune conditions or who are immunocompromised should not use echinacea.
 

Magnesium

Magnesium also is used to treat migraines with a dose of 300-500 mg daily, although also it can be consumed in food, such as soy beans, black beans, tofu, seeds, nuts, whole grains, and shellfish (Expert Rev Neurother. 2009 Mar;9[3]:369-79; Neurology. 2012 Apr 24;78[17]:1346-53).

Side effects can include diarrhea and interactions with bisphosphonates, antibiotics] and diuretics. Taking proton pump inhibitors also may reduce magnesium levels.
 

Melatonin

Wjeger/Thinkstockphotos

Melatonin, a synthetic version of the hormone produced in humans to signal the onset of nighttime, has been studied extensively for jet lag, insomnia, shift-work disorder, circadian rhythm disorders, and withdrawal from benzodiazepine and nicotine.

Research shows that melatonin can improve sleep onset, duration, and quality. Some research has shown increased total sleep time (PLoS One. 2013 May 17;8(5):e63773).

Some evidence suggests it has endocrine-disrupting adverse effects, such as inhibiting ovulation and impairing glucose utilization.
 

N-acetyl cysteine (NAC)

Although it’s primarily an antidote for acetaminophen and carbon monoxide poisoning, NAC has been used for a wide range of conditions, including reducing lipoprotein levels with hyperlipidemia and reducing risk of cardiovascular events in people with end-stage renal disease and other conditions. It also has been used in people with bipolar disorder, schizophrenia, PTSD, substance disorders, and Tourette syndrome.

“Some clinical research shows that taking NAC 900 mg daily for 4 weeks, followed by 900 mg twice daily for 4 weeks and then 900 mg three times daily for 4 weeks improves symptoms of irritability in children with autism,” Dr. Breuner said. Other research showed reduced irritability in children with autism when they took 1,200 mg of NAC daily with risperidone, compared with risperidone alone. One study also has found “that NAC adds to the effect of citalopram in improving resistance/control to compulsions in OCD children and adolescents” (Iran J Psychiatry. 2017 Apr;12[2]:134-141).

Side effects can include diarrhea, nausea, and heartburn.
 

Omega-3 fatty acids: DHA and EHA

Docosahexanoic acid (DHA) and eicosapentanoic acid (EHA) have been used to treat ADHD, depression, heart disease, and also to lower the risk of macular degeneration.

A systematic review of 25 randomized controlled trials of more than 3,600 subjects found that “omega-3 supplementation generally correlated with improvements in blood biomarkers” (Nutrients. 2018 Aug 15;10[8]. pii: E1094). A small study in children with Tourette syndrome found that omega-3 fatty acids did not reduce tic scores, but “may be beneficial in reduction of tic-related impairment” for some children and teens (Pediatrics. 2012 Jun;129[6]:e1493-500).

Possible adverse effects include fishy taste, belching, nosebleeds, nausea, loose stools, and – at higher doses – decreased blood coagulation.
 

St. John’s wort

Alexandru Magurean/Thinkstock

This herb has long been used to treat depression and appears to work by inhibiting serotonin reuptake, monoamine oxidase (MAO), 5-hydroxytryptamine (5-HT), dopamine, noradrenaline, gamma aminobutyric acid (GABA), and glutamate. A 2005 Cochrane review found St. John’s wort to work better than placebo with similar effectiveness as standard antidepressants for mild to moderate depression, but its benefit for major depression is questionable (Cochrane Database Syst Rev. 2005 Apr 18;[2]:CD000448).

An ideal dose is 300 mg daily, but physicians should be aware of the herb’s potential for certain drug interactions. It may increase metabolism of warfarin, cyclosporin, HIV protease inhibitors, theophylline, digoxin, and oral contraceptives (Expert Opin Drug Metab Toxicol. 2012 Jun;8[6]:691-708). Other potential side effects include decreased platelet aggregation, serotonin syndrome, and photosensitivity.
 

Turmeric (curcumin)

SyedMirazurRahman/Thinkstock

Turmeric is an anti-inflammatory agent used for a wide range of complaints, but research primarily has focused on its use for pain. No studies exist in children, but a handful of studies have found reduction in joint pain and rheumatoid arthritis symptoms in adults with 500-mg doses twice daily (Phytother Res. 2012 Nov;26[11]:1719-25; J Med Food. 2017 Oct;20[10]:1022-30). One of these studies focused on a specific product, Instaflex, that contained turmeric among multiple other active ingredients (Nutr J. 2013 Nov 25;12[1]:154).

Potential adverse effects of turmeric/curcumin include constipation, dyspepsia, diarrhea, dissension, reflux, nausea, vomiting, itching, and hives.
 

Zinc

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Like echinacea, zinc is commonly used to treat the common cold. A 2013 Cochrane review of randomized, controlled trials found that taking zinc “within 24 hours of onset of symptoms reduces the duration of common cold symptoms in healthy people, but some caution is needed due to the heterogeneity of the data” (Cochrane Database Syst Rev. 2013 Jun 18;[6]:CD001364). The dose is 75 mg a day, and potential adverse effects include bad taste, nausea, and anosmia.

Dr. Breuner said she had no relevant financial disclosures.

NEW ORLEANS – With more than 10% of children receiving complementary or alternative medicine (CAM), you should be familiar with what does and doesn’t work when it comes to using supplements for various medical issues, said Cora Breuner, MD, a professor of pediatrics at the University of Washington, Seattle, and attending physician at Seattle Children’s Hospital.

Dr. Breuner presented an overview of more than a dozen popular supplements with their uses and evidence at the American Academy of Pediatrics annual meeting. Most of the evidence comes from studies in adults, not children, and the evidence overall is sometimes scant, but it can guide physicians in discussing options with parents interested in CAM.
 

Butterbur

This root primarily is used to treat migraines via anti-inflammatory effects. The ideal dose is 50-75 mg daily in 2-3 divided doses for children aged 8-9 years and 100-150 mg daily in 2-3 divided doses for those aged 10 and older (Headache. 2005 Mar;45:196-203; Eur J Pain. 2008;12:301-13; Neurology. 2012 Apr 24;78[17]:1346-53).

Adverse effects are mostly gastrointestinal, such as diarrhea and stomach upset, and dermal/allergic reactions, such as itchy eyes, asthma, and itching.
 

Caffeine

Caffeine is the most popular drug of choice for reducing drowsiness and increasing alertness and has the strongest evidence base, including for improving sports and work performance (J Strength Cond Res. 2010 Jan;24[1]:257-65). Regular caffeine use can lead to dependence, however, and it can cause anxiety, nervousness, irritability, insomnia, peptic ulcers, palpitations, gastroesophageal reflux disease (GERD), and tremors. Withdrawal can involve headaches, irritability, and anxiety.

Cannabidiol

Marijuana has more than 80 cannabinoids, and a nonpsychoactive one, cannabidiol, makes up about 40% of cannabis extracts, Dr. Breuner said. It’s been used as an anticonvulsant and to combat anxiety, psychosis, nausea and rheumatoid arthritis pain. In a study using a rat model for arthritis, inflammation and pain-related behaviors decreased in rats that received cannabidiol (Eur J Pain. 2016 Jul;20[6]:936-48).

A human dose would be about 160-300 mg daily, but side effects can include dry mouth, hypotension, lightheadedness, psychomotor slowing, sedation, and sleepiness.
 

Coenzyme Q10

This antioxidant is fat-soluble and has a chemical structure similar to vitamin K. It has been used in people with autism, chronic fatigue syndrome, fatigue from chemotherapy, Lyme disease, and muscular dystrophy, but the evidence focuses on fibromyalgia. One study of patients with fibromyalgia found that a 300-mg daily dose for 40 days reduced pain by 52%-56%, fatigue by 47%, morning tiredness by 56%, and tender points by 44%, compared with baseline (Antioxid Redox Signal. 2013;19[12]:1356-61.)

In another, 200 mg of coenzyme Q10 with 200 mg ginkgo daily for 3 months resulted in improvement of quality of life measures, including physical fitness levels, emotional feelings, social activities, overall health, and pain (J Int Med Res. 2002;30:195-9).

Potential adverse effects of coenzyme Q10 include nausea, vomiting, diarrhea, appetite suppression, and heartburn, albeit typically in less than 1% of patients.
 

Echinacea

magicflute002/Thinkstock

Echinacea actually is approved in Germany for supportive therapy in treating upper respiratory tract infections, urogenital infections, and wound healing, Dr. Breuner said. Hypothesized mechanisms of action include stimulation of the alternate complement pathway, immune-modulating effects, activating nonspecific T cells, inhibiting viral replication, and enhancing phagocytosis.

However, in clinical studies, echinacea did not reduce the duration or severity of upper respiratory tract infections or the occurrence or severity of infection, compared with placebo (JAMA. 2003 Dec 3;290[21]:2824-30; N Engl J Med. 2005 Jul 28;353[4]:341-8); this was tested in children aged 2-11 years in the first study, and the mean age of the subjects in the second study was 21 years. A 2014 Cochrane review found no overall benefits for treating common colds but noted the possibility of “a weak benefit from some echinacea products” based on individual trials with consistently positive, yet nonsignificant, trends, albeit with “questionable clinical relevance” (Cochrane Database Syst Rev. 2014 Feb 20;[2]:CD000530).

People with autoimmune conditions or who are immunocompromised should not use echinacea.
 

Magnesium

Magnesium also is used to treat migraines with a dose of 300-500 mg daily, although also it can be consumed in food, such as soy beans, black beans, tofu, seeds, nuts, whole grains, and shellfish (Expert Rev Neurother. 2009 Mar;9[3]:369-79; Neurology. 2012 Apr 24;78[17]:1346-53).

Side effects can include diarrhea and interactions with bisphosphonates, antibiotics] and diuretics. Taking proton pump inhibitors also may reduce magnesium levels.
 

Melatonin

Wjeger/Thinkstockphotos

Melatonin, a synthetic version of the hormone produced in humans to signal the onset of nighttime, has been studied extensively for jet lag, insomnia, shift-work disorder, circadian rhythm disorders, and withdrawal from benzodiazepine and nicotine.

Research shows that melatonin can improve sleep onset, duration, and quality. Some research has shown increased total sleep time (PLoS One. 2013 May 17;8(5):e63773).

Some evidence suggests it has endocrine-disrupting adverse effects, such as inhibiting ovulation and impairing glucose utilization.
 

N-acetyl cysteine (NAC)

Although it’s primarily an antidote for acetaminophen and carbon monoxide poisoning, NAC has been used for a wide range of conditions, including reducing lipoprotein levels with hyperlipidemia and reducing risk of cardiovascular events in people with end-stage renal disease and other conditions. It also has been used in people with bipolar disorder, schizophrenia, PTSD, substance disorders, and Tourette syndrome.

“Some clinical research shows that taking NAC 900 mg daily for 4 weeks, followed by 900 mg twice daily for 4 weeks and then 900 mg three times daily for 4 weeks improves symptoms of irritability in children with autism,” Dr. Breuner said. Other research showed reduced irritability in children with autism when they took 1,200 mg of NAC daily with risperidone, compared with risperidone alone. One study also has found “that NAC adds to the effect of citalopram in improving resistance/control to compulsions in OCD children and adolescents” (Iran J Psychiatry. 2017 Apr;12[2]:134-141).

Side effects can include diarrhea, nausea, and heartburn.
 

Omega-3 fatty acids: DHA and EHA

Docosahexanoic acid (DHA) and eicosapentanoic acid (EHA) have been used to treat ADHD, depression, heart disease, and also to lower the risk of macular degeneration.

A systematic review of 25 randomized controlled trials of more than 3,600 subjects found that “omega-3 supplementation generally correlated with improvements in blood biomarkers” (Nutrients. 2018 Aug 15;10[8]. pii: E1094). A small study in children with Tourette syndrome found that omega-3 fatty acids did not reduce tic scores, but “may be beneficial in reduction of tic-related impairment” for some children and teens (Pediatrics. 2012 Jun;129[6]:e1493-500).

Possible adverse effects include fishy taste, belching, nosebleeds, nausea, loose stools, and – at higher doses – decreased blood coagulation.
 

St. John’s wort

Alexandru Magurean/Thinkstock

This herb has long been used to treat depression and appears to work by inhibiting serotonin reuptake, monoamine oxidase (MAO), 5-hydroxytryptamine (5-HT), dopamine, noradrenaline, gamma aminobutyric acid (GABA), and glutamate. A 2005 Cochrane review found St. John’s wort to work better than placebo with similar effectiveness as standard antidepressants for mild to moderate depression, but its benefit for major depression is questionable (Cochrane Database Syst Rev. 2005 Apr 18;[2]:CD000448).

An ideal dose is 300 mg daily, but physicians should be aware of the herb’s potential for certain drug interactions. It may increase metabolism of warfarin, cyclosporin, HIV protease inhibitors, theophylline, digoxin, and oral contraceptives (Expert Opin Drug Metab Toxicol. 2012 Jun;8[6]:691-708). Other potential side effects include decreased platelet aggregation, serotonin syndrome, and photosensitivity.
 

Turmeric (curcumin)

SyedMirazurRahman/Thinkstock

Turmeric is an anti-inflammatory agent used for a wide range of complaints, but research primarily has focused on its use for pain. No studies exist in children, but a handful of studies have found reduction in joint pain and rheumatoid arthritis symptoms in adults with 500-mg doses twice daily (Phytother Res. 2012 Nov;26[11]:1719-25; J Med Food. 2017 Oct;20[10]:1022-30). One of these studies focused on a specific product, Instaflex, that contained turmeric among multiple other active ingredients (Nutr J. 2013 Nov 25;12[1]:154).

Potential adverse effects of turmeric/curcumin include constipation, dyspepsia, diarrhea, dissension, reflux, nausea, vomiting, itching, and hives.
 

Zinc

ilkab/Thinkstock

Like echinacea, zinc is commonly used to treat the common cold. A 2013 Cochrane review of randomized, controlled trials found that taking zinc “within 24 hours of onset of symptoms reduces the duration of common cold symptoms in healthy people, but some caution is needed due to the heterogeneity of the data” (Cochrane Database Syst Rev. 2013 Jun 18;[6]:CD001364). The dose is 75 mg a day, and potential adverse effects include bad taste, nausea, and anosmia.

Dr. Breuner said she had no relevant financial disclosures.

NEW ORLEANS – With more than 10% of children receiving complementary or alternative medicine (CAM), you should be familiar with what does and doesn’t work when it comes to using supplements for various medical issues, said Cora Breuner, MD, a professor of pediatrics at the University of Washington, Seattle, and attending physician at Seattle Children’s Hospital.

Dr. Breuner presented an overview of more than a dozen popular supplements with their uses and evidence at the American Academy of Pediatrics annual meeting. Most of the evidence comes from studies in adults, not children, and the evidence overall is sometimes scant, but it can guide physicians in discussing options with parents interested in CAM.
 

Butterbur

This root primarily is used to treat migraines via anti-inflammatory effects. The ideal dose is 50-75 mg daily in 2-3 divided doses for children aged 8-9 years and 100-150 mg daily in 2-3 divided doses for those aged 10 and older (Headache. 2005 Mar;45:196-203; Eur J Pain. 2008;12:301-13; Neurology. 2012 Apr 24;78[17]:1346-53).

Adverse effects are mostly gastrointestinal, such as diarrhea and stomach upset, and dermal/allergic reactions, such as itchy eyes, asthma, and itching.
 

Caffeine

Caffeine is the most popular drug of choice for reducing drowsiness and increasing alertness and has the strongest evidence base, including for improving sports and work performance (J Strength Cond Res. 2010 Jan;24[1]:257-65). Regular caffeine use can lead to dependence, however, and it can cause anxiety, nervousness, irritability, insomnia, peptic ulcers, palpitations, gastroesophageal reflux disease (GERD), and tremors. Withdrawal can involve headaches, irritability, and anxiety.

Cannabidiol

Marijuana has more than 80 cannabinoids, and a nonpsychoactive one, cannabidiol, makes up about 40% of cannabis extracts, Dr. Breuner said. It’s been used as an anticonvulsant and to combat anxiety, psychosis, nausea and rheumatoid arthritis pain. In a study using a rat model for arthritis, inflammation and pain-related behaviors decreased in rats that received cannabidiol (Eur J Pain. 2016 Jul;20[6]:936-48).

A human dose would be about 160-300 mg daily, but side effects can include dry mouth, hypotension, lightheadedness, psychomotor slowing, sedation, and sleepiness.
 

Coenzyme Q10

This antioxidant is fat-soluble and has a chemical structure similar to vitamin K. It has been used in people with autism, chronic fatigue syndrome, fatigue from chemotherapy, Lyme disease, and muscular dystrophy, but the evidence focuses on fibromyalgia. One study of patients with fibromyalgia found that a 300-mg daily dose for 40 days reduced pain by 52%-56%, fatigue by 47%, morning tiredness by 56%, and tender points by 44%, compared with baseline (Antioxid Redox Signal. 2013;19[12]:1356-61.)

In another, 200 mg of coenzyme Q10 with 200 mg ginkgo daily for 3 months resulted in improvement of quality of life measures, including physical fitness levels, emotional feelings, social activities, overall health, and pain (J Int Med Res. 2002;30:195-9).

Potential adverse effects of coenzyme Q10 include nausea, vomiting, diarrhea, appetite suppression, and heartburn, albeit typically in less than 1% of patients.
 

Echinacea

magicflute002/Thinkstock

Echinacea actually is approved in Germany for supportive therapy in treating upper respiratory tract infections, urogenital infections, and wound healing, Dr. Breuner said. Hypothesized mechanisms of action include stimulation of the alternate complement pathway, immune-modulating effects, activating nonspecific T cells, inhibiting viral replication, and enhancing phagocytosis.

However, in clinical studies, echinacea did not reduce the duration or severity of upper respiratory tract infections or the occurrence or severity of infection, compared with placebo (JAMA. 2003 Dec 3;290[21]:2824-30; N Engl J Med. 2005 Jul 28;353[4]:341-8); this was tested in children aged 2-11 years in the first study, and the mean age of the subjects in the second study was 21 years. A 2014 Cochrane review found no overall benefits for treating common colds but noted the possibility of “a weak benefit from some echinacea products” based on individual trials with consistently positive, yet nonsignificant, trends, albeit with “questionable clinical relevance” (Cochrane Database Syst Rev. 2014 Feb 20;[2]:CD000530).

People with autoimmune conditions or who are immunocompromised should not use echinacea.
 

Magnesium

Magnesium also is used to treat migraines with a dose of 300-500 mg daily, although also it can be consumed in food, such as soy beans, black beans, tofu, seeds, nuts, whole grains, and shellfish (Expert Rev Neurother. 2009 Mar;9[3]:369-79; Neurology. 2012 Apr 24;78[17]:1346-53).

Side effects can include diarrhea and interactions with bisphosphonates, antibiotics] and diuretics. Taking proton pump inhibitors also may reduce magnesium levels.
 

Melatonin

Wjeger/Thinkstockphotos

Melatonin, a synthetic version of the hormone produced in humans to signal the onset of nighttime, has been studied extensively for jet lag, insomnia, shift-work disorder, circadian rhythm disorders, and withdrawal from benzodiazepine and nicotine.

Research shows that melatonin can improve sleep onset, duration, and quality. Some research has shown increased total sleep time (PLoS One. 2013 May 17;8(5):e63773).

Some evidence suggests it has endocrine-disrupting adverse effects, such as inhibiting ovulation and impairing glucose utilization.
 

N-acetyl cysteine (NAC)

Although it’s primarily an antidote for acetaminophen and carbon monoxide poisoning, NAC has been used for a wide range of conditions, including reducing lipoprotein levels with hyperlipidemia and reducing risk of cardiovascular events in people with end-stage renal disease and other conditions. It also has been used in people with bipolar disorder, schizophrenia, PTSD, substance disorders, and Tourette syndrome.

“Some clinical research shows that taking NAC 900 mg daily for 4 weeks, followed by 900 mg twice daily for 4 weeks and then 900 mg three times daily for 4 weeks improves symptoms of irritability in children with autism,” Dr. Breuner said. Other research showed reduced irritability in children with autism when they took 1,200 mg of NAC daily with risperidone, compared with risperidone alone. One study also has found “that NAC adds to the effect of citalopram in improving resistance/control to compulsions in OCD children and adolescents” (Iran J Psychiatry. 2017 Apr;12[2]:134-141).

Side effects can include diarrhea, nausea, and heartburn.
 

Omega-3 fatty acids: DHA and EHA

Docosahexanoic acid (DHA) and eicosapentanoic acid (EHA) have been used to treat ADHD, depression, heart disease, and also to lower the risk of macular degeneration.

A systematic review of 25 randomized controlled trials of more than 3,600 subjects found that “omega-3 supplementation generally correlated with improvements in blood biomarkers” (Nutrients. 2018 Aug 15;10[8]. pii: E1094). A small study in children with Tourette syndrome found that omega-3 fatty acids did not reduce tic scores, but “may be beneficial in reduction of tic-related impairment” for some children and teens (Pediatrics. 2012 Jun;129[6]:e1493-500).

Possible adverse effects include fishy taste, belching, nosebleeds, nausea, loose stools, and – at higher doses – decreased blood coagulation.
 

St. John’s wort

Alexandru Magurean/Thinkstock

This herb has long been used to treat depression and appears to work by inhibiting serotonin reuptake, monoamine oxidase (MAO), 5-hydroxytryptamine (5-HT), dopamine, noradrenaline, gamma aminobutyric acid (GABA), and glutamate. A 2005 Cochrane review found St. John’s wort to work better than placebo with similar effectiveness as standard antidepressants for mild to moderate depression, but its benefit for major depression is questionable (Cochrane Database Syst Rev. 2005 Apr 18;[2]:CD000448).

An ideal dose is 300 mg daily, but physicians should be aware of the herb’s potential for certain drug interactions. It may increase metabolism of warfarin, cyclosporin, HIV protease inhibitors, theophylline, digoxin, and oral contraceptives (Expert Opin Drug Metab Toxicol. 2012 Jun;8[6]:691-708). Other potential side effects include decreased platelet aggregation, serotonin syndrome, and photosensitivity.
 

Turmeric (curcumin)

SyedMirazurRahman/Thinkstock

Turmeric is an anti-inflammatory agent used for a wide range of complaints, but research primarily has focused on its use for pain. No studies exist in children, but a handful of studies have found reduction in joint pain and rheumatoid arthritis symptoms in adults with 500-mg doses twice daily (Phytother Res. 2012 Nov;26[11]:1719-25; J Med Food. 2017 Oct;20[10]:1022-30). One of these studies focused on a specific product, Instaflex, that contained turmeric among multiple other active ingredients (Nutr J. 2013 Nov 25;12[1]:154).

Potential adverse effects of turmeric/curcumin include constipation, dyspepsia, diarrhea, dissension, reflux, nausea, vomiting, itching, and hives.
 

Zinc

ilkab/Thinkstock

Like echinacea, zinc is commonly used to treat the common cold. A 2013 Cochrane review of randomized, controlled trials found that taking zinc “within 24 hours of onset of symptoms reduces the duration of common cold symptoms in healthy people, but some caution is needed due to the heterogeneity of the data” (Cochrane Database Syst Rev. 2013 Jun 18;[6]:CD001364). The dose is 75 mg a day, and potential adverse effects include bad taste, nausea, and anosmia.

Dr. Breuner said she had no relevant financial disclosures.

NEW ORLEANS – More than 1 in 10 children (12%) have received complementary or alternative medicine (CAM), according to the 2012 National Health Interview Survey. It’s therefore vital that you are familiar with the options and evidence on these treatments, according to Cora Breuner, MD, a professor of pediatrics at the University of Washington, Seattle, and attending physician at Seattle Children’s Hospital.

“Use of CAM by a parent was strongly associated with the child’s use of CAM,” Dr. Breuner told attendees at the annual meeting of the American Academy of Pediatrics. Parents of children using CAM were more likely to have a college education and to use prescription medication, the National Health Interview Survey found, and teens were more frequent users of CAM than infants.

The most common conditions treated in children with CAM were back and neck pain, colds, anxiety, stress, ADHD, insomnia, and general musculoskeletal conditions or complaints. Fish oil, melatonin, probiotics, and chiropractic and osteopathic manipulation were used more frequently than any other CAM treatments, but Dr. Breuner’s presentation focused specifically on supplements, including vitamins and herbs.

Physicians generally know that regulation of supplements is far less strict than for prescription medication, but patients may be less aware of how lax the law is when it comes to the safety and effectiveness of vitamins, minerals, herbs, and other dietary supplements.

“Products can go on the market with no testing of efficacy, and companies do not have to prove that their products are safe – only offer reasonable assurance of safety,” Dr. Breuner explained. “Supplements do not have to be manufactured to any standards, and FDA [Food and Drug Administration] approval is not needed for package or marketing claims,” although the reputable manufacturers favor standards.

She cited a 2011 study of popular supplement products on the market that found 75% of them did not include key safety messages (BMC Med. 2011 Aug 9;9:94). The study focused on St. John’s wort, ginkgo, ginseng, garlic, and echinacea products, and it’s likely other products lack such safety information as well. Yet researchers have identified a wide range of potential adverse effects from herbal medicines (Clin Med [Lond]. 2013 Feb;13[1]:7-12).

Physicians and consumers can rely on a handful of voluntary standards and online databases to guide therapeutic decisions and learn more about the evidence on specific products. The U.S. Pharmacopeia Dietary Supplement Verification Program is a seal consumers can look for on supplement products that indicates the product meets stricter standards than what the FDA allows.

Other resources include ConsumerLab.com, the Natural Medicines Research Collaboration, and the Pubmed Dietary Supplement Subset database from the National Institute of Medicine. The latter contains more than 676,000 unique scientific citations on published studies about vitamins, minerals, and botanicals, Dr. Breuner said.

Dr. Breuner presented an overview of more than a dozen popular supplements that included their uses and the evidence related to their use. Although not exhaustive, her list included the most common supplements for which some research has been done: butterbur, caffeine, cannabidiol, coenzyme Q10, echinacea, magnesium, melatonin, N-acetylcysteine, omega 3 fatty acids, St. John’s wort, turmeric (curcumin), and zinc.

The findings from these studies, however, vary greatly, and the studies themselves are often small and limited to adults. Shared decision making is key in working with families interested in using CAM, and families should be aware that supplements can have side effects just as FDA-approved drugs do.

Dr. Breuner reported that she had no relevant financial disclosures.

NEW ORLEANS – More than 1 in 10 children (12%) have received complementary or alternative medicine (CAM), according to the 2012 National Health Interview Survey. It’s therefore vital that you are familiar with the options and evidence on these treatments, according to Cora Breuner, MD, a professor of pediatrics at the University of Washington, Seattle, and attending physician at Seattle Children’s Hospital.

“Use of CAM by a parent was strongly associated with the child’s use of CAM,” Dr. Breuner told attendees at the annual meeting of the American Academy of Pediatrics. Parents of children using CAM were more likely to have a college education and to use prescription medication, the National Health Interview Survey found, and teens were more frequent users of CAM than infants.

The most common conditions treated in children with CAM were back and neck pain, colds, anxiety, stress, ADHD, insomnia, and general musculoskeletal conditions or complaints. Fish oil, melatonin, probiotics, and chiropractic and osteopathic manipulation were used more frequently than any other CAM treatments, but Dr. Breuner’s presentation focused specifically on supplements, including vitamins and herbs.

Physicians generally know that regulation of supplements is far less strict than for prescription medication, but patients may be less aware of how lax the law is when it comes to the safety and effectiveness of vitamins, minerals, herbs, and other dietary supplements.

“Products can go on the market with no testing of efficacy, and companies do not have to prove that their products are safe – only offer reasonable assurance of safety,” Dr. Breuner explained. “Supplements do not have to be manufactured to any standards, and FDA [Food and Drug Administration] approval is not needed for package or marketing claims,” although the reputable manufacturers favor standards.

She cited a 2011 study of popular supplement products on the market that found 75% of them did not include key safety messages (BMC Med. 2011 Aug 9;9:94). The study focused on St. John’s wort, ginkgo, ginseng, garlic, and echinacea products, and it’s likely other products lack such safety information as well. Yet researchers have identified a wide range of potential adverse effects from herbal medicines (Clin Med [Lond]. 2013 Feb;13[1]:7-12).

Physicians and consumers can rely on a handful of voluntary standards and online databases to guide therapeutic decisions and learn more about the evidence on specific products. The U.S. Pharmacopeia Dietary Supplement Verification Program is a seal consumers can look for on supplement products that indicates the product meets stricter standards than what the FDA allows.

Other resources include ConsumerLab.com, the Natural Medicines Research Collaboration, and the Pubmed Dietary Supplement Subset database from the National Institute of Medicine. The latter contains more than 676,000 unique scientific citations on published studies about vitamins, minerals, and botanicals, Dr. Breuner said.

Dr. Breuner presented an overview of more than a dozen popular supplements that included their uses and the evidence related to their use. Although not exhaustive, her list included the most common supplements for which some research has been done: butterbur, caffeine, cannabidiol, coenzyme Q10, echinacea, magnesium, melatonin, N-acetylcysteine, omega 3 fatty acids, St. John’s wort, turmeric (curcumin), and zinc.

The findings from these studies, however, vary greatly, and the studies themselves are often small and limited to adults. Shared decision making is key in working with families interested in using CAM, and families should be aware that supplements can have side effects just as FDA-approved drugs do.

Dr. Breuner reported that she had no relevant financial disclosures.

NEW ORLEANS – More than 1 in 10 children (12%) have received complementary or alternative medicine (CAM), according to the 2012 National Health Interview Survey. It’s therefore vital that you are familiar with the options and evidence on these treatments, according to Cora Breuner, MD, a professor of pediatrics at the University of Washington, Seattle, and attending physician at Seattle Children’s Hospital.

“Use of CAM by a parent was strongly associated with the child’s use of CAM,” Dr. Breuner told attendees at the annual meeting of the American Academy of Pediatrics. Parents of children using CAM were more likely to have a college education and to use prescription medication, the National Health Interview Survey found, and teens were more frequent users of CAM than infants.

The most common conditions treated in children with CAM were back and neck pain, colds, anxiety, stress, ADHD, insomnia, and general musculoskeletal conditions or complaints. Fish oil, melatonin, probiotics, and chiropractic and osteopathic manipulation were used more frequently than any other CAM treatments, but Dr. Breuner’s presentation focused specifically on supplements, including vitamins and herbs.

Physicians generally know that regulation of supplements is far less strict than for prescription medication, but patients may be less aware of how lax the law is when it comes to the safety and effectiveness of vitamins, minerals, herbs, and other dietary supplements.

“Products can go on the market with no testing of efficacy, and companies do not have to prove that their products are safe – only offer reasonable assurance of safety,” Dr. Breuner explained. “Supplements do not have to be manufactured to any standards, and FDA [Food and Drug Administration] approval is not needed for package or marketing claims,” although the reputable manufacturers favor standards.

She cited a 2011 study of popular supplement products on the market that found 75% of them did not include key safety messages (BMC Med. 2011 Aug 9;9:94). The study focused on St. John’s wort, ginkgo, ginseng, garlic, and echinacea products, and it’s likely other products lack such safety information as well. Yet researchers have identified a wide range of potential adverse effects from herbal medicines (Clin Med [Lond]. 2013 Feb;13[1]:7-12).

Physicians and consumers can rely on a handful of voluntary standards and online databases to guide therapeutic decisions and learn more about the evidence on specific products. The U.S. Pharmacopeia Dietary Supplement Verification Program is a seal consumers can look for on supplement products that indicates the product meets stricter standards than what the FDA allows.

Other resources include ConsumerLab.com, the Natural Medicines Research Collaboration, and the Pubmed Dietary Supplement Subset database from the National Institute of Medicine. The latter contains more than 676,000 unique scientific citations on published studies about vitamins, minerals, and botanicals, Dr. Breuner said.

Dr. Breuner presented an overview of more than a dozen popular supplements that included their uses and the evidence related to their use. Although not exhaustive, her list included the most common supplements for which some research has been done: butterbur, caffeine, cannabidiol, coenzyme Q10, echinacea, magnesium, melatonin, N-acetylcysteine, omega 3 fatty acids, St. John’s wort, turmeric (curcumin), and zinc.

The findings from these studies, however, vary greatly, and the studies themselves are often small and limited to adults. Shared decision making is key in working with families interested in using CAM, and families should be aware that supplements can have side effects just as FDA-approved drugs do.

Dr. Breuner reported that she had no relevant financial disclosures.

NEW ORLEANS – After Massachusetts passed antibullying legislation in 2009, Peter C. Raffalli, MD, saw an opportunity to improve care for the increasing numbers of children presenting to his neurology practice at Boston Children’s Hospital who were victims of bullying – especially those with developmental disabilities.

omgimages/thinkstockphotos.com

“I had been thinking of a clinic to help kids with these issues, aside from just helping them deal with the fallout: the depression, anxiety, et cetera, that comes with being bullied,” Dr. Raffalli recalled at the annual meeting of the American Academy of Pediatrics. “I wanted to do something to help present to families the evidence-based strategies regarding bullying prevention, detection, and intervention that might help to stop the bullying.”

This led him to launch the Bullying and Cyberbullying Prevention and Advocacy Collaborative (BACPAC) at Boston Children’s Hospital, which began in 2009 as an educational resource for families, medical colleagues, and schools. Dr. Raffalli also formed an alliance with the Massachusetts Aggression Reduction Center at Bridgewater State University (Ann Neurol. 2016;79[2]:167-8).

Two years later in 2011, BACPAC became a formal clinic at Boston Children’s that serves as a subspecialty consult service for victims of bullying and their families. The clinic team consists of a child neurologist, a social worker, and an education resource specialist who meet with the bullying victim and his/her family in initial consultation for 90 minutes. The goal is to develop an evidence-based plan for bullying prevention, detection, and intervention that is individualized to the patient’s developmental and social needs.

“We tell families that bullying is recognized medically and legally as a form of abuse,” said Dr. Raffalli. “The medical and psychological consequences are similar to other forms of abuse. In the clinic, I explain to families that bullying is never the victim’s fault, and they should not blame themselves for the bullying. You’d be surprised how often patients do think the bullying is their fault.”
 

The extent of the problem

Researchers estimate that 25%-30% of children will experience some form of bullying between kindergarten and grade 12, and about 8% will engage in bullying themselves. When BACPAC began in 2009, Dr. Raffalli conducted an informal search of peer-reviewed literature on bullying in children with special needs; it yielded just four articles. “Since then, there’s been an exponential explosion of literature on various aspects of bullying,” he said. Now there is ample evidence in the peer-reviewed literature to show the increased risk for bullying/cyberbullying in children/teens, not just with neurodevelopmental disorders, but also for kids with other medical disorders such as obesity, asthma, and allergies.

“We’ve had a good number of kids over the years with peanut allergy who were literally threatened physically with peanut butter at school,” he said. “It’s incredible how callous some kids can be. Kids with oppositional defiant disorder, impulse control disorder, and callous/unemotional traits from a psychological standpoint are hardest to reach when it comes to getting them to stop bullying. You’d be surprised how frequently bullies use the phrase [to their victims], ‘You should kill yourself.’ They don’t realize the damage they’re doing to people. Bullying can lead to severe psychological but also long-term medical problems, including suicidal ideation.”

Published studies show that the highest incidences of bullying occur in children with neurodevelopmental conditions such as ADHD, autistic spectrum disorders, Tourette syndrome, and other learning disabilities (Eur J Spec Needs Ed. 2010;25[1]:77-91). This population of children is overrepresented in bullying “because the services they receive at school make their disabilities more visible,” explained Dr. Raffalli, who is also an assistant professor of neurology at Harvard Medical School, Boston. “They stand out, and they have social information–processing deficits or distortions that exacerbate bullying involvement. They also have difficulty interpreting social cues or attributing hostile characteristics to their peer’s behavior.”
 

The consequences of bullying

The psychological and educational consequences of bullying among children in general include being more likely to develop depression, loneliness, low self-esteem, alcohol and drug abuse, sleeping difficulties, self-harm, and suicidal ideation and attempts. “We’re social creatures, and when we don’t have those social connections, we get very depressed.”

Bullying victims also are more likely to develop school avoidance and absence, decreased school performance, poor concentration, high anxiety, and social withdrawal – all of which limit their opportunities to learn. “The No. 1 thing you can do to help these kids is to believe their story – to explain to them that it’s not their fault, and to explain that you are there for them and that you support them,” he said. “When a kid gets the feeling that someone is willing to listen to them and believe them, it does an enormous good for their emotional state.”

Doug Brunk/MDedge News

Dr. Raffalli added that a toxic stress response can occur when a child experiences strong, frequent, and/or prolonged adversity – such as physical or emotional abuse, chronic neglect, caregiver substance abuse or mental illness, exposure to violence, and/or the accumulated burdens of family economic hardship – without adequate adult support. This kind of prolonged activation of the stress response systems can disrupt the development of brain architecture and other organ systems, and increase the risk for stress-related disease and cognitive impairment well into the adult years.

In the Harvard Review of Psychiatry, researchers set out to investigate what’s known about the long-term health effects of childhood bullying. They found that bullying can induce “aspects of the stress response, via epigenetic, inflammatory, and metabolic mediators [that] have the capacity to compromise mental and physical health, and to increase the risk of disease.” The researchers advised clinicians who care for children to assess the mental and physical health effects of bullying (Harv Rev Psychiatry. 2017;25[2]:89-95).

Additional vulnerabilities for bullying victims include parents and children whose primary language is not English, as well as parents with mental illness or substance abuse and families living in poverty. “We have to keep in mind how much additional stress they may be dealing with. This can make it harder for them to cope. Bullies also are shown to be at higher risk for psychological and legal trouble into adulthood, so we should be trying to help them too. We have to keep in mind that these are all developing kids.”
 

Cyberbullying

In Dr. Raffalli’s clinical experience, cyberbullying has become the bully’s weapon of choice. “I call it the stealth bomber of bullying,” he said. “Cyberbullying can start as early as the second or third grade. Most parents are not giving phones to second-graders. I’m worried that it’s going to get worse, though, with the excuse that ‘I feel safer if they have a cell phone so they can call me.’ I tell parents that they still make flip phones. You don’t have to get a smartphone for a second- or third-grader, or even for a sixth-grader.”

By the time kids reach fourth and fifth grade, he continued, they begin to form their opinion “about what they believe is cool and not cool, and they begin to get into cliques that have similar beliefs, and support each other, and may break off from old friends.” He added that, while adult predation “makes the news and is certainly something we should all be concerned about, the incidence of being harassed and bullied by someone in your own age group at school is actually much higher and still has serious outcomes, including the possibility of death.”

The Massachusetts antibullying law stipulates that all teachers and all school personnel have to participate in mandatory bullying training. Schools also are required to draft and follow a bullying investigative protocol.

“Apparently the schools have all done this, yet the number of times that schools use interventions that are not advisable, such as mediation, is incredible to me,” Dr. Raffalli said. “Bringing the bully and the victim together for a ‘cup of coffee and a handshake’ is not advisable. Mediation has been shown in a number of studies to be detrimental in bullying situations. Things can easily get worse.”

Often, family members who bring their child to the BACPAC “feel that their child’s school is not helping them,” he said. “We should try to figure out why those schools are having such a hard time and see if we can help them.”

Dr. Raffalli reported having no financial disclosures.

[email protected]

NEW ORLEANS – After Massachusetts passed antibullying legislation in 2009, Peter C. Raffalli, MD, saw an opportunity to improve care for the increasing numbers of children presenting to his neurology practice at Boston Children’s Hospital who were victims of bullying – especially those with developmental disabilities.

omgimages/thinkstockphotos.com

“I had been thinking of a clinic to help kids with these issues, aside from just helping them deal with the fallout: the depression, anxiety, et cetera, that comes with being bullied,” Dr. Raffalli recalled at the annual meeting of the American Academy of Pediatrics. “I wanted to do something to help present to families the evidence-based strategies regarding bullying prevention, detection, and intervention that might help to stop the bullying.”

This led him to launch the Bullying and Cyberbullying Prevention and Advocacy Collaborative (BACPAC) at Boston Children’s Hospital, which began in 2009 as an educational resource for families, medical colleagues, and schools. Dr. Raffalli also formed an alliance with the Massachusetts Aggression Reduction Center at Bridgewater State University (Ann Neurol. 2016;79[2]:167-8).

Two years later in 2011, BACPAC became a formal clinic at Boston Children’s that serves as a subspecialty consult service for victims of bullying and their families. The clinic team consists of a child neurologist, a social worker, and an education resource specialist who meet with the bullying victim and his/her family in initial consultation for 90 minutes. The goal is to develop an evidence-based plan for bullying prevention, detection, and intervention that is individualized to the patient’s developmental and social needs.

“We tell families that bullying is recognized medically and legally as a form of abuse,” said Dr. Raffalli. “The medical and psychological consequences are similar to other forms of abuse. In the clinic, I explain to families that bullying is never the victim’s fault, and they should not blame themselves for the bullying. You’d be surprised how often patients do think the bullying is their fault.”
 

The extent of the problem

Researchers estimate that 25%-30% of children will experience some form of bullying between kindergarten and grade 12, and about 8% will engage in bullying themselves. When BACPAC began in 2009, Dr. Raffalli conducted an informal search of peer-reviewed literature on bullying in children with special needs; it yielded just four articles. “Since then, there’s been an exponential explosion of literature on various aspects of bullying,” he said. Now there is ample evidence in the peer-reviewed literature to show the increased risk for bullying/cyberbullying in children/teens, not just with neurodevelopmental disorders, but also for kids with other medical disorders such as obesity, asthma, and allergies.

“We’ve had a good number of kids over the years with peanut allergy who were literally threatened physically with peanut butter at school,” he said. “It’s incredible how callous some kids can be. Kids with oppositional defiant disorder, impulse control disorder, and callous/unemotional traits from a psychological standpoint are hardest to reach when it comes to getting them to stop bullying. You’d be surprised how frequently bullies use the phrase [to their victims], ‘You should kill yourself.’ They don’t realize the damage they’re doing to people. Bullying can lead to severe psychological but also long-term medical problems, including suicidal ideation.”

Published studies show that the highest incidences of bullying occur in children with neurodevelopmental conditions such as ADHD, autistic spectrum disorders, Tourette syndrome, and other learning disabilities (Eur J Spec Needs Ed. 2010;25[1]:77-91). This population of children is overrepresented in bullying “because the services they receive at school make their disabilities more visible,” explained Dr. Raffalli, who is also an assistant professor of neurology at Harvard Medical School, Boston. “They stand out, and they have social information–processing deficits or distortions that exacerbate bullying involvement. They also have difficulty interpreting social cues or attributing hostile characteristics to their peer’s behavior.”
 

The consequences of bullying

The psychological and educational consequences of bullying among children in general include being more likely to develop depression, loneliness, low self-esteem, alcohol and drug abuse, sleeping difficulties, self-harm, and suicidal ideation and attempts. “We’re social creatures, and when we don’t have those social connections, we get very depressed.”

Bullying victims also are more likely to develop school avoidance and absence, decreased school performance, poor concentration, high anxiety, and social withdrawal – all of which limit their opportunities to learn. “The No. 1 thing you can do to help these kids is to believe their story – to explain to them that it’s not their fault, and to explain that you are there for them and that you support them,” he said. “When a kid gets the feeling that someone is willing to listen to them and believe them, it does an enormous good for their emotional state.”

Doug Brunk/MDedge News

Dr. Raffalli added that a toxic stress response can occur when a child experiences strong, frequent, and/or prolonged adversity – such as physical or emotional abuse, chronic neglect, caregiver substance abuse or mental illness, exposure to violence, and/or the accumulated burdens of family economic hardship – without adequate adult support. This kind of prolonged activation of the stress response systems can disrupt the development of brain architecture and other organ systems, and increase the risk for stress-related disease and cognitive impairment well into the adult years.

In the Harvard Review of Psychiatry, researchers set out to investigate what’s known about the long-term health effects of childhood bullying. They found that bullying can induce “aspects of the stress response, via epigenetic, inflammatory, and metabolic mediators [that] have the capacity to compromise mental and physical health, and to increase the risk of disease.” The researchers advised clinicians who care for children to assess the mental and physical health effects of bullying (Harv Rev Psychiatry. 2017;25[2]:89-95).

Additional vulnerabilities for bullying victims include parents and children whose primary language is not English, as well as parents with mental illness or substance abuse and families living in poverty. “We have to keep in mind how much additional stress they may be dealing with. This can make it harder for them to cope. Bullies also are shown to be at higher risk for psychological and legal trouble into adulthood, so we should be trying to help them too. We have to keep in mind that these are all developing kids.”
 

Cyberbullying

In Dr. Raffalli’s clinical experience, cyberbullying has become the bully’s weapon of choice. “I call it the stealth bomber of bullying,” he said. “Cyberbullying can start as early as the second or third grade. Most parents are not giving phones to second-graders. I’m worried that it’s going to get worse, though, with the excuse that ‘I feel safer if they have a cell phone so they can call me.’ I tell parents that they still make flip phones. You don’t have to get a smartphone for a second- or third-grader, or even for a sixth-grader.”

By the time kids reach fourth and fifth grade, he continued, they begin to form their opinion “about what they believe is cool and not cool, and they begin to get into cliques that have similar beliefs, and support each other, and may break off from old friends.” He added that, while adult predation “makes the news and is certainly something we should all be concerned about, the incidence of being harassed and bullied by someone in your own age group at school is actually much higher and still has serious outcomes, including the possibility of death.”

The Massachusetts antibullying law stipulates that all teachers and all school personnel have to participate in mandatory bullying training. Schools also are required to draft and follow a bullying investigative protocol.

“Apparently the schools have all done this, yet the number of times that schools use interventions that are not advisable, such as mediation, is incredible to me,” Dr. Raffalli said. “Bringing the bully and the victim together for a ‘cup of coffee and a handshake’ is not advisable. Mediation has been shown in a number of studies to be detrimental in bullying situations. Things can easily get worse.”

Often, family members who bring their child to the BACPAC “feel that their child’s school is not helping them,” he said. “We should try to figure out why those schools are having such a hard time and see if we can help them.”

Dr. Raffalli reported having no financial disclosures.

[email protected]

NEW ORLEANS – After Massachusetts passed antibullying legislation in 2009, Peter C. Raffalli, MD, saw an opportunity to improve care for the increasing numbers of children presenting to his neurology practice at Boston Children’s Hospital who were victims of bullying – especially those with developmental disabilities.

omgimages/thinkstockphotos.com

“I had been thinking of a clinic to help kids with these issues, aside from just helping them deal with the fallout: the depression, anxiety, et cetera, that comes with being bullied,” Dr. Raffalli recalled at the annual meeting of the American Academy of Pediatrics. “I wanted to do something to help present to families the evidence-based strategies regarding bullying prevention, detection, and intervention that might help to stop the bullying.”

This led him to launch the Bullying and Cyberbullying Prevention and Advocacy Collaborative (BACPAC) at Boston Children’s Hospital, which began in 2009 as an educational resource for families, medical colleagues, and schools. Dr. Raffalli also formed an alliance with the Massachusetts Aggression Reduction Center at Bridgewater State University (Ann Neurol. 2016;79[2]:167-8).

Two years later in 2011, BACPAC became a formal clinic at Boston Children’s that serves as a subspecialty consult service for victims of bullying and their families. The clinic team consists of a child neurologist, a social worker, and an education resource specialist who meet with the bullying victim and his/her family in initial consultation for 90 minutes. The goal is to develop an evidence-based plan for bullying prevention, detection, and intervention that is individualized to the patient’s developmental and social needs.

“We tell families that bullying is recognized medically and legally as a form of abuse,” said Dr. Raffalli. “The medical and psychological consequences are similar to other forms of abuse. In the clinic, I explain to families that bullying is never the victim’s fault, and they should not blame themselves for the bullying. You’d be surprised how often patients do think the bullying is their fault.”
 

The extent of the problem

Researchers estimate that 25%-30% of children will experience some form of bullying between kindergarten and grade 12, and about 8% will engage in bullying themselves. When BACPAC began in 2009, Dr. Raffalli conducted an informal search of peer-reviewed literature on bullying in children with special needs; it yielded just four articles. “Since then, there’s been an exponential explosion of literature on various aspects of bullying,” he said. Now there is ample evidence in the peer-reviewed literature to show the increased risk for bullying/cyberbullying in children/teens, not just with neurodevelopmental disorders, but also for kids with other medical disorders such as obesity, asthma, and allergies.

“We’ve had a good number of kids over the years with peanut allergy who were literally threatened physically with peanut butter at school,” he said. “It’s incredible how callous some kids can be. Kids with oppositional defiant disorder, impulse control disorder, and callous/unemotional traits from a psychological standpoint are hardest to reach when it comes to getting them to stop bullying. You’d be surprised how frequently bullies use the phrase [to their victims], ‘You should kill yourself.’ They don’t realize the damage they’re doing to people. Bullying can lead to severe psychological but also long-term medical problems, including suicidal ideation.”

Published studies show that the highest incidences of bullying occur in children with neurodevelopmental conditions such as ADHD, autistic spectrum disorders, Tourette syndrome, and other learning disabilities (Eur J Spec Needs Ed. 2010;25[1]:77-91). This population of children is overrepresented in bullying “because the services they receive at school make their disabilities more visible,” explained Dr. Raffalli, who is also an assistant professor of neurology at Harvard Medical School, Boston. “They stand out, and they have social information–processing deficits or distortions that exacerbate bullying involvement. They also have difficulty interpreting social cues or attributing hostile characteristics to their peer’s behavior.”
 

The consequences of bullying

The psychological and educational consequences of bullying among children in general include being more likely to develop depression, loneliness, low self-esteem, alcohol and drug abuse, sleeping difficulties, self-harm, and suicidal ideation and attempts. “We’re social creatures, and when we don’t have those social connections, we get very depressed.”

Bullying victims also are more likely to develop school avoidance and absence, decreased school performance, poor concentration, high anxiety, and social withdrawal – all of which limit their opportunities to learn. “The No. 1 thing you can do to help these kids is to believe their story – to explain to them that it’s not their fault, and to explain that you are there for them and that you support them,” he said. “When a kid gets the feeling that someone is willing to listen to them and believe them, it does an enormous good for their emotional state.”

Doug Brunk/MDedge News

Dr. Raffalli added that a toxic stress response can occur when a child experiences strong, frequent, and/or prolonged adversity – such as physical or emotional abuse, chronic neglect, caregiver substance abuse or mental illness, exposure to violence, and/or the accumulated burdens of family economic hardship – without adequate adult support. This kind of prolonged activation of the stress response systems can disrupt the development of brain architecture and other organ systems, and increase the risk for stress-related disease and cognitive impairment well into the adult years.

In the Harvard Review of Psychiatry, researchers set out to investigate what’s known about the long-term health effects of childhood bullying. They found that bullying can induce “aspects of the stress response, via epigenetic, inflammatory, and metabolic mediators [that] have the capacity to compromise mental and physical health, and to increase the risk of disease.” The researchers advised clinicians who care for children to assess the mental and physical health effects of bullying (Harv Rev Psychiatry. 2017;25[2]:89-95).

Additional vulnerabilities for bullying victims include parents and children whose primary language is not English, as well as parents with mental illness or substance abuse and families living in poverty. “We have to keep in mind how much additional stress they may be dealing with. This can make it harder for them to cope. Bullies also are shown to be at higher risk for psychological and legal trouble into adulthood, so we should be trying to help them too. We have to keep in mind that these are all developing kids.”
 

Cyberbullying

In Dr. Raffalli’s clinical experience, cyberbullying has become the bully’s weapon of choice. “I call it the stealth bomber of bullying,” he said. “Cyberbullying can start as early as the second or third grade. Most parents are not giving phones to second-graders. I’m worried that it’s going to get worse, though, with the excuse that ‘I feel safer if they have a cell phone so they can call me.’ I tell parents that they still make flip phones. You don’t have to get a smartphone for a second- or third-grader, or even for a sixth-grader.”

By the time kids reach fourth and fifth grade, he continued, they begin to form their opinion “about what they believe is cool and not cool, and they begin to get into cliques that have similar beliefs, and support each other, and may break off from old friends.” He added that, while adult predation “makes the news and is certainly something we should all be concerned about, the incidence of being harassed and bullied by someone in your own age group at school is actually much higher and still has serious outcomes, including the possibility of death.”

The Massachusetts antibullying law stipulates that all teachers and all school personnel have to participate in mandatory bullying training. Schools also are required to draft and follow a bullying investigative protocol.

“Apparently the schools have all done this, yet the number of times that schools use interventions that are not advisable, such as mediation, is incredible to me,” Dr. Raffalli said. “Bringing the bully and the victim together for a ‘cup of coffee and a handshake’ is not advisable. Mediation has been shown in a number of studies to be detrimental in bullying situations. Things can easily get worse.”

Often, family members who bring their child to the BACPAC “feel that their child’s school is not helping them,” he said. “We should try to figure out why those schools are having such a hard time and see if we can help them.”

Dr. Raffalli reported having no financial disclosures.

[email protected]

NEW ORLEANS – When Timothy P. Brigham, MDiv, PhD, thinks about the impact of burnout and stress on the ability of physicians to practice medicine, Lewin’s equation comes to mind.

FatCamera/Getty Images

Developed by psychologist Kurt Lewin in 1936, the equation holds that behavior stems from a person’s personality and the environment that person inhabits.

“We suspect that 70%-80% of the problem with burnout and stress in medicine is environmental,” Dr. Brigham, chief of staff and chief education and organizational development officer at the Chicago-based Accreditation Council for Graduate Medical Education (ACGME), said at the annual meeting of the American Academy of Pediatrics.

“It’s a toxic mine, in some ways. What we tend to do is when we detect that physicians in general are, or a particular residency program is, too stressed out or burned out, we give them resilience training. Not that that’s unimportant, but it’s like putting a canary in a toxic mine full of poison and saying, ‘We’re going to teach you to hold your breath a little bit longer.’ Our job is to detoxify the mine.”

Troubled by the rise of suicides among physicians in recent years as well as mounting evidence about the adverse impact of burnout and stress on the practice of medicine, Dr. Brigham said that the ACGME is deepening its commitment to the well-being of faculty, residents, patients, and all members of the health care team. Since launching a “call to arms” on the topic at its annual educational conference in 2015, the ACGME has added courses on well-being to its annual meeting and remolded its Clinical Learning Environmental Review program to include all clinicians, “because everybody is affected by this: nurses, coordinators, et cetera,” he said. The ACGME also has revised Common Program Requirements, disseminated tools and resources to promote well-being and new knowledge on the topic, and partnered with the National Academy of Medicine Action Collaborative on Clinician Well-Being and Resilience – all in an effort to bring about culture change.

“But we’re well aware that the ACGME can’t do this alone,” Dr. Brigham said. “We can’t ‘requirement’ our way out of this problem. It’s going to take a culture shift. Only you physicians, in collaboration with everyone in your community of learning, can create the systemic change required to improve our culture. We have a good handle on the problem at this point, but the solutions are a little bit more difficult to get a hold of. As Martin Luther King Jr. once said, ‘You don’t have to see the whole staircase, just take the first step.’ ”

The ACGME wants to work with physicians “to collect data and do joint research, to share insights, and to share tools and resources to create a better world for practicing physicians, for other members of the health care team, and for patients. After all, clinicians who care for themselves provide better care for others. They’re less likely to make errors or leave the profession,” Dr. Brigham told attendees.

He added that clinicians can gauge their risk for burnout by asking themselves three simple questions about their work environment: Does it support self-care? Does it increase and support connection with colleagues? Does it connect people to purpose and meaningful work?

“One of the problems with our resident clinical work hours is not terrible program directors saying, ‘work longer.’ It’s residents who want to take care of families for 1 more hour,” Dr. Brigham continued. “It’s residents who want to take care of patients who are going through a difficult time. You represent the top 2% in the world in terms of your intelligence and achievement, yet that’s not what makes you special. What makes you special is that the level of self-doubt in this room exceeds that of the general population by about 10 times. You also tend to run toward what everyone else runs away from: disease, despair, people who are injured and suffering. That takes a toll.”

Courtesy AAP

He emphasized that positive social relationships with others are crucial to joy and well-being in the practice of medicine. “Burnout isn’t just about exhaustion; it’s about loneliness,” Dr. Brigham said. “There’s a surprising power in just asking people how they’re doing, and really wanting to know the answer.”

Negative social connections are highly correlated with burnout and depression, such as harassment, bullying, mistreatment, discrimination, “and using the power gradient to squash somebody who’s trying their best to be a physician,” he said.

Dr. Brigham acknowledged the tall task of bringing a spotlight to well-being as physicians continue to engage in tasks such as the burden and lack of standardization of prior authorization requirements, the burden of clinical documentation requirements, electronic health records and related work flow, and quality payment programs. “This is what we need to shift; this is what we need to take away so you can get back in touch with why you became a physician in the first place.”

Dr. Brigham reported having no financial disclosures.

[email protected]

NEW ORLEANS – When Timothy P. Brigham, MDiv, PhD, thinks about the impact of burnout and stress on the ability of physicians to practice medicine, Lewin’s equation comes to mind.

FatCamera/Getty Images

Developed by psychologist Kurt Lewin in 1936, the equation holds that behavior stems from a person’s personality and the environment that person inhabits.

“We suspect that 70%-80% of the problem with burnout and stress in medicine is environmental,” Dr. Brigham, chief of staff and chief education and organizational development officer at the Chicago-based Accreditation Council for Graduate Medical Education (ACGME), said at the annual meeting of the American Academy of Pediatrics.

“It’s a toxic mine, in some ways. What we tend to do is when we detect that physicians in general are, or a particular residency program is, too stressed out or burned out, we give them resilience training. Not that that’s unimportant, but it’s like putting a canary in a toxic mine full of poison and saying, ‘We’re going to teach you to hold your breath a little bit longer.’ Our job is to detoxify the mine.”

Troubled by the rise of suicides among physicians in recent years as well as mounting evidence about the adverse impact of burnout and stress on the practice of medicine, Dr. Brigham said that the ACGME is deepening its commitment to the well-being of faculty, residents, patients, and all members of the health care team. Since launching a “call to arms” on the topic at its annual educational conference in 2015, the ACGME has added courses on well-being to its annual meeting and remolded its Clinical Learning Environmental Review program to include all clinicians, “because everybody is affected by this: nurses, coordinators, et cetera,” he said. The ACGME also has revised Common Program Requirements, disseminated tools and resources to promote well-being and new knowledge on the topic, and partnered with the National Academy of Medicine Action Collaborative on Clinician Well-Being and Resilience – all in an effort to bring about culture change.

“But we’re well aware that the ACGME can’t do this alone,” Dr. Brigham said. “We can’t ‘requirement’ our way out of this problem. It’s going to take a culture shift. Only you physicians, in collaboration with everyone in your community of learning, can create the systemic change required to improve our culture. We have a good handle on the problem at this point, but the solutions are a little bit more difficult to get a hold of. As Martin Luther King Jr. once said, ‘You don’t have to see the whole staircase, just take the first step.’ ”

The ACGME wants to work with physicians “to collect data and do joint research, to share insights, and to share tools and resources to create a better world for practicing physicians, for other members of the health care team, and for patients. After all, clinicians who care for themselves provide better care for others. They’re less likely to make errors or leave the profession,” Dr. Brigham told attendees.

He added that clinicians can gauge their risk for burnout by asking themselves three simple questions about their work environment: Does it support self-care? Does it increase and support connection with colleagues? Does it connect people to purpose and meaningful work?

“One of the problems with our resident clinical work hours is not terrible program directors saying, ‘work longer.’ It’s residents who want to take care of families for 1 more hour,” Dr. Brigham continued. “It’s residents who want to take care of patients who are going through a difficult time. You represent the top 2% in the world in terms of your intelligence and achievement, yet that’s not what makes you special. What makes you special is that the level of self-doubt in this room exceeds that of the general population by about 10 times. You also tend to run toward what everyone else runs away from: disease, despair, people who are injured and suffering. That takes a toll.”

Courtesy AAP

He emphasized that positive social relationships with others are crucial to joy and well-being in the practice of medicine. “Burnout isn’t just about exhaustion; it’s about loneliness,” Dr. Brigham said. “There’s a surprising power in just asking people how they’re doing, and really wanting to know the answer.”

Negative social connections are highly correlated with burnout and depression, such as harassment, bullying, mistreatment, discrimination, “and using the power gradient to squash somebody who’s trying their best to be a physician,” he said.

Dr. Brigham acknowledged the tall task of bringing a spotlight to well-being as physicians continue to engage in tasks such as the burden and lack of standardization of prior authorization requirements, the burden of clinical documentation requirements, electronic health records and related work flow, and quality payment programs. “This is what we need to shift; this is what we need to take away so you can get back in touch with why you became a physician in the first place.”

Dr. Brigham reported having no financial disclosures.

[email protected]

NEW ORLEANS – When Timothy P. Brigham, MDiv, PhD, thinks about the impact of burnout and stress on the ability of physicians to practice medicine, Lewin’s equation comes to mind.

FatCamera/Getty Images

Developed by psychologist Kurt Lewin in 1936, the equation holds that behavior stems from a person’s personality and the environment that person inhabits.

“We suspect that 70%-80% of the problem with burnout and stress in medicine is environmental,” Dr. Brigham, chief of staff and chief education and organizational development officer at the Chicago-based Accreditation Council for Graduate Medical Education (ACGME), said at the annual meeting of the American Academy of Pediatrics.

“It’s a toxic mine, in some ways. What we tend to do is when we detect that physicians in general are, or a particular residency program is, too stressed out or burned out, we give them resilience training. Not that that’s unimportant, but it’s like putting a canary in a toxic mine full of poison and saying, ‘We’re going to teach you to hold your breath a little bit longer.’ Our job is to detoxify the mine.”

Troubled by the rise of suicides among physicians in recent years as well as mounting evidence about the adverse impact of burnout and stress on the practice of medicine, Dr. Brigham said that the ACGME is deepening its commitment to the well-being of faculty, residents, patients, and all members of the health care team. Since launching a “call to arms” on the topic at its annual educational conference in 2015, the ACGME has added courses on well-being to its annual meeting and remolded its Clinical Learning Environmental Review program to include all clinicians, “because everybody is affected by this: nurses, coordinators, et cetera,” he said. The ACGME also has revised Common Program Requirements, disseminated tools and resources to promote well-being and new knowledge on the topic, and partnered with the National Academy of Medicine Action Collaborative on Clinician Well-Being and Resilience – all in an effort to bring about culture change.

“But we’re well aware that the ACGME can’t do this alone,” Dr. Brigham said. “We can’t ‘requirement’ our way out of this problem. It’s going to take a culture shift. Only you physicians, in collaboration with everyone in your community of learning, can create the systemic change required to improve our culture. We have a good handle on the problem at this point, but the solutions are a little bit more difficult to get a hold of. As Martin Luther King Jr. once said, ‘You don’t have to see the whole staircase, just take the first step.’ ”

The ACGME wants to work with physicians “to collect data and do joint research, to share insights, and to share tools and resources to create a better world for practicing physicians, for other members of the health care team, and for patients. After all, clinicians who care for themselves provide better care for others. They’re less likely to make errors or leave the profession,” Dr. Brigham told attendees.

He added that clinicians can gauge their risk for burnout by asking themselves three simple questions about their work environment: Does it support self-care? Does it increase and support connection with colleagues? Does it connect people to purpose and meaningful work?

“One of the problems with our resident clinical work hours is not terrible program directors saying, ‘work longer.’ It’s residents who want to take care of families for 1 more hour,” Dr. Brigham continued. “It’s residents who want to take care of patients who are going through a difficult time. You represent the top 2% in the world in terms of your intelligence and achievement, yet that’s not what makes you special. What makes you special is that the level of self-doubt in this room exceeds that of the general population by about 10 times. You also tend to run toward what everyone else runs away from: disease, despair, people who are injured and suffering. That takes a toll.”

Courtesy AAP

He emphasized that positive social relationships with others are crucial to joy and well-being in the practice of medicine. “Burnout isn’t just about exhaustion; it’s about loneliness,” Dr. Brigham said. “There’s a surprising power in just asking people how they’re doing, and really wanting to know the answer.”

Negative social connections are highly correlated with burnout and depression, such as harassment, bullying, mistreatment, discrimination, “and using the power gradient to squash somebody who’s trying their best to be a physician,” he said.

Dr. Brigham acknowledged the tall task of bringing a spotlight to well-being as physicians continue to engage in tasks such as the burden and lack of standardization of prior authorization requirements, the burden of clinical documentation requirements, electronic health records and related work flow, and quality payment programs. “This is what we need to shift; this is what we need to take away so you can get back in touch with why you became a physician in the first place.”

Dr. Brigham reported having no financial disclosures.

[email protected]

NEW ORLEANS – Managing painful or fear-provoking procedures in children is a balance of preparation, intuition, and technical skills, Baruch S. Krauss, MD, EdM said at the annual meeting of the American Academy of Pediatrics.

Doug Brunk/MDedge News

Dr. Krauss, a pediatric emergency physician at Boston Children’s Hospital, shared tips for producing a positive experience when children present for minor procedures such as an intravenous catheter insertion or a laceration repair.
 

Control the environment

Setting the stage for a positive experience for children and their parents involves decreasing sensory stimuli by minimizing noise and bustle, the number of people in the room, and the reminder cues. “Even if you have trust with the child, there are certain things that could trigger the child to become fearful and anxious,” said Dr. Krauss, who also holds an academic post in the department of pediatrics at Harvard Medical School, Boston. “You want to make sure that medical equipment or a syringe is covered – anything that would remind the child or trigger the child to be more concerned and anxious.”

He recommends careful use of lighting, particularly in children who present with a head laceration or a facial laceration. “You may need to put a light near the wound, but that may be fearful for the child,” said Dr. Krauss, who coauthored a recent article on the topic that contains links to instructional videos (Ann Emerg Med 2019;74[1]:30-5). “Read the cues of the child,” he said. One desensitization technique he uses in such cases is to tell the child a story about the sun. He then goes on to liken the warmth of the exam light to the warmth of the sun.

Limiting the number of clinicians who speak to the child during the procedure also is key. “One person should speak to the child,” he advised. “Otherwise, it creates confusion for the child and it is hard for them to focus their attention. What you really want is to be able to control the child’s attention. You want to be able to capture their attention.”

It’s also important to keep medical equipment out of view. “I can’t tell you how many times I’ve seen consultants come in and a child needs to have a laceration repair, and they’re filling the syringe with lidocaine in front of the child,” Dr. Krauss said. “You want to avoid that. You also want to work outside of the child’s visual field if you can. Positioning is critical. I will try whatever position works for the child and the family.” This may including asking the parent to hold and swaddle an infant during the procedure, or positioning young children in the parent’s lap with their arm secured.

“Two things that upset kids during laceration repair are water dripping into their eyes during irrigation and the suture falling across their face as you’re stitching,” he added. “You want to develop your procedural skills so you can avoid that happening.”
 

Tailor the approach to the individual child

Some children will want to watch what you’re doing, but normally Dr. Krauss uses towels or blankets to cover the area being worked on. “If the child is part of your practice and you know his temperament and coping style, that makes it a lot easier; you know how to approach him,” he said. “They can trust you but they still can be quite fearful.” Sometimes, the child is relaxed but the parent becomes anxious. That anxiety can be transmitted to child. “If I see that the parents are anxious, I work directly with the child, and not the parent,” he said. “There’s not much I can tell a parent verbally that’s going to change their anxiety or fear level. But, as soon I start moving the child’s emotional state from fear to trust, the parent senses that and they relax, and that gets transmitted back to the child.”

Use age-appropriate language

When treating infants and children, Dr. Krauss often uses “parentese,” a simplified way that parents use to talk to young children. “It’s clearer, simpler, more attention-maintaining, and has longer pauses,” he said. “That can be very comforting to children.” Content and phrasing become important in older children. “You want to avoid the nocebo effect,” he continued. “If you tell a child, ‘This is really going to sting or hurt,’ you’re tipping the scales toward them having that experience.”

In an article about behavioral approaches to anxiety and pain management for pediatric venous access, Lindsey L. Cohen, PhD, devised a list of suggested phrasing to use. For example, instead of saying “You will be fine; there is nothing to worry about,” ask, “What did you do in school today?” as a form of distraction. Instead of saying, “It will feel like a bee sting,” ask, “Tell me how it feels.” And instead of saying, “Don’t cry,” say, “That was hard; I am proud of you” (Pediatrics 2008;122[suppl 3]:S134-9).

In a more recent article, Dr. Krauss and colleagues discussed current concepts of managing pain in children who present to the emergency department (Lancet 2016;387:83-92). Among distracting activities to try with infants and preschoolers are blowing bubbles, the use of a lighted wand, sound, music, or books, they noted. Distracting activities to try with preschoolers and in older children include art activities such as drawing, coloring, and the use of play dough, and computer games.

Clinicians also can ask the child to engage in a developmental task as a form of distraction. Dr. Krauss recalled a 22-month-old boy who presented to the emergency department with a forehead laceration. Mindful that the boy was developing eye-hand coordination and fine motor activity, Dr. Krauss offered him a coloring book that contained a picture of a clown, and instructed him to color the clown’s eyes red while Dr. Krauss tended to the wound. “His attention was completely fixed on that learning task,” he said.

Dr. Krauss reported having no financial disclosures.

[email protected]

NEW ORLEANS – Managing painful or fear-provoking procedures in children is a balance of preparation, intuition, and technical skills, Baruch S. Krauss, MD, EdM said at the annual meeting of the American Academy of Pediatrics.

Doug Brunk/MDedge News

Dr. Krauss, a pediatric emergency physician at Boston Children’s Hospital, shared tips for producing a positive experience when children present for minor procedures such as an intravenous catheter insertion or a laceration repair.
 

Control the environment

Setting the stage for a positive experience for children and their parents involves decreasing sensory stimuli by minimizing noise and bustle, the number of people in the room, and the reminder cues. “Even if you have trust with the child, there are certain things that could trigger the child to become fearful and anxious,” said Dr. Krauss, who also holds an academic post in the department of pediatrics at Harvard Medical School, Boston. “You want to make sure that medical equipment or a syringe is covered – anything that would remind the child or trigger the child to be more concerned and anxious.”

He recommends careful use of lighting, particularly in children who present with a head laceration or a facial laceration. “You may need to put a light near the wound, but that may be fearful for the child,” said Dr. Krauss, who coauthored a recent article on the topic that contains links to instructional videos (Ann Emerg Med 2019;74[1]:30-5). “Read the cues of the child,” he said. One desensitization technique he uses in such cases is to tell the child a story about the sun. He then goes on to liken the warmth of the exam light to the warmth of the sun.

Limiting the number of clinicians who speak to the child during the procedure also is key. “One person should speak to the child,” he advised. “Otherwise, it creates confusion for the child and it is hard for them to focus their attention. What you really want is to be able to control the child’s attention. You want to be able to capture their attention.”

It’s also important to keep medical equipment out of view. “I can’t tell you how many times I’ve seen consultants come in and a child needs to have a laceration repair, and they’re filling the syringe with lidocaine in front of the child,” Dr. Krauss said. “You want to avoid that. You also want to work outside of the child’s visual field if you can. Positioning is critical. I will try whatever position works for the child and the family.” This may including asking the parent to hold and swaddle an infant during the procedure, or positioning young children in the parent’s lap with their arm secured.

“Two things that upset kids during laceration repair are water dripping into their eyes during irrigation and the suture falling across their face as you’re stitching,” he added. “You want to develop your procedural skills so you can avoid that happening.”
 

Tailor the approach to the individual child

Some children will want to watch what you’re doing, but normally Dr. Krauss uses towels or blankets to cover the area being worked on. “If the child is part of your practice and you know his temperament and coping style, that makes it a lot easier; you know how to approach him,” he said. “They can trust you but they still can be quite fearful.” Sometimes, the child is relaxed but the parent becomes anxious. That anxiety can be transmitted to child. “If I see that the parents are anxious, I work directly with the child, and not the parent,” he said. “There’s not much I can tell a parent verbally that’s going to change their anxiety or fear level. But, as soon I start moving the child’s emotional state from fear to trust, the parent senses that and they relax, and that gets transmitted back to the child.”

Use age-appropriate language

When treating infants and children, Dr. Krauss often uses “parentese,” a simplified way that parents use to talk to young children. “It’s clearer, simpler, more attention-maintaining, and has longer pauses,” he said. “That can be very comforting to children.” Content and phrasing become important in older children. “You want to avoid the nocebo effect,” he continued. “If you tell a child, ‘This is really going to sting or hurt,’ you’re tipping the scales toward them having that experience.”

In an article about behavioral approaches to anxiety and pain management for pediatric venous access, Lindsey L. Cohen, PhD, devised a list of suggested phrasing to use. For example, instead of saying “You will be fine; there is nothing to worry about,” ask, “What did you do in school today?” as a form of distraction. Instead of saying, “It will feel like a bee sting,” ask, “Tell me how it feels.” And instead of saying, “Don’t cry,” say, “That was hard; I am proud of you” (Pediatrics 2008;122[suppl 3]:S134-9).

In a more recent article, Dr. Krauss and colleagues discussed current concepts of managing pain in children who present to the emergency department (Lancet 2016;387:83-92). Among distracting activities to try with infants and preschoolers are blowing bubbles, the use of a lighted wand, sound, music, or books, they noted. Distracting activities to try with preschoolers and in older children include art activities such as drawing, coloring, and the use of play dough, and computer games.

Clinicians also can ask the child to engage in a developmental task as a form of distraction. Dr. Krauss recalled a 22-month-old boy who presented to the emergency department with a forehead laceration. Mindful that the boy was developing eye-hand coordination and fine motor activity, Dr. Krauss offered him a coloring book that contained a picture of a clown, and instructed him to color the clown’s eyes red while Dr. Krauss tended to the wound. “His attention was completely fixed on that learning task,” he said.

Dr. Krauss reported having no financial disclosures.

[email protected]

NEW ORLEANS – Managing painful or fear-provoking procedures in children is a balance of preparation, intuition, and technical skills, Baruch S. Krauss, MD, EdM said at the annual meeting of the American Academy of Pediatrics.

Doug Brunk/MDedge News

Dr. Krauss, a pediatric emergency physician at Boston Children’s Hospital, shared tips for producing a positive experience when children present for minor procedures such as an intravenous catheter insertion or a laceration repair.
 

Control the environment

Setting the stage for a positive experience for children and their parents involves decreasing sensory stimuli by minimizing noise and bustle, the number of people in the room, and the reminder cues. “Even if you have trust with the child, there are certain things that could trigger the child to become fearful and anxious,” said Dr. Krauss, who also holds an academic post in the department of pediatrics at Harvard Medical School, Boston. “You want to make sure that medical equipment or a syringe is covered – anything that would remind the child or trigger the child to be more concerned and anxious.”

He recommends careful use of lighting, particularly in children who present with a head laceration or a facial laceration. “You may need to put a light near the wound, but that may be fearful for the child,” said Dr. Krauss, who coauthored a recent article on the topic that contains links to instructional videos (Ann Emerg Med 2019;74[1]:30-5). “Read the cues of the child,” he said. One desensitization technique he uses in such cases is to tell the child a story about the sun. He then goes on to liken the warmth of the exam light to the warmth of the sun.

Limiting the number of clinicians who speak to the child during the procedure also is key. “One person should speak to the child,” he advised. “Otherwise, it creates confusion for the child and it is hard for them to focus their attention. What you really want is to be able to control the child’s attention. You want to be able to capture their attention.”

It’s also important to keep medical equipment out of view. “I can’t tell you how many times I’ve seen consultants come in and a child needs to have a laceration repair, and they’re filling the syringe with lidocaine in front of the child,” Dr. Krauss said. “You want to avoid that. You also want to work outside of the child’s visual field if you can. Positioning is critical. I will try whatever position works for the child and the family.” This may including asking the parent to hold and swaddle an infant during the procedure, or positioning young children in the parent’s lap with their arm secured.

“Two things that upset kids during laceration repair are water dripping into their eyes during irrigation and the suture falling across their face as you’re stitching,” he added. “You want to develop your procedural skills so you can avoid that happening.”
 

Tailor the approach to the individual child

Some children will want to watch what you’re doing, but normally Dr. Krauss uses towels or blankets to cover the area being worked on. “If the child is part of your practice and you know his temperament and coping style, that makes it a lot easier; you know how to approach him,” he said. “They can trust you but they still can be quite fearful.” Sometimes, the child is relaxed but the parent becomes anxious. That anxiety can be transmitted to child. “If I see that the parents are anxious, I work directly with the child, and not the parent,” he said. “There’s not much I can tell a parent verbally that’s going to change their anxiety or fear level. But, as soon I start moving the child’s emotional state from fear to trust, the parent senses that and they relax, and that gets transmitted back to the child.”

Use age-appropriate language

When treating infants and children, Dr. Krauss often uses “parentese,” a simplified way that parents use to talk to young children. “It’s clearer, simpler, more attention-maintaining, and has longer pauses,” he said. “That can be very comforting to children.” Content and phrasing become important in older children. “You want to avoid the nocebo effect,” he continued. “If you tell a child, ‘This is really going to sting or hurt,’ you’re tipping the scales toward them having that experience.”

In an article about behavioral approaches to anxiety and pain management for pediatric venous access, Lindsey L. Cohen, PhD, devised a list of suggested phrasing to use. For example, instead of saying “You will be fine; there is nothing to worry about,” ask, “What did you do in school today?” as a form of distraction. Instead of saying, “It will feel like a bee sting,” ask, “Tell me how it feels.” And instead of saying, “Don’t cry,” say, “That was hard; I am proud of you” (Pediatrics 2008;122[suppl 3]:S134-9).

In a more recent article, Dr. Krauss and colleagues discussed current concepts of managing pain in children who present to the emergency department (Lancet 2016;387:83-92). Among distracting activities to try with infants and preschoolers are blowing bubbles, the use of a lighted wand, sound, music, or books, they noted. Distracting activities to try with preschoolers and in older children include art activities such as drawing, coloring, and the use of play dough, and computer games.

Clinicians also can ask the child to engage in a developmental task as a form of distraction. Dr. Krauss recalled a 22-month-old boy who presented to the emergency department with a forehead laceration. Mindful that the boy was developing eye-hand coordination and fine motor activity, Dr. Krauss offered him a coloring book that contained a picture of a clown, and instructed him to color the clown’s eyes red while Dr. Krauss tended to the wound. “His attention was completely fixed on that learning task,” he said.

Dr. Krauss reported having no financial disclosures.

[email protected]

NEW ORLEANS – Teens need to drive for a wide range of reasons, from going to and from school or work to overall mobility, but driving still is the most dangerous thing teenagers do, according to Brian Johnston, MD, MPH, professor of pediatrics at the University of Washington in Seattle.

Kali9/E+/Getty Images

Motor vehicle traffic accidents continue to be the leading cause of death of adolescents aged 15-19 years, according to 2017 data from the National Center for Health Statistics at the Centers for the Disease Control and Prevention.

“Inexperience drives the statistics we see,” Dr. Johnston said at the annual meeting of the American Academy of Pediatrics. “There is a steep learning curve among drivers of all ages, and crash rates are highest during the first few months after teens begin driving without supervision.”

Although the risk of accidents is higher than average for any new driver, it’s disproportionately higher for younger teens, compared with other ages: 16-year-old novice drivers have a higher accident risk than that of 17-year-olds, whose risk is similar to that of 18- and 19-year-old novices.

How long drivers have been licensed has a far bigger impact on crash risk, Dr. Johnston said (Traffic Inj. Prev. 2009 Jun;10[3]:209-19).

But the risk of an accident also increases with each additional passenger a teen driver has, particularly for younger and male drivers (Traffic Inj Prev. 2013;14[3]:283-92). More passengers likely means more distraction, and distraction, driving too fast for road conditions, and not scanning the roadway are the three most common errors – together accounting for about half of all teen drivers’ crashes.

Risk factors for accidents

Speed is a contributing factor in just over a third (36%) of teens’ fatal crashes. Adolescents drive faster and keep shorter following distances than adults do. But as with adults, wearing seat belts substantially reduces the risk of death in accidents.

Lap-shoulder seat belts reduce the risk of death in a crash by 45%, but teens use their seat belts far less often than do older drivers. Nationally, 90% of drivers use seat belts, with higher rates in states with primary enforcement (92%) than those in states with secondary enforcement (83%).

But barely more than half (54%) of U.S. high school students say they “always” wear a seat belt, and just under half of teens (47%) who died in crashes in 2017 weren’t wearing one. As seen in adults, teens are more likely to buckle up, by 12%, in states with primary seat belt laws.

Distraction during driving can be visual, manual, or cognitive – and handheld electronic devices such as smartphones cause all three distraction types. Cell phones nearly double the proportion of teen drivers who die in crashes, from 7% to 13%.

But if teens can keep their eyes on the roadway at all times, even the risks posed by cellphones drop considerably.

“The best evidence shows that secondary tasks only degrade driving performance when they require drivers to look away from the road,” Dr. Johnston said. Looking away for 2 seconds or longer increases crash risk more than fivefold.

Two other risk factors for teen car accidents are drowsiness and nighttime driving. Sleepiness can play a role in crashes at any time of day, and Dr. Johnston noted that some research has associated later high school start times with reduced crash risk.

Teens aged 16-19 years are about four times more likely to have a car accident at night than during the day per each mile driven, the pediatrician noted. Many licensing laws restrict teen driving starting at 11 p.m. or later, but about 50%-60% of their crashes occur between 9 and 11 p.m.

One reason for the increased risk is less experience driving in more difficult conditions, but teens also are more likely to have teen passengers, to be driving excessively fast, or to be under the influence of alcohol at night.

Adolescents’ crash risk is higher than that of adults for any level of blood alcohol content. Self-reported driving after drinking dropped by almost half – from 10% to 5.5% – from 2013 to 2017, but alcohol still is implicated in a substantial number of fatal teen crashes.

As drunk driving has declined, however, driving while under the influence of marijuana has been increasing. According to the National Highway Traffic Safety Administration, case control studies show drivers with tetrahydrocannabinol (THC) in their blood have a 25% increased risk of accidents – but the excess risk associated with THC vanishes when researchers control for age, sex, and concurrent use of alcohol. Not enough research exists to determine what the crash risk would be for adolescent drivers using THC alone.

A less-recognized risk factor for car accidents in teen drivers is ADHD, which increases a teen’s risk of crashing by 36%, particularly in the first month after getting a license, Dr. Johnston said.

ADHD medication appears to mitigate the danger, according to data: Crash risk was 40% lower in adult drivers with ADHD during months they filled their stimulant prescriptions. But one study found only 12% of teens with ADHD filled their prescriptions the month they got their license, and adolescents may not take their medications or still have them in their system on weekends or at night.

Teens recovering from concussion also may have an increased risk. Some evidence suggests driving impairment continues even when other symptoms have resolved, but not enough data exist to determine appropriate criteria for clearing teens to begin driving again.

Interventions to improve teens’ driving safety

Most teens take a basic driver education course before getting their licenses, but no evidence shows that it reduces risk of citations, crashes, or injury. In fact, “skid control training and other kinds of advanced skill training seem to increase crash risk, particularly among young males,” Dr. Johnston said.

What helps teens most is, ironically, more driving.

“If I say inexperience is the single most important risk factor for dying in a crash as a teen, driving experience is the intervention,” he said. More time spent driving – “with supervision in particular, and under diverse conditions,” Dr. Johnston said – increases the repertoire of skills and abilities.

Parents should be encouraged to ride along as their teens drive under diverse road conditions: different roads, different times of the day, and different weather conditions, for example. Parents can narrate their own driving, pointing out hazards and times when they slow down for increased caution, Dr. Johnston said. It might feel “awkward and unnatural,” but “some of the things you as a driver notice all the time are novel to teen drivers.”

Parents can influence road safety for teens in terms of their own behavior and in selecting a safer vehicle. A strong correlation exists between parental texting while driving when children are younger and what they do as teen drivers, for example.

Safer vehicles are bigger, heavier cars with electronic stability control, which reduces risk of death about as much as wearing seat belts. Parents should avoid vehicles with high horsepower and look for cars with the best safety ratings they can afford, Dr. Johnston said.

Several special features in newer cars can help reduce crash risk, such as blind spot detection, automatic breaking, collision avoidance systems, lane departure warning systems, and driver drowsiness detection. Parents may worry that relying on this technology could reduce teens’ learning, but it actually can compensate for skill deficits as they are becoming more skilled drivers.

Parents can look into feedback programs such as smartphone apps or other in-car units that allow parents to see data on teens’ speed, unsafe driving, “near-misses,” and similar driving behaviors. Research has shown that unsafe driving in newly licensed teens dropped by 66% over 4 months of using one of these feedback programs, compared with teens who didn’t use it.

Dr. Johnston also discussed the idea of prelicensure medical exams, similar to physicals that are required before playing sports. These already exist for commercial licenses in most states, but no data exist on whether it’s effective for teens. The goal would be to promote a discussion between parents and their teens about driving: reviewing medications the teen is taking and whether they affect driving; discussing safety of different vehicles; and assessing the teens’ risks, including any cognitive or other medical conditions that could affect driving safety. Even if such a “driving physical” is not currently required, pediatricians can do their own version of one with families.

Dr. Johnston had no disclosures.

NEW ORLEANS – Teens need to drive for a wide range of reasons, from going to and from school or work to overall mobility, but driving still is the most dangerous thing teenagers do, according to Brian Johnston, MD, MPH, professor of pediatrics at the University of Washington in Seattle.

Kali9/E+/Getty Images

Motor vehicle traffic accidents continue to be the leading cause of death of adolescents aged 15-19 years, according to 2017 data from the National Center for Health Statistics at the Centers for the Disease Control and Prevention.

“Inexperience drives the statistics we see,” Dr. Johnston said at the annual meeting of the American Academy of Pediatrics. “There is a steep learning curve among drivers of all ages, and crash rates are highest during the first few months after teens begin driving without supervision.”

Although the risk of accidents is higher than average for any new driver, it’s disproportionately higher for younger teens, compared with other ages: 16-year-old novice drivers have a higher accident risk than that of 17-year-olds, whose risk is similar to that of 18- and 19-year-old novices.

How long drivers have been licensed has a far bigger impact on crash risk, Dr. Johnston said (Traffic Inj. Prev. 2009 Jun;10[3]:209-19).

But the risk of an accident also increases with each additional passenger a teen driver has, particularly for younger and male drivers (Traffic Inj Prev. 2013;14[3]:283-92). More passengers likely means more distraction, and distraction, driving too fast for road conditions, and not scanning the roadway are the three most common errors – together accounting for about half of all teen drivers’ crashes.

Risk factors for accidents

Speed is a contributing factor in just over a third (36%) of teens’ fatal crashes. Adolescents drive faster and keep shorter following distances than adults do. But as with adults, wearing seat belts substantially reduces the risk of death in accidents.

Lap-shoulder seat belts reduce the risk of death in a crash by 45%, but teens use their seat belts far less often than do older drivers. Nationally, 90% of drivers use seat belts, with higher rates in states with primary enforcement (92%) than those in states with secondary enforcement (83%).

But barely more than half (54%) of U.S. high school students say they “always” wear a seat belt, and just under half of teens (47%) who died in crashes in 2017 weren’t wearing one. As seen in adults, teens are more likely to buckle up, by 12%, in states with primary seat belt laws.

Distraction during driving can be visual, manual, or cognitive – and handheld electronic devices such as smartphones cause all three distraction types. Cell phones nearly double the proportion of teen drivers who die in crashes, from 7% to 13%.

But if teens can keep their eyes on the roadway at all times, even the risks posed by cellphones drop considerably.

“The best evidence shows that secondary tasks only degrade driving performance when they require drivers to look away from the road,” Dr. Johnston said. Looking away for 2 seconds or longer increases crash risk more than fivefold.

Two other risk factors for teen car accidents are drowsiness and nighttime driving. Sleepiness can play a role in crashes at any time of day, and Dr. Johnston noted that some research has associated later high school start times with reduced crash risk.

Teens aged 16-19 years are about four times more likely to have a car accident at night than during the day per each mile driven, the pediatrician noted. Many licensing laws restrict teen driving starting at 11 p.m. or later, but about 50%-60% of their crashes occur between 9 and 11 p.m.

One reason for the increased risk is less experience driving in more difficult conditions, but teens also are more likely to have teen passengers, to be driving excessively fast, or to be under the influence of alcohol at night.

Adolescents’ crash risk is higher than that of adults for any level of blood alcohol content. Self-reported driving after drinking dropped by almost half – from 10% to 5.5% – from 2013 to 2017, but alcohol still is implicated in a substantial number of fatal teen crashes.

As drunk driving has declined, however, driving while under the influence of marijuana has been increasing. According to the National Highway Traffic Safety Administration, case control studies show drivers with tetrahydrocannabinol (THC) in their blood have a 25% increased risk of accidents – but the excess risk associated with THC vanishes when researchers control for age, sex, and concurrent use of alcohol. Not enough research exists to determine what the crash risk would be for adolescent drivers using THC alone.

A less-recognized risk factor for car accidents in teen drivers is ADHD, which increases a teen’s risk of crashing by 36%, particularly in the first month after getting a license, Dr. Johnston said.

ADHD medication appears to mitigate the danger, according to data: Crash risk was 40% lower in adult drivers with ADHD during months they filled their stimulant prescriptions. But one study found only 12% of teens with ADHD filled their prescriptions the month they got their license, and adolescents may not take their medications or still have them in their system on weekends or at night.

Teens recovering from concussion also may have an increased risk. Some evidence suggests driving impairment continues even when other symptoms have resolved, but not enough data exist to determine appropriate criteria for clearing teens to begin driving again.

Interventions to improve teens’ driving safety

Most teens take a basic driver education course before getting their licenses, but no evidence shows that it reduces risk of citations, crashes, or injury. In fact, “skid control training and other kinds of advanced skill training seem to increase crash risk, particularly among young males,” Dr. Johnston said.

What helps teens most is, ironically, more driving.

“If I say inexperience is the single most important risk factor for dying in a crash as a teen, driving experience is the intervention,” he said. More time spent driving – “with supervision in particular, and under diverse conditions,” Dr. Johnston said – increases the repertoire of skills and abilities.

Parents should be encouraged to ride along as their teens drive under diverse road conditions: different roads, different times of the day, and different weather conditions, for example. Parents can narrate their own driving, pointing out hazards and times when they slow down for increased caution, Dr. Johnston said. It might feel “awkward and unnatural,” but “some of the things you as a driver notice all the time are novel to teen drivers.”

Parents can influence road safety for teens in terms of their own behavior and in selecting a safer vehicle. A strong correlation exists between parental texting while driving when children are younger and what they do as teen drivers, for example.

Safer vehicles are bigger, heavier cars with electronic stability control, which reduces risk of death about as much as wearing seat belts. Parents should avoid vehicles with high horsepower and look for cars with the best safety ratings they can afford, Dr. Johnston said.

Several special features in newer cars can help reduce crash risk, such as blind spot detection, automatic breaking, collision avoidance systems, lane departure warning systems, and driver drowsiness detection. Parents may worry that relying on this technology could reduce teens’ learning, but it actually can compensate for skill deficits as they are becoming more skilled drivers.

Parents can look into feedback programs such as smartphone apps or other in-car units that allow parents to see data on teens’ speed, unsafe driving, “near-misses,” and similar driving behaviors. Research has shown that unsafe driving in newly licensed teens dropped by 66% over 4 months of using one of these feedback programs, compared with teens who didn’t use it.

Dr. Johnston also discussed the idea of prelicensure medical exams, similar to physicals that are required before playing sports. These already exist for commercial licenses in most states, but no data exist on whether it’s effective for teens. The goal would be to promote a discussion between parents and their teens about driving: reviewing medications the teen is taking and whether they affect driving; discussing safety of different vehicles; and assessing the teens’ risks, including any cognitive or other medical conditions that could affect driving safety. Even if such a “driving physical” is not currently required, pediatricians can do their own version of one with families.

Dr. Johnston had no disclosures.

NEW ORLEANS – Teens need to drive for a wide range of reasons, from going to and from school or work to overall mobility, but driving still is the most dangerous thing teenagers do, according to Brian Johnston, MD, MPH, professor of pediatrics at the University of Washington in Seattle.

Kali9/E+/Getty Images

Motor vehicle traffic accidents continue to be the leading cause of death of adolescents aged 15-19 years, according to 2017 data from the National Center for Health Statistics at the Centers for the Disease Control and Prevention.

“Inexperience drives the statistics we see,” Dr. Johnston said at the annual meeting of the American Academy of Pediatrics. “There is a steep learning curve among drivers of all ages, and crash rates are highest during the first few months after teens begin driving without supervision.”

Although the risk of accidents is higher than average for any new driver, it’s disproportionately higher for younger teens, compared with other ages: 16-year-old novice drivers have a higher accident risk than that of 17-year-olds, whose risk is similar to that of 18- and 19-year-old novices.

How long drivers have been licensed has a far bigger impact on crash risk, Dr. Johnston said (Traffic Inj. Prev. 2009 Jun;10[3]:209-19).

But the risk of an accident also increases with each additional passenger a teen driver has, particularly for younger and male drivers (Traffic Inj Prev. 2013;14[3]:283-92). More passengers likely means more distraction, and distraction, driving too fast for road conditions, and not scanning the roadway are the three most common errors – together accounting for about half of all teen drivers’ crashes.

Risk factors for accidents

Speed is a contributing factor in just over a third (36%) of teens’ fatal crashes. Adolescents drive faster and keep shorter following distances than adults do. But as with adults, wearing seat belts substantially reduces the risk of death in accidents.

Lap-shoulder seat belts reduce the risk of death in a crash by 45%, but teens use their seat belts far less often than do older drivers. Nationally, 90% of drivers use seat belts, with higher rates in states with primary enforcement (92%) than those in states with secondary enforcement (83%).

But barely more than half (54%) of U.S. high school students say they “always” wear a seat belt, and just under half of teens (47%) who died in crashes in 2017 weren’t wearing one. As seen in adults, teens are more likely to buckle up, by 12%, in states with primary seat belt laws.

Distraction during driving can be visual, manual, or cognitive – and handheld electronic devices such as smartphones cause all three distraction types. Cell phones nearly double the proportion of teen drivers who die in crashes, from 7% to 13%.

But if teens can keep their eyes on the roadway at all times, even the risks posed by cellphones drop considerably.

“The best evidence shows that secondary tasks only degrade driving performance when they require drivers to look away from the road,” Dr. Johnston said. Looking away for 2 seconds or longer increases crash risk more than fivefold.

Two other risk factors for teen car accidents are drowsiness and nighttime driving. Sleepiness can play a role in crashes at any time of day, and Dr. Johnston noted that some research has associated later high school start times with reduced crash risk.

Teens aged 16-19 years are about four times more likely to have a car accident at night than during the day per each mile driven, the pediatrician noted. Many licensing laws restrict teen driving starting at 11 p.m. or later, but about 50%-60% of their crashes occur between 9 and 11 p.m.

One reason for the increased risk is less experience driving in more difficult conditions, but teens also are more likely to have teen passengers, to be driving excessively fast, or to be under the influence of alcohol at night.

Adolescents’ crash risk is higher than that of adults for any level of blood alcohol content. Self-reported driving after drinking dropped by almost half – from 10% to 5.5% – from 2013 to 2017, but alcohol still is implicated in a substantial number of fatal teen crashes.

As drunk driving has declined, however, driving while under the influence of marijuana has been increasing. According to the National Highway Traffic Safety Administration, case control studies show drivers with tetrahydrocannabinol (THC) in their blood have a 25% increased risk of accidents – but the excess risk associated with THC vanishes when researchers control for age, sex, and concurrent use of alcohol. Not enough research exists to determine what the crash risk would be for adolescent drivers using THC alone.

A less-recognized risk factor for car accidents in teen drivers is ADHD, which increases a teen’s risk of crashing by 36%, particularly in the first month after getting a license, Dr. Johnston said.

ADHD medication appears to mitigate the danger, according to data: Crash risk was 40% lower in adult drivers with ADHD during months they filled their stimulant prescriptions. But one study found only 12% of teens with ADHD filled their prescriptions the month they got their license, and adolescents may not take their medications or still have them in their system on weekends or at night.

Teens recovering from concussion also may have an increased risk. Some evidence suggests driving impairment continues even when other symptoms have resolved, but not enough data exist to determine appropriate criteria for clearing teens to begin driving again.

Interventions to improve teens’ driving safety

Most teens take a basic driver education course before getting their licenses, but no evidence shows that it reduces risk of citations, crashes, or injury. In fact, “skid control training and other kinds of advanced skill training seem to increase crash risk, particularly among young males,” Dr. Johnston said.

What helps teens most is, ironically, more driving.

“If I say inexperience is the single most important risk factor for dying in a crash as a teen, driving experience is the intervention,” he said. More time spent driving – “with supervision in particular, and under diverse conditions,” Dr. Johnston said – increases the repertoire of skills and abilities.

Parents should be encouraged to ride along as their teens drive under diverse road conditions: different roads, different times of the day, and different weather conditions, for example. Parents can narrate their own driving, pointing out hazards and times when they slow down for increased caution, Dr. Johnston said. It might feel “awkward and unnatural,” but “some of the things you as a driver notice all the time are novel to teen drivers.”

Parents can influence road safety for teens in terms of their own behavior and in selecting a safer vehicle. A strong correlation exists between parental texting while driving when children are younger and what they do as teen drivers, for example.

Safer vehicles are bigger, heavier cars with electronic stability control, which reduces risk of death about as much as wearing seat belts. Parents should avoid vehicles with high horsepower and look for cars with the best safety ratings they can afford, Dr. Johnston said.

Several special features in newer cars can help reduce crash risk, such as blind spot detection, automatic breaking, collision avoidance systems, lane departure warning systems, and driver drowsiness detection. Parents may worry that relying on this technology could reduce teens’ learning, but it actually can compensate for skill deficits as they are becoming more skilled drivers.

Parents can look into feedback programs such as smartphone apps or other in-car units that allow parents to see data on teens’ speed, unsafe driving, “near-misses,” and similar driving behaviors. Research has shown that unsafe driving in newly licensed teens dropped by 66% over 4 months of using one of these feedback programs, compared with teens who didn’t use it.

Dr. Johnston also discussed the idea of prelicensure medical exams, similar to physicals that are required before playing sports. These already exist for commercial licenses in most states, but no data exist on whether it’s effective for teens. The goal would be to promote a discussion between parents and their teens about driving: reviewing medications the teen is taking and whether they affect driving; discussing safety of different vehicles; and assessing the teens’ risks, including any cognitive or other medical conditions that could affect driving safety. Even if such a “driving physical” is not currently required, pediatricians can do their own version of one with families.

Dr. Johnston had no disclosures.

NEW ORLEANS – The incidence of acute otitis media has decreased by 25% to 35% in the past decade, thanks largely to the widespread and near universal use of the pneumococcal conjugate vaccine, according to Ellen R. Wald, MD.

Courtesy Wikimedia Commons/Mar10029/Creative Commons License

“To a smaller degree, it is also attributable to the use of influenza vaccine, and to the use of more stringent diagnostic criteria,” Dr. Wald, who chairs the department of pediatrics at the University of Wisconsin, Madison, said at the annual meeting of the American Academy of Pediatrics. “The fact that we are decreasing the number of episodes of otitis media in children in the first year of life means that we’re going to have fewer otitis-prone children and therefore less of a need for tympanostomy tubes, either as a solution to the problem of recurrence of acute otitis media (AOM) or for the problem of persistent effusion.”

The best way to limit antimicrobial use is for clinicians to increase their ability to differentiate AOM from otitis media with effusion (OME), said Dr. Wald, pediatrician-in-chief at the American Family Children’s Hospital in Madison. She noted that OME is a nonbacterial inflammatory state that usually resolves spontaneously. It tends to occur before or after AOM, and often without ever progressing to AOM. “Its principal importance is as a cause of hearing loss and as a confounder in the diagnosis AOM,” she explained. “Because it is a nonbacterial process, antibiotics are not indicated in the management of OME. In contrast, children with AOM have a bacterial infection that will benefit from the use of antimicrobials.”*

Middle ear effusion is common to both OME and AOM, she continued. To discriminate between the two conditions, clinicians must look for signs of acute inflammation of the tympanic membrane, “which we expect to see in AOM,” she said. “The most powerful sign of inflammation of the tympanic membrane is distinct fullness or bulging of the tympanic membrane on exam.”

Dr. Wald advises clinicians to be as systematic as possible when conducting the otoscopic exam, by looking at color and classifying it as pink, gray, white, yellow, red, amber, or blue, and by documenting the position as neutral, retracted, full, or bulging. “When we gauge how light passes through the tympanic membrane, we judge it as translucent, opaque, or partially opaque, and mobility as normal, decreased, or absent,” she added. “When we find decreased or absent mobility of the tympanic membrane, it tells us that we have fluid in the middle ear, but it does not discriminate between AOM and OME.”

Advances in digital otoscopy are helping pediatricians to improve their diagnostic skills. An early device, the iPhone otoscope by CellScope, uses an iOS smartphone to capture images and videos of the external ear canal and eardrum. “The image is pretty much the same as that seen through the eye of a hand-held otoscope,” Dr. Wald said. “The problem with this particular design is that the speculum is kind of large. It does still require the removal of cerumen, and the smartphone is kind of awkward to use as a handle during an otoscopic exam.”

A new digital otoscope called Wispr was unveiled at the AAP meeting. First developed at the University of Wisconsin and now marketed by WiscMed, Wispr delivers high-resolution views of the eardrum in even small or partially obstructed ear canals with one-button image and video capture. WiscMed was founded by Jim Berbee, MD, MBA, an engineer turned emergency medicine physician.

“One of the advantages of this particular model is that it handles a lot more like a usual otoscope and can be attached to the rechargeable handles that are commercially available,” Dr. Wald said. “It has an extremely tiny speculum. Within the head, there is even a smaller camera that allows the photographs to be taken. Because the speculum is so tiny, it allows the device to sometimes avoid the presence of cerumen, or sometimes go through it and still obtain an image.”

[email protected]

*This article was updated 12/13/2019

NEW ORLEANS – The incidence of acute otitis media has decreased by 25% to 35% in the past decade, thanks largely to the widespread and near universal use of the pneumococcal conjugate vaccine, according to Ellen R. Wald, MD.

Courtesy Wikimedia Commons/Mar10029/Creative Commons License

“To a smaller degree, it is also attributable to the use of influenza vaccine, and to the use of more stringent diagnostic criteria,” Dr. Wald, who chairs the department of pediatrics at the University of Wisconsin, Madison, said at the annual meeting of the American Academy of Pediatrics. “The fact that we are decreasing the number of episodes of otitis media in children in the first year of life means that we’re going to have fewer otitis-prone children and therefore less of a need for tympanostomy tubes, either as a solution to the problem of recurrence of acute otitis media (AOM) or for the problem of persistent effusion.”

The best way to limit antimicrobial use is for clinicians to increase their ability to differentiate AOM from otitis media with effusion (OME), said Dr. Wald, pediatrician-in-chief at the American Family Children’s Hospital in Madison. She noted that OME is a nonbacterial inflammatory state that usually resolves spontaneously. It tends to occur before or after AOM, and often without ever progressing to AOM. “Its principal importance is as a cause of hearing loss and as a confounder in the diagnosis AOM,” she explained. “Because it is a nonbacterial process, antibiotics are not indicated in the management of OME. In contrast, children with AOM have a bacterial infection that will benefit from the use of antimicrobials.”*

Middle ear effusion is common to both OME and AOM, she continued. To discriminate between the two conditions, clinicians must look for signs of acute inflammation of the tympanic membrane, “which we expect to see in AOM,” she said. “The most powerful sign of inflammation of the tympanic membrane is distinct fullness or bulging of the tympanic membrane on exam.”

Dr. Wald advises clinicians to be as systematic as possible when conducting the otoscopic exam, by looking at color and classifying it as pink, gray, white, yellow, red, amber, or blue, and by documenting the position as neutral, retracted, full, or bulging. “When we gauge how light passes through the tympanic membrane, we judge it as translucent, opaque, or partially opaque, and mobility as normal, decreased, or absent,” she added. “When we find decreased or absent mobility of the tympanic membrane, it tells us that we have fluid in the middle ear, but it does not discriminate between AOM and OME.”

Advances in digital otoscopy are helping pediatricians to improve their diagnostic skills. An early device, the iPhone otoscope by CellScope, uses an iOS smartphone to capture images and videos of the external ear canal and eardrum. “The image is pretty much the same as that seen through the eye of a hand-held otoscope,” Dr. Wald said. “The problem with this particular design is that the speculum is kind of large. It does still require the removal of cerumen, and the smartphone is kind of awkward to use as a handle during an otoscopic exam.”

A new digital otoscope called Wispr was unveiled at the AAP meeting. First developed at the University of Wisconsin and now marketed by WiscMed, Wispr delivers high-resolution views of the eardrum in even small or partially obstructed ear canals with one-button image and video capture. WiscMed was founded by Jim Berbee, MD, MBA, an engineer turned emergency medicine physician.

“One of the advantages of this particular model is that it handles a lot more like a usual otoscope and can be attached to the rechargeable handles that are commercially available,” Dr. Wald said. “It has an extremely tiny speculum. Within the head, there is even a smaller camera that allows the photographs to be taken. Because the speculum is so tiny, it allows the device to sometimes avoid the presence of cerumen, or sometimes go through it and still obtain an image.”

[email protected]

*This article was updated 12/13/2019

NEW ORLEANS – The incidence of acute otitis media has decreased by 25% to 35% in the past decade, thanks largely to the widespread and near universal use of the pneumococcal conjugate vaccine, according to Ellen R. Wald, MD.

Courtesy Wikimedia Commons/Mar10029/Creative Commons License

“To a smaller degree, it is also attributable to the use of influenza vaccine, and to the use of more stringent diagnostic criteria,” Dr. Wald, who chairs the department of pediatrics at the University of Wisconsin, Madison, said at the annual meeting of the American Academy of Pediatrics. “The fact that we are decreasing the number of episodes of otitis media in children in the first year of life means that we’re going to have fewer otitis-prone children and therefore less of a need for tympanostomy tubes, either as a solution to the problem of recurrence of acute otitis media (AOM) or for the problem of persistent effusion.”

The best way to limit antimicrobial use is for clinicians to increase their ability to differentiate AOM from otitis media with effusion (OME), said Dr. Wald, pediatrician-in-chief at the American Family Children’s Hospital in Madison. She noted that OME is a nonbacterial inflammatory state that usually resolves spontaneously. It tends to occur before or after AOM, and often without ever progressing to AOM. “Its principal importance is as a cause of hearing loss and as a confounder in the diagnosis AOM,” she explained. “Because it is a nonbacterial process, antibiotics are not indicated in the management of OME. In contrast, children with AOM have a bacterial infection that will benefit from the use of antimicrobials.”*

Middle ear effusion is common to both OME and AOM, she continued. To discriminate between the two conditions, clinicians must look for signs of acute inflammation of the tympanic membrane, “which we expect to see in AOM,” she said. “The most powerful sign of inflammation of the tympanic membrane is distinct fullness or bulging of the tympanic membrane on exam.”

Dr. Wald advises clinicians to be as systematic as possible when conducting the otoscopic exam, by looking at color and classifying it as pink, gray, white, yellow, red, amber, or blue, and by documenting the position as neutral, retracted, full, or bulging. “When we gauge how light passes through the tympanic membrane, we judge it as translucent, opaque, or partially opaque, and mobility as normal, decreased, or absent,” she added. “When we find decreased or absent mobility of the tympanic membrane, it tells us that we have fluid in the middle ear, but it does not discriminate between AOM and OME.”

Advances in digital otoscopy are helping pediatricians to improve their diagnostic skills. An early device, the iPhone otoscope by CellScope, uses an iOS smartphone to capture images and videos of the external ear canal and eardrum. “The image is pretty much the same as that seen through the eye of a hand-held otoscope,” Dr. Wald said. “The problem with this particular design is that the speculum is kind of large. It does still require the removal of cerumen, and the smartphone is kind of awkward to use as a handle during an otoscopic exam.”

A new digital otoscope called Wispr was unveiled at the AAP meeting. First developed at the University of Wisconsin and now marketed by WiscMed, Wispr delivers high-resolution views of the eardrum in even small or partially obstructed ear canals with one-button image and video capture. WiscMed was founded by Jim Berbee, MD, MBA, an engineer turned emergency medicine physician.

“One of the advantages of this particular model is that it handles a lot more like a usual otoscope and can be attached to the rechargeable handles that are commercially available,” Dr. Wald said. “It has an extremely tiny speculum. Within the head, there is even a smaller camera that allows the photographs to be taken. Because the speculum is so tiny, it allows the device to sometimes avoid the presence of cerumen, or sometimes go through it and still obtain an image.”

[email protected]

*This article was updated 12/13/2019

NEW ORLEANS – One way to make sure your practice providing immunizations is in the black is to calculate your “carrying costs” and apply them to the cost of your vaccines.

Another is to make sure that you join an effectively managed and effective group purchasing organization.

Doug Brunk/MDedge News

Those are two tips that Chip Hart shared with attendees at the annual meeting of the American Academy of Pediatrics.

“Your practices will fail if immunizations are not paid,” said Mr. Hart, director of the Winooski, Vt.–based the Pediatric Solutions Consulting Group at the Physicians Computer Company. “Providing immunizations is the single most valuable thing that you do, by far. Yet you get ripped off by the payers all the time.”

Two documents from the AAP – “The business case for pricing vaccines” and “The business case for pricing immunization administration” – provide clear-cut guidance on the impact of vaccine delivery to your bottom line. Based on data from his company’s client base, Mr. Hart said that vaccines have grown from 13% of an average pediatric practice’s revenue in 2003 to 22% in 2018. “The AAP’s own research shows that you need to generate 17%-28% above what you paid for the vaccine in order just to break even,” he said. That’s to cover the administrative overhead required to purchase and store the product in an office-based refrigerator, and the staff time to administer it. Such “carrying costs” often are not factored into the analysis of many managing pediatricians.

“The unfortunate reality is, you are not paid for carrying costs related to the administration of vaccines, including your refrigerator, your sharps and waste management, claim denials, and especially every time you waste a vaccine,” Mr. Hart said. “None of those things are part of any fee schedule.”

How to determine your vaccine product overhead

There are two ways to go about determining your vaccine product overhead. The first is to perform an in-depth analysis of your costs, including time studies and cost accounting. For example, he said that if your hazardous waste costs are $3,500 per year and half of the material is composed of vaccine waste, that leaves $1,750. “If you divide that by the number of vaccines you did last year, it might come out to 13 cents per vaccine,” Mr. Hart said, “but these things add up.” On the administration side, he offered the example of a nurse who makes $45,000 per year and who devotes 10% of her time to vaccines in a practice that administers 13,000 vaccinations per year. In this case, $45,000 per year divided by 13,000 vaccines equals 35 cents than can be added to the cost of every vaccine.

“You can go into each one of these elements and figure out how much you need to clear in order to do all right,” he said.

Alternatively, you can use the research from the AAP to presume that you need to have a margin of 17%-28% on your product. “Use a figure like 20% or 25% – it’s likely as accurate as any analysis a busy private practice is capable of doing, and you can immediately determine if you are in the profitability ballpark,” Mr. Hart said. On the administration side of the equation, in 2009, researchers estimated that the total documented variable cost per injection, excluding vaccine cost, was $11.51 (Pediatrics. 2009 Dec;124 [Suppl 5]:S492-8). That figure is more like $14 or $15 per vaccine in today’s dollars, Mr. Hart estimated. “You can perform a time-motion study and determine all of your immunization administration costs or you can just simply pick an evidence-based figure like $14 and see how well you are doing,” he said.

On his company’s web site, he offers a free administrative analysis tool that clinicians can use to determine how they fare. The AAP also provides information about vaccine financing here.

How to make sure you are operating in the red

Mr. Hart advises practices operating in the red to review their vaccine delivery work flow “to look for leaks,” to use proper administrative codes, and to negotiate the price of vaccine product with payers. “The only payers that don’t negotiate are state Medicaid and Tricare,” he said. “Everyone else negotiates. You want to determine the methodology they use to calculate what they pay you for the vaccine product. Different payers have different rule sets.”

Another strategy to join a group purchasing organization (GPO), which can leverage volume purchasing to negotiate discounts on vaccines. “They’re like [the] Costco or Sam’s Club of vaccine purchasing, and in most cases they can save you about $10,000 per year,” Mr. Hart said. A list of GPOs from the AAP can be found here.

Implementing effective inventory management is also key. “Practices that have the discipline to maintain their inventories are inevitably the ones who are more profitable,” Mr. Hart said. “I’ve worked with too many practices where flu shots go missing. Staff take them home or bring in their friends after hours. You need inventory control, and you should be able to generate an inventory report out of your practice management system. You also should be able to generate a report out of your EHR.”

Mr. Hart reported having no relevant financial disclosures.

[email protected]

NEW ORLEANS – One way to make sure your practice providing immunizations is in the black is to calculate your “carrying costs” and apply them to the cost of your vaccines.

Another is to make sure that you join an effectively managed and effective group purchasing organization.

Doug Brunk/MDedge News

Those are two tips that Chip Hart shared with attendees at the annual meeting of the American Academy of Pediatrics.

“Your practices will fail if immunizations are not paid,” said Mr. Hart, director of the Winooski, Vt.–based the Pediatric Solutions Consulting Group at the Physicians Computer Company. “Providing immunizations is the single most valuable thing that you do, by far. Yet you get ripped off by the payers all the time.”

Two documents from the AAP – “The business case for pricing vaccines” and “The business case for pricing immunization administration” – provide clear-cut guidance on the impact of vaccine delivery to your bottom line. Based on data from his company’s client base, Mr. Hart said that vaccines have grown from 13% of an average pediatric practice’s revenue in 2003 to 22% in 2018. “The AAP’s own research shows that you need to generate 17%-28% above what you paid for the vaccine in order just to break even,” he said. That’s to cover the administrative overhead required to purchase and store the product in an office-based refrigerator, and the staff time to administer it. Such “carrying costs” often are not factored into the analysis of many managing pediatricians.

“The unfortunate reality is, you are not paid for carrying costs related to the administration of vaccines, including your refrigerator, your sharps and waste management, claim denials, and especially every time you waste a vaccine,” Mr. Hart said. “None of those things are part of any fee schedule.”

How to determine your vaccine product overhead

There are two ways to go about determining your vaccine product overhead. The first is to perform an in-depth analysis of your costs, including time studies and cost accounting. For example, he said that if your hazardous waste costs are $3,500 per year and half of the material is composed of vaccine waste, that leaves $1,750. “If you divide that by the number of vaccines you did last year, it might come out to 13 cents per vaccine,” Mr. Hart said, “but these things add up.” On the administration side, he offered the example of a nurse who makes $45,000 per year and who devotes 10% of her time to vaccines in a practice that administers 13,000 vaccinations per year. In this case, $45,000 per year divided by 13,000 vaccines equals 35 cents than can be added to the cost of every vaccine.

“You can go into each one of these elements and figure out how much you need to clear in order to do all right,” he said.

Alternatively, you can use the research from the AAP to presume that you need to have a margin of 17%-28% on your product. “Use a figure like 20% or 25% – it’s likely as accurate as any analysis a busy private practice is capable of doing, and you can immediately determine if you are in the profitability ballpark,” Mr. Hart said. On the administration side of the equation, in 2009, researchers estimated that the total documented variable cost per injection, excluding vaccine cost, was $11.51 (Pediatrics. 2009 Dec;124 [Suppl 5]:S492-8). That figure is more like $14 or $15 per vaccine in today’s dollars, Mr. Hart estimated. “You can perform a time-motion study and determine all of your immunization administration costs or you can just simply pick an evidence-based figure like $14 and see how well you are doing,” he said.

On his company’s web site, he offers a free administrative analysis tool that clinicians can use to determine how they fare. The AAP also provides information about vaccine financing here.

How to make sure you are operating in the red

Mr. Hart advises practices operating in the red to review their vaccine delivery work flow “to look for leaks,” to use proper administrative codes, and to negotiate the price of vaccine product with payers. “The only payers that don’t negotiate are state Medicaid and Tricare,” he said. “Everyone else negotiates. You want to determine the methodology they use to calculate what they pay you for the vaccine product. Different payers have different rule sets.”

Another strategy to join a group purchasing organization (GPO), which can leverage volume purchasing to negotiate discounts on vaccines. “They’re like [the] Costco or Sam’s Club of vaccine purchasing, and in most cases they can save you about $10,000 per year,” Mr. Hart said. A list of GPOs from the AAP can be found here.

Implementing effective inventory management is also key. “Practices that have the discipline to maintain their inventories are inevitably the ones who are more profitable,” Mr. Hart said. “I’ve worked with too many practices where flu shots go missing. Staff take them home or bring in their friends after hours. You need inventory control, and you should be able to generate an inventory report out of your practice management system. You also should be able to generate a report out of your EHR.”

Mr. Hart reported having no relevant financial disclosures.

[email protected]

NEW ORLEANS – One way to make sure your practice providing immunizations is in the black is to calculate your “carrying costs” and apply them to the cost of your vaccines.

Another is to make sure that you join an effectively managed and effective group purchasing organization.

Doug Brunk/MDedge News

Those are two tips that Chip Hart shared with attendees at the annual meeting of the American Academy of Pediatrics.

“Your practices will fail if immunizations are not paid,” said Mr. Hart, director of the Winooski, Vt.–based the Pediatric Solutions Consulting Group at the Physicians Computer Company. “Providing immunizations is the single most valuable thing that you do, by far. Yet you get ripped off by the payers all the time.”

Two documents from the AAP – “The business case for pricing vaccines” and “The business case for pricing immunization administration” – provide clear-cut guidance on the impact of vaccine delivery to your bottom line. Based on data from his company’s client base, Mr. Hart said that vaccines have grown from 13% of an average pediatric practice’s revenue in 2003 to 22% in 2018. “The AAP’s own research shows that you need to generate 17%-28% above what you paid for the vaccine in order just to break even,” he said. That’s to cover the administrative overhead required to purchase and store the product in an office-based refrigerator, and the staff time to administer it. Such “carrying costs” often are not factored into the analysis of many managing pediatricians.

“The unfortunate reality is, you are not paid for carrying costs related to the administration of vaccines, including your refrigerator, your sharps and waste management, claim denials, and especially every time you waste a vaccine,” Mr. Hart said. “None of those things are part of any fee schedule.”

How to determine your vaccine product overhead

There are two ways to go about determining your vaccine product overhead. The first is to perform an in-depth analysis of your costs, including time studies and cost accounting. For example, he said that if your hazardous waste costs are $3,500 per year and half of the material is composed of vaccine waste, that leaves $1,750. “If you divide that by the number of vaccines you did last year, it might come out to 13 cents per vaccine,” Mr. Hart said, “but these things add up.” On the administration side, he offered the example of a nurse who makes $45,000 per year and who devotes 10% of her time to vaccines in a practice that administers 13,000 vaccinations per year. In this case, $45,000 per year divided by 13,000 vaccines equals 35 cents than can be added to the cost of every vaccine.

“You can go into each one of these elements and figure out how much you need to clear in order to do all right,” he said.

Alternatively, you can use the research from the AAP to presume that you need to have a margin of 17%-28% on your product. “Use a figure like 20% or 25% – it’s likely as accurate as any analysis a busy private practice is capable of doing, and you can immediately determine if you are in the profitability ballpark,” Mr. Hart said. On the administration side of the equation, in 2009, researchers estimated that the total documented variable cost per injection, excluding vaccine cost, was $11.51 (Pediatrics. 2009 Dec;124 [Suppl 5]:S492-8). That figure is more like $14 or $15 per vaccine in today’s dollars, Mr. Hart estimated. “You can perform a time-motion study and determine all of your immunization administration costs or you can just simply pick an evidence-based figure like $14 and see how well you are doing,” he said.

On his company’s web site, he offers a free administrative analysis tool that clinicians can use to determine how they fare. The AAP also provides information about vaccine financing here.

How to make sure you are operating in the red

Mr. Hart advises practices operating in the red to review their vaccine delivery work flow “to look for leaks,” to use proper administrative codes, and to negotiate the price of vaccine product with payers. “The only payers that don’t negotiate are state Medicaid and Tricare,” he said. “Everyone else negotiates. You want to determine the methodology they use to calculate what they pay you for the vaccine product. Different payers have different rule sets.”

Another strategy to join a group purchasing organization (GPO), which can leverage volume purchasing to negotiate discounts on vaccines. “They’re like [the] Costco or Sam’s Club of vaccine purchasing, and in most cases they can save you about $10,000 per year,” Mr. Hart said. A list of GPOs from the AAP can be found here.

Implementing effective inventory management is also key. “Practices that have the discipline to maintain their inventories are inevitably the ones who are more profitable,” Mr. Hart said. “I’ve worked with too many practices where flu shots go missing. Staff take them home or bring in their friends after hours. You need inventory control, and you should be able to generate an inventory report out of your practice management system. You also should be able to generate a report out of your EHR.”

Mr. Hart reported having no relevant financial disclosures.

[email protected]