Commentary

Urban legends never seem to die. They haunt those who chase the truth because most legends have a kernel of truth. Reflux nephropathy is one of those legends.

In the 1970s, neurosurgeons began treating children with spina bifida rather than allowing them to die shortly after birth. As these children entered their second and third decade of life, episodes of renal failure were noted. The reflux and recurring urinary tract infections (UTIs) from neurogenic bladders damaged kidneys. Self-catheter programs were invented and were effective. Surgical correction of anatomic urinary obstructions and severe reflux yielded similar benefits. By the 1990s, this paradigm had been extrapolated to all children with vesicoureteral reflux (VUR) and codified in the 1999 practice parameter. The unproven hope was that aggressive antibiotic prophylaxis to protect young, growing kidneys from infections would reduce the incidence of renal failure and hypertension in adults.

This is a common methodology for quality improvement at a Mortality and Morbidity conference. A problem is identified. A solution is developed to prevent the bad outcome. The solution is implemented without fully proving that the obvious, customized intervention truly works. No one ever assesses whether the remedy causes more mischief than benefit.

VUR has a pyramid shaped spectrum. Few children have the severe grade V reflux which responds to surgical intervention. At the base of the pyramid are a much larger group of children with mild reflux that usually resolves spontaneously by age 5 years. This pyramid is a setup for overdiagnosis and overtreatment of mild disease. Pediatricians soon recognized that the small portion of the 1999 practice parameter addressing reflux nephropathy was overly aggressive and based on unsound science. However, that same lack of clear evidence delayed creating a new consensus until 2011.

The recent efforts to prove the benefit of prophylaxis used exemplary evidence-based medicine. The RIVUR study over 4 years assessed 10,000 children in a multicenter study involving 19 locations. It enrolled 600 children in a prospective, double-blind, randomized, controlled trial with a placebo control. It followed the children for 2 years. Even by modern standards, this was a huge, prolonged and well-designed trial. It did demonstrate a benefit. About 20% of children on placebo had a recurrent UTI in that 2-year time frame. There was a 50% reduction in the number of UTIs in the children treated with antibiotic prophylaxis. Phrased that way, it was a success. But the numbers can be spun differently. The article duly noted a number needed to treat of eight. Eight children treated for 2 years at 365 days per year and one dose per day, means that 6,000 doses of antibiotics were necessary to prevent one UTI. There was no demonstrated benefit in renal scarring, renal failure, or other long-term outcomes. There was a downside. The rate of antibiotic-resistant organisms in the breakthrough UTIs tripled from 19% of the placebo group to 63% of the prophylaxis group. As large as this study was, it wasn’t able to measure the rate of other known adverse outcomes, such as Stevens-Johnson syndrome from the use of sulfa medications or the impact on resistant infections elsewhere in the body.

With the 2011 practice parameter, pediatricians became less aggressive at working up first UTIs. Urologists disagreed. The May 2015 issue of AAP News had a full page article by Dr. Saul Greenfield, who is the chairperson-elect for the Executive Committee of the American Academy of Pediatrics Section on Urology, a urologist in Buffalo, N.Y., and one of the RIVUR trial’s investigators (AAP News 2015;36:13). He rehashed the RIVUR study results emphasizing the reduction in UTIs, but offered no quantitative assessment of the risks, costs, and harms of prophylaxis.

A June 2015 article in Pediatrics gives the results of the CUTIE study, which ran in parallel with the RIVUR study (Pediatrics 2015 [doi:10.1542/peds.2015-0409]). The conclusions: “VUR and BBD [bladder and bowel dysfunction] are risk factors for recurrent UTI, especially when they appear in combination. Strategies for preventing recurrent UTI include antimicrobial prophylaxis and treatment of BBD.”

The article concludes with, “Therefore, clinicians must help families decide whether the benefits of prophylaxis outweigh the risks and inconvenience. … Additional research is needed to validate the risk factors and profiles that we identified.”

But six pages of discussing renal scarring (which is only a proxy for a small risk of future renal failure or hypertension), followed by a couple paragraphs, without numbers, about the risks of prophylaxis, does not provide the balanced presentation clinicians need to help families make wise decisions. In the new era of Choosing Wisely, scientific articles making clinical recommendations should not be published without an accompanying risk-benefit analysis, either in the article or in an editorial. The maxim in surgery, channeling Voltaire, is that “perfect is the enemy of good.”

There is mounting evidence that giving any antibiotics to young infants is harmful. Even 2 days of antibiotics before 1 month of age leads to measurable changes in the gut microbiota 6 months later. Antibiotics in infancy are associated with obesity at 24 months and at 48 months of age. All medical treatments introduce a substantial risk of harm. As Shakespeare wrote 400 years ago, “Striving to better, oft we mar what’s well.” I don’t doubt the conclusion that prophylaxis reduces UTIs, but giving 6,000 doses to prevent one UTI?! Even Kaley Cuoco can’t sell that.

Ultimately, this choice is not up to the hospitalist, the emergency department doctor, or the urologist. The decision belongs to the parents guided by a primary care doctor they trust. Our professional duty, ethically and legally, is to communicate the risks and benefits to the parents in a manner which they can understand and to provide them the support and counseling necessary to make a wise choice for their child. By focusing on the child and that duty, medical professionals can defuse any clashes of egos, departmental power struggles, or autocratic hierarchy that might interfere. Doctors educate and recommend, but the parent decides what is best for his or her child.

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Dr. Powell said he had no relevant financial disclosures or conflicts of interest. E-mail him at [email protected].

Urban legends never seem to die. They haunt those who chase the truth because most legends have a kernel of truth. Reflux nephropathy is one of those legends.

In the 1970s, neurosurgeons began treating children with spina bifida rather than allowing them to die shortly after birth. As these children entered their second and third decade of life, episodes of renal failure were noted. The reflux and recurring urinary tract infections (UTIs) from neurogenic bladders damaged kidneys. Self-catheter programs were invented and were effective. Surgical correction of anatomic urinary obstructions and severe reflux yielded similar benefits. By the 1990s, this paradigm had been extrapolated to all children with vesicoureteral reflux (VUR) and codified in the 1999 practice parameter. The unproven hope was that aggressive antibiotic prophylaxis to protect young, growing kidneys from infections would reduce the incidence of renal failure and hypertension in adults.

This is a common methodology for quality improvement at a Mortality and Morbidity conference. A problem is identified. A solution is developed to prevent the bad outcome. The solution is implemented without fully proving that the obvious, customized intervention truly works. No one ever assesses whether the remedy causes more mischief than benefit.

VUR has a pyramid shaped spectrum. Few children have the severe grade V reflux which responds to surgical intervention. At the base of the pyramid are a much larger group of children with mild reflux that usually resolves spontaneously by age 5 years. This pyramid is a setup for overdiagnosis and overtreatment of mild disease. Pediatricians soon recognized that the small portion of the 1999 practice parameter addressing reflux nephropathy was overly aggressive and based on unsound science. However, that same lack of clear evidence delayed creating a new consensus until 2011.

The recent efforts to prove the benefit of prophylaxis used exemplary evidence-based medicine. The RIVUR study over 4 years assessed 10,000 children in a multicenter study involving 19 locations. It enrolled 600 children in a prospective, double-blind, randomized, controlled trial with a placebo control. It followed the children for 2 years. Even by modern standards, this was a huge, prolonged and well-designed trial. It did demonstrate a benefit. About 20% of children on placebo had a recurrent UTI in that 2-year time frame. There was a 50% reduction in the number of UTIs in the children treated with antibiotic prophylaxis. Phrased that way, it was a success. But the numbers can be spun differently. The article duly noted a number needed to treat of eight. Eight children treated for 2 years at 365 days per year and one dose per day, means that 6,000 doses of antibiotics were necessary to prevent one UTI. There was no demonstrated benefit in renal scarring, renal failure, or other long-term outcomes. There was a downside. The rate of antibiotic-resistant organisms in the breakthrough UTIs tripled from 19% of the placebo group to 63% of the prophylaxis group. As large as this study was, it wasn’t able to measure the rate of other known adverse outcomes, such as Stevens-Johnson syndrome from the use of sulfa medications or the impact on resistant infections elsewhere in the body.

With the 2011 practice parameter, pediatricians became less aggressive at working up first UTIs. Urologists disagreed. The May 2015 issue of AAP News had a full page article by Dr. Saul Greenfield, who is the chairperson-elect for the Executive Committee of the American Academy of Pediatrics Section on Urology, a urologist in Buffalo, N.Y., and one of the RIVUR trial’s investigators (AAP News 2015;36:13). He rehashed the RIVUR study results emphasizing the reduction in UTIs, but offered no quantitative assessment of the risks, costs, and harms of prophylaxis.

A June 2015 article in Pediatrics gives the results of the CUTIE study, which ran in parallel with the RIVUR study (Pediatrics 2015 [doi:10.1542/peds.2015-0409]). The conclusions: “VUR and BBD [bladder and bowel dysfunction] are risk factors for recurrent UTI, especially when they appear in combination. Strategies for preventing recurrent UTI include antimicrobial prophylaxis and treatment of BBD.”

The article concludes with, “Therefore, clinicians must help families decide whether the benefits of prophylaxis outweigh the risks and inconvenience. … Additional research is needed to validate the risk factors and profiles that we identified.”

But six pages of discussing renal scarring (which is only a proxy for a small risk of future renal failure or hypertension), followed by a couple paragraphs, without numbers, about the risks of prophylaxis, does not provide the balanced presentation clinicians need to help families make wise decisions. In the new era of Choosing Wisely, scientific articles making clinical recommendations should not be published without an accompanying risk-benefit analysis, either in the article or in an editorial. The maxim in surgery, channeling Voltaire, is that “perfect is the enemy of good.”

There is mounting evidence that giving any antibiotics to young infants is harmful. Even 2 days of antibiotics before 1 month of age leads to measurable changes in the gut microbiota 6 months later. Antibiotics in infancy are associated with obesity at 24 months and at 48 months of age. All medical treatments introduce a substantial risk of harm. As Shakespeare wrote 400 years ago, “Striving to better, oft we mar what’s well.” I don’t doubt the conclusion that prophylaxis reduces UTIs, but giving 6,000 doses to prevent one UTI?! Even Kaley Cuoco can’t sell that.

Ultimately, this choice is not up to the hospitalist, the emergency department doctor, or the urologist. The decision belongs to the parents guided by a primary care doctor they trust. Our professional duty, ethically and legally, is to communicate the risks and benefits to the parents in a manner which they can understand and to provide them the support and counseling necessary to make a wise choice for their child. By focusing on the child and that duty, medical professionals can defuse any clashes of egos, departmental power struggles, or autocratic hierarchy that might interfere. Doctors educate and recommend, but the parent decides what is best for his or her child.

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Dr. Powell said he had no relevant financial disclosures or conflicts of interest. E-mail him at [email protected].

Urban legends never seem to die. They haunt those who chase the truth because most legends have a kernel of truth. Reflux nephropathy is one of those legends.

In the 1970s, neurosurgeons began treating children with spina bifida rather than allowing them to die shortly after birth. As these children entered their second and third decade of life, episodes of renal failure were noted. The reflux and recurring urinary tract infections (UTIs) from neurogenic bladders damaged kidneys. Self-catheter programs were invented and were effective. Surgical correction of anatomic urinary obstructions and severe reflux yielded similar benefits. By the 1990s, this paradigm had been extrapolated to all children with vesicoureteral reflux (VUR) and codified in the 1999 practice parameter. The unproven hope was that aggressive antibiotic prophylaxis to protect young, growing kidneys from infections would reduce the incidence of renal failure and hypertension in adults.

This is a common methodology for quality improvement at a Mortality and Morbidity conference. A problem is identified. A solution is developed to prevent the bad outcome. The solution is implemented without fully proving that the obvious, customized intervention truly works. No one ever assesses whether the remedy causes more mischief than benefit.

VUR has a pyramid shaped spectrum. Few children have the severe grade V reflux which responds to surgical intervention. At the base of the pyramid are a much larger group of children with mild reflux that usually resolves spontaneously by age 5 years. This pyramid is a setup for overdiagnosis and overtreatment of mild disease. Pediatricians soon recognized that the small portion of the 1999 practice parameter addressing reflux nephropathy was overly aggressive and based on unsound science. However, that same lack of clear evidence delayed creating a new consensus until 2011.

The recent efforts to prove the benefit of prophylaxis used exemplary evidence-based medicine. The RIVUR study over 4 years assessed 10,000 children in a multicenter study involving 19 locations. It enrolled 600 children in a prospective, double-blind, randomized, controlled trial with a placebo control. It followed the children for 2 years. Even by modern standards, this was a huge, prolonged and well-designed trial. It did demonstrate a benefit. About 20% of children on placebo had a recurrent UTI in that 2-year time frame. There was a 50% reduction in the number of UTIs in the children treated with antibiotic prophylaxis. Phrased that way, it was a success. But the numbers can be spun differently. The article duly noted a number needed to treat of eight. Eight children treated for 2 years at 365 days per year and one dose per day, means that 6,000 doses of antibiotics were necessary to prevent one UTI. There was no demonstrated benefit in renal scarring, renal failure, or other long-term outcomes. There was a downside. The rate of antibiotic-resistant organisms in the breakthrough UTIs tripled from 19% of the placebo group to 63% of the prophylaxis group. As large as this study was, it wasn’t able to measure the rate of other known adverse outcomes, such as Stevens-Johnson syndrome from the use of sulfa medications or the impact on resistant infections elsewhere in the body.

With the 2011 practice parameter, pediatricians became less aggressive at working up first UTIs. Urologists disagreed. The May 2015 issue of AAP News had a full page article by Dr. Saul Greenfield, who is the chairperson-elect for the Executive Committee of the American Academy of Pediatrics Section on Urology, a urologist in Buffalo, N.Y., and one of the RIVUR trial’s investigators (AAP News 2015;36:13). He rehashed the RIVUR study results emphasizing the reduction in UTIs, but offered no quantitative assessment of the risks, costs, and harms of prophylaxis.

A June 2015 article in Pediatrics gives the results of the CUTIE study, which ran in parallel with the RIVUR study (Pediatrics 2015 [doi:10.1542/peds.2015-0409]). The conclusions: “VUR and BBD [bladder and bowel dysfunction] are risk factors for recurrent UTI, especially when they appear in combination. Strategies for preventing recurrent UTI include antimicrobial prophylaxis and treatment of BBD.”

The article concludes with, “Therefore, clinicians must help families decide whether the benefits of prophylaxis outweigh the risks and inconvenience. … Additional research is needed to validate the risk factors and profiles that we identified.”

But six pages of discussing renal scarring (which is only a proxy for a small risk of future renal failure or hypertension), followed by a couple paragraphs, without numbers, about the risks of prophylaxis, does not provide the balanced presentation clinicians need to help families make wise decisions. In the new era of Choosing Wisely, scientific articles making clinical recommendations should not be published without an accompanying risk-benefit analysis, either in the article or in an editorial. The maxim in surgery, channeling Voltaire, is that “perfect is the enemy of good.”

There is mounting evidence that giving any antibiotics to young infants is harmful. Even 2 days of antibiotics before 1 month of age leads to measurable changes in the gut microbiota 6 months later. Antibiotics in infancy are associated with obesity at 24 months and at 48 months of age. All medical treatments introduce a substantial risk of harm. As Shakespeare wrote 400 years ago, “Striving to better, oft we mar what’s well.” I don’t doubt the conclusion that prophylaxis reduces UTIs, but giving 6,000 doses to prevent one UTI?! Even Kaley Cuoco can’t sell that.

Ultimately, this choice is not up to the hospitalist, the emergency department doctor, or the urologist. The decision belongs to the parents guided by a primary care doctor they trust. Our professional duty, ethically and legally, is to communicate the risks and benefits to the parents in a manner which they can understand and to provide them the support and counseling necessary to make a wise choice for their child. By focusing on the child and that duty, medical professionals can defuse any clashes of egos, departmental power struggles, or autocratic hierarchy that might interfere. Doctors educate and recommend, but the parent decides what is best for his or her child.

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Dr. Powell said he had no relevant financial disclosures or conflicts of interest. E-mail him at [email protected].

For decades, bullying has been viewed as an unpleasant but generally benign rite of passage that many children experience and overcome without significant consequences. Some high-profile examples of youth suicide coupled with several stunning research studies demonstrating major negative effects of bullying that rival the impact of things like child abuse and out-of-home placement on future physical and mental health, however, have caused many clinicians across specialties to stop and take notice (Lancet Psychiatry 2015;2:524-31). The result has been concerted antibullying efforts from varied sources including the federal government, such as stopbullying.gov, and many professional organizations. Pediatricians are in a prime position both to help individual children and families and to serve as community advocates against this significant public health concern.

Case summary

Jeremy is an 11-year-old boy who has been followed by his pediatrician since birth. He has had few health concerns over the years other than some low levels of anxiety and being somewhat overweight. At an annual checkup, his mother reports that Jeremy has missed much more school this year, often making somewhat vague physical complaints. He also has told his mother that a couple of peers at school are particularly “mean” to him. He doesn’t elaborate and doesn’t want his parents to make “a big deal” about it for fear of causing further embarrassment at school.

Discussion

At least moderate levels of bullying are estimated to occur in about 30% of school-age children, resulting in approximately160,000 lost days of school. Bullying behavior can include anything from name calling to outright physical assault. Online bullying in the form of texts, e-mails, and social media also is increasingly common. School grounds remain the most common site for bullying, and physical appearance is the most common target of bullying behavior. What is thought to separate bullying from other forms of peer conflict is that there exists some sort of power differential between the bully and the victim in terms of physical size, social status, or other features. Some interesting data also suggest some sex differences regarding bullying with boys being more likely to bully children outside of their core group of friends, and girls being more likely to bully individuals within the network of individuals with whom they typically interact.

A key element of helping bullied children involves getting them to talk about the experience with a parent, teacher, physician, or counselor. Some tips that can help get kids to talk include reassurance that the child has control over what will happen with the information (within legal limits) and that no action will be taken without their knowledge and agreement, and having adults relate stories about their own past experience with bullying. Pediatricians also may want to consider opening up the conversation more broadly by asking if bullying is a problem “at your school” rather than in a particular child’s life.

In making an appropriate intervention, parents and physicians may want to differentiate lower levels of bullying (name calling, teasing) from higher levels (overt threats, physical violence, and intimidation), keeping in mind that all forms can be potentially harmful.

For lower-level bullying, the following tips can be helpful to keep in mind in working with kids directly and in helping parents help their children:

1. Don’t underestimate the power of sympathetic listening. Overt expressions to a child that he or she doesn’t deserve this, and that such behaviors are really hurtful can be very important to many kids. Positive experiences with friends and families also can go a long way to counteract a negative encounter with a bully.

2. Coach bully victims about how to respond. The old adage of telling a bully that he or she is hurting your feelings has been replaced with advice to react emotionally as little as possible. Some children also can be helped by rehearsing specific responses or learning to join groups during higher-risk activities.

3. If the bullying is occurring online, encourage kids to save the texts or social media posts if needed as evidence.

4. Consider the option of an anonymous report to a school principal or guidance counselor. While school personnel will be unable to make a direct response, they might be able, for example, to provide more monitoring in high-risk areas such as bathrooms, school buses, or locker rooms.

For higher levels of bullying, it often is important to have more direct involvement with school staff or even the police. Many states now have mandatory bullying prevention and intervention policies. While parents of bullying victims may have strong and natural urges to confront directly the parents of the alleged bully, this step often does not help the situation and often can makes things worse.

Finally, if there is evidence that bullying is having a strong negative impact on the child, a more in-depth evaluation to rule out anxiety disorders, depression, and the presence of any suicidal or homicidal thinking should be strongly considered (JAMA 2001;285:2094-100).

Case follow-up

After reassuring Jeremy that action would not be taken without his consent, the pediatrician was able to elicit more information. She learned that two older boys have been teasing Jeremy in the cafeteria and once took away part of his lunch while telling him he was too fat to need it. After some discussion, the pediatrician agreed to call the school principal to inform the school anonymously about bullying in the cafeteria. The mother, now aware of the situation, was able to offer some support and suggestions such as having lunch in a larger group and sitting at a table that is closer to adult supervision. They agreed to meet again to make sure improvements were occurring.

Dr. Rettew is an associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. Follow him on Twitter @pedipsych. E-mail him at [email protected].

For decades, bullying has been viewed as an unpleasant but generally benign rite of passage that many children experience and overcome without significant consequences. Some high-profile examples of youth suicide coupled with several stunning research studies demonstrating major negative effects of bullying that rival the impact of things like child abuse and out-of-home placement on future physical and mental health, however, have caused many clinicians across specialties to stop and take notice (Lancet Psychiatry 2015;2:524-31). The result has been concerted antibullying efforts from varied sources including the federal government, such as stopbullying.gov, and many professional organizations. Pediatricians are in a prime position both to help individual children and families and to serve as community advocates against this significant public health concern.

Case summary

Jeremy is an 11-year-old boy who has been followed by his pediatrician since birth. He has had few health concerns over the years other than some low levels of anxiety and being somewhat overweight. At an annual checkup, his mother reports that Jeremy has missed much more school this year, often making somewhat vague physical complaints. He also has told his mother that a couple of peers at school are particularly “mean” to him. He doesn’t elaborate and doesn’t want his parents to make “a big deal” about it for fear of causing further embarrassment at school.

Discussion

At least moderate levels of bullying are estimated to occur in about 30% of school-age children, resulting in approximately160,000 lost days of school. Bullying behavior can include anything from name calling to outright physical assault. Online bullying in the form of texts, e-mails, and social media also is increasingly common. School grounds remain the most common site for bullying, and physical appearance is the most common target of bullying behavior. What is thought to separate bullying from other forms of peer conflict is that there exists some sort of power differential between the bully and the victim in terms of physical size, social status, or other features. Some interesting data also suggest some sex differences regarding bullying with boys being more likely to bully children outside of their core group of friends, and girls being more likely to bully individuals within the network of individuals with whom they typically interact.

A key element of helping bullied children involves getting them to talk about the experience with a parent, teacher, physician, or counselor. Some tips that can help get kids to talk include reassurance that the child has control over what will happen with the information (within legal limits) and that no action will be taken without their knowledge and agreement, and having adults relate stories about their own past experience with bullying. Pediatricians also may want to consider opening up the conversation more broadly by asking if bullying is a problem “at your school” rather than in a particular child’s life.

In making an appropriate intervention, parents and physicians may want to differentiate lower levels of bullying (name calling, teasing) from higher levels (overt threats, physical violence, and intimidation), keeping in mind that all forms can be potentially harmful.

For lower-level bullying, the following tips can be helpful to keep in mind in working with kids directly and in helping parents help their children:

1. Don’t underestimate the power of sympathetic listening. Overt expressions to a child that he or she doesn’t deserve this, and that such behaviors are really hurtful can be very important to many kids. Positive experiences with friends and families also can go a long way to counteract a negative encounter with a bully.

2. Coach bully victims about how to respond. The old adage of telling a bully that he or she is hurting your feelings has been replaced with advice to react emotionally as little as possible. Some children also can be helped by rehearsing specific responses or learning to join groups during higher-risk activities.

3. If the bullying is occurring online, encourage kids to save the texts or social media posts if needed as evidence.

4. Consider the option of an anonymous report to a school principal or guidance counselor. While school personnel will be unable to make a direct response, they might be able, for example, to provide more monitoring in high-risk areas such as bathrooms, school buses, or locker rooms.

For higher levels of bullying, it often is important to have more direct involvement with school staff or even the police. Many states now have mandatory bullying prevention and intervention policies. While parents of bullying victims may have strong and natural urges to confront directly the parents of the alleged bully, this step often does not help the situation and often can makes things worse.

Finally, if there is evidence that bullying is having a strong negative impact on the child, a more in-depth evaluation to rule out anxiety disorders, depression, and the presence of any suicidal or homicidal thinking should be strongly considered (JAMA 2001;285:2094-100).

Case follow-up

After reassuring Jeremy that action would not be taken without his consent, the pediatrician was able to elicit more information. She learned that two older boys have been teasing Jeremy in the cafeteria and once took away part of his lunch while telling him he was too fat to need it. After some discussion, the pediatrician agreed to call the school principal to inform the school anonymously about bullying in the cafeteria. The mother, now aware of the situation, was able to offer some support and suggestions such as having lunch in a larger group and sitting at a table that is closer to adult supervision. They agreed to meet again to make sure improvements were occurring.

Dr. Rettew is an associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. Follow him on Twitter @pedipsych. E-mail him at [email protected].

For decades, bullying has been viewed as an unpleasant but generally benign rite of passage that many children experience and overcome without significant consequences. Some high-profile examples of youth suicide coupled with several stunning research studies demonstrating major negative effects of bullying that rival the impact of things like child abuse and out-of-home placement on future physical and mental health, however, have caused many clinicians across specialties to stop and take notice (Lancet Psychiatry 2015;2:524-31). The result has been concerted antibullying efforts from varied sources including the federal government, such as stopbullying.gov, and many professional organizations. Pediatricians are in a prime position both to help individual children and families and to serve as community advocates against this significant public health concern.

Case summary

Jeremy is an 11-year-old boy who has been followed by his pediatrician since birth. He has had few health concerns over the years other than some low levels of anxiety and being somewhat overweight. At an annual checkup, his mother reports that Jeremy has missed much more school this year, often making somewhat vague physical complaints. He also has told his mother that a couple of peers at school are particularly “mean” to him. He doesn’t elaborate and doesn’t want his parents to make “a big deal” about it for fear of causing further embarrassment at school.

Discussion

At least moderate levels of bullying are estimated to occur in about 30% of school-age children, resulting in approximately160,000 lost days of school. Bullying behavior can include anything from name calling to outright physical assault. Online bullying in the form of texts, e-mails, and social media also is increasingly common. School grounds remain the most common site for bullying, and physical appearance is the most common target of bullying behavior. What is thought to separate bullying from other forms of peer conflict is that there exists some sort of power differential between the bully and the victim in terms of physical size, social status, or other features. Some interesting data also suggest some sex differences regarding bullying with boys being more likely to bully children outside of their core group of friends, and girls being more likely to bully individuals within the network of individuals with whom they typically interact.

A key element of helping bullied children involves getting them to talk about the experience with a parent, teacher, physician, or counselor. Some tips that can help get kids to talk include reassurance that the child has control over what will happen with the information (within legal limits) and that no action will be taken without their knowledge and agreement, and having adults relate stories about their own past experience with bullying. Pediatricians also may want to consider opening up the conversation more broadly by asking if bullying is a problem “at your school” rather than in a particular child’s life.

In making an appropriate intervention, parents and physicians may want to differentiate lower levels of bullying (name calling, teasing) from higher levels (overt threats, physical violence, and intimidation), keeping in mind that all forms can be potentially harmful.

For lower-level bullying, the following tips can be helpful to keep in mind in working with kids directly and in helping parents help their children:

1. Don’t underestimate the power of sympathetic listening. Overt expressions to a child that he or she doesn’t deserve this, and that such behaviors are really hurtful can be very important to many kids. Positive experiences with friends and families also can go a long way to counteract a negative encounter with a bully.

2. Coach bully victims about how to respond. The old adage of telling a bully that he or she is hurting your feelings has been replaced with advice to react emotionally as little as possible. Some children also can be helped by rehearsing specific responses or learning to join groups during higher-risk activities.

3. If the bullying is occurring online, encourage kids to save the texts or social media posts if needed as evidence.

4. Consider the option of an anonymous report to a school principal or guidance counselor. While school personnel will be unable to make a direct response, they might be able, for example, to provide more monitoring in high-risk areas such as bathrooms, school buses, or locker rooms.

For higher levels of bullying, it often is important to have more direct involvement with school staff or even the police. Many states now have mandatory bullying prevention and intervention policies. While parents of bullying victims may have strong and natural urges to confront directly the parents of the alleged bully, this step often does not help the situation and often can makes things worse.

Finally, if there is evidence that bullying is having a strong negative impact on the child, a more in-depth evaluation to rule out anxiety disorders, depression, and the presence of any suicidal or homicidal thinking should be strongly considered (JAMA 2001;285:2094-100).

Case follow-up

After reassuring Jeremy that action would not be taken without his consent, the pediatrician was able to elicit more information. She learned that two older boys have been teasing Jeremy in the cafeteria and once took away part of his lunch while telling him he was too fat to need it. After some discussion, the pediatrician agreed to call the school principal to inform the school anonymously about bullying in the cafeteria. The mother, now aware of the situation, was able to offer some support and suggestions such as having lunch in a larger group and sitting at a table that is closer to adult supervision. They agreed to meet again to make sure improvements were occurring.

Dr. Rettew is an associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. Follow him on Twitter @pedipsych. E-mail him at [email protected].

Sleep deprivation being a health issue in adolescence is no surprise. We hear repeated reports on cellphone use and excessive video gaming as contributors to sleep deprivation, but how many pediatricians are actually warning their patient during annual exams about the health impact of sleep deprivation?

The American Academy of Pediatrics recently published its policy on sleep and recommended adolescents get at least 8.5 hours of sleep per night and that school start time for middle schools be 8:30 a.m. (Pediatrics 2014;134:642-9). Despite this recommendation, more than 60% of U.S. schools have start times earlier than 8:00 a.m. A recent study also showed that 59% of 6th-8th graders and 87% of high school students obtained less the recommended 8.5 hours.

The reasoning behind the recommendation was based on the natural change in sleep cycle that occurs during adolescence, in which the circadian rhythm changes, resulting in decreased secretion of melatonin and delayed onset of sleep. With later start times, adolescents actually get up to an extra hour of sleep, which in turn results in fewer absences, improved focus, concentration, and better behavior (Pediatrics 2014 [doi:10.1542/peds.2014-1697]).

But beyond biologic cause for delayed sleep, social media, texting, and video games further impact the amount of sleep obtained, which leaves the majority of teens sleep deprived. Watching TV more than 3 hours per night impacts your ability not only to fall asleep, but to stay asleep, which again increases daytime sleepiness. Many may think that the “weekend catch-up” might ameliorate the deprivation, but studies show that the inconsistency of appropriate sleep further disrupts the wake-sleep cycles and further reduces the secretion of melatonin.

So how does sleep deprivation impact health? The obvious increased daytime sleepiness which results in poor concentration and focus is well known, and clearly contributes to the number of car accidents in this age group. But there are clear physiologic changes that occur when there is inadequate sleep that result in increased risk for diabetes, obesity, depression, cardiovascular disease, and even Alzheimer’s (Psychiatry Res. 2010;176:34-9; Sleep 2004;27:1351-8; Endocr. Dev. 2010;17:11-21). Lack of sleep has shown alterations in metabolic profiles, such as insulin, cortisol, and leptin, which lead to insulin resistance, increased sympathetic nervous system activity, increased hunger, and decreased satiety (Pediatrics 2014 [doi:10.1542/peds.2014-1697]).

The resulting lack of sleep in adolescence has cause increased intake of caffeine as well. Recent surveys show that caffeine use has skyrocketed this age group. If it is taken in the form of energy drinks, coffee, or soda, people who drink excessive caffeine are twice as likely to have sleep issues and shortened REM sleep (J. Adolesc. 2009;32:1189-207). It suppresses appetite and has withdrawal symptoms that further increase daytime sleepiness.

Adolescents also show increased use of sleep aids and stimulant drinks that have significant side effects of residual daytime sleepiness and tachycardia, respectively. So the treatment is further impacting the problem.

As physicians, we need to emphasize the physiologic impact of sleep deprivation and how it impacts many of the symptoms with which patients present. Many patients may overlook limited sleep as a cause of their symptoms.

Natural alternatives for improved sleep include chamomile, passionflower, or valerian, which come as a tea, capsule, liquid, or essential oil. Magnesium with or without calcium also is commonly used. Although all are deemed generally safe, there is no definitive effective dose in pediatrics, and they are not without side effects, so caution should be used when recommending these. Almond milk is a rich source of calcium, and calcium in the brain gets converted to melatonin.

Suggesting to parents that cellphones, video games, and computers be removed from the bedrooms by 9 p.m. will allow for the required 8.5 hours sleep. Avoiding sleeping until noon on weekends will improve sleep cycles. Avoiding caffeinated drinks and eating at late hours also will improve the quality of sleep and lessen daytime sleepiness. But the best advice to parents is for them to be good role models, and for them to get the appropriate amount of sleep, so that they also can avoid the hazards of sleep deprivation.

Dr. Pearce is a pediatrician in Frankfort, Ill. E-mail her at [email protected]. Scan this QR code or go to pediatricnews.com.

Sleep deprivation being a health issue in adolescence is no surprise. We hear repeated reports on cellphone use and excessive video gaming as contributors to sleep deprivation, but how many pediatricians are actually warning their patient during annual exams about the health impact of sleep deprivation?

The American Academy of Pediatrics recently published its policy on sleep and recommended adolescents get at least 8.5 hours of sleep per night and that school start time for middle schools be 8:30 a.m. (Pediatrics 2014;134:642-9). Despite this recommendation, more than 60% of U.S. schools have start times earlier than 8:00 a.m. A recent study also showed that 59% of 6th-8th graders and 87% of high school students obtained less the recommended 8.5 hours.

The reasoning behind the recommendation was based on the natural change in sleep cycle that occurs during adolescence, in which the circadian rhythm changes, resulting in decreased secretion of melatonin and delayed onset of sleep. With later start times, adolescents actually get up to an extra hour of sleep, which in turn results in fewer absences, improved focus, concentration, and better behavior (Pediatrics 2014 [doi:10.1542/peds.2014-1697]).

But beyond biologic cause for delayed sleep, social media, texting, and video games further impact the amount of sleep obtained, which leaves the majority of teens sleep deprived. Watching TV more than 3 hours per night impacts your ability not only to fall asleep, but to stay asleep, which again increases daytime sleepiness. Many may think that the “weekend catch-up” might ameliorate the deprivation, but studies show that the inconsistency of appropriate sleep further disrupts the wake-sleep cycles and further reduces the secretion of melatonin.

So how does sleep deprivation impact health? The obvious increased daytime sleepiness which results in poor concentration and focus is well known, and clearly contributes to the number of car accidents in this age group. But there are clear physiologic changes that occur when there is inadequate sleep that result in increased risk for diabetes, obesity, depression, cardiovascular disease, and even Alzheimer’s (Psychiatry Res. 2010;176:34-9; Sleep 2004;27:1351-8; Endocr. Dev. 2010;17:11-21). Lack of sleep has shown alterations in metabolic profiles, such as insulin, cortisol, and leptin, which lead to insulin resistance, increased sympathetic nervous system activity, increased hunger, and decreased satiety (Pediatrics 2014 [doi:10.1542/peds.2014-1697]).

The resulting lack of sleep in adolescence has cause increased intake of caffeine as well. Recent surveys show that caffeine use has skyrocketed this age group. If it is taken in the form of energy drinks, coffee, or soda, people who drink excessive caffeine are twice as likely to have sleep issues and shortened REM sleep (J. Adolesc. 2009;32:1189-207). It suppresses appetite and has withdrawal symptoms that further increase daytime sleepiness.

Adolescents also show increased use of sleep aids and stimulant drinks that have significant side effects of residual daytime sleepiness and tachycardia, respectively. So the treatment is further impacting the problem.

As physicians, we need to emphasize the physiologic impact of sleep deprivation and how it impacts many of the symptoms with which patients present. Many patients may overlook limited sleep as a cause of their symptoms.

Natural alternatives for improved sleep include chamomile, passionflower, or valerian, which come as a tea, capsule, liquid, or essential oil. Magnesium with or without calcium also is commonly used. Although all are deemed generally safe, there is no definitive effective dose in pediatrics, and they are not without side effects, so caution should be used when recommending these. Almond milk is a rich source of calcium, and calcium in the brain gets converted to melatonin.

Suggesting to parents that cellphones, video games, and computers be removed from the bedrooms by 9 p.m. will allow for the required 8.5 hours sleep. Avoiding sleeping until noon on weekends will improve sleep cycles. Avoiding caffeinated drinks and eating at late hours also will improve the quality of sleep and lessen daytime sleepiness. But the best advice to parents is for them to be good role models, and for them to get the appropriate amount of sleep, so that they also can avoid the hazards of sleep deprivation.

Dr. Pearce is a pediatrician in Frankfort, Ill. E-mail her at [email protected]. Scan this QR code or go to pediatricnews.com.

Sleep deprivation being a health issue in adolescence is no surprise. We hear repeated reports on cellphone use and excessive video gaming as contributors to sleep deprivation, but how many pediatricians are actually warning their patient during annual exams about the health impact of sleep deprivation?

The American Academy of Pediatrics recently published its policy on sleep and recommended adolescents get at least 8.5 hours of sleep per night and that school start time for middle schools be 8:30 a.m. (Pediatrics 2014;134:642-9). Despite this recommendation, more than 60% of U.S. schools have start times earlier than 8:00 a.m. A recent study also showed that 59% of 6th-8th graders and 87% of high school students obtained less the recommended 8.5 hours.

The reasoning behind the recommendation was based on the natural change in sleep cycle that occurs during adolescence, in which the circadian rhythm changes, resulting in decreased secretion of melatonin and delayed onset of sleep. With later start times, adolescents actually get up to an extra hour of sleep, which in turn results in fewer absences, improved focus, concentration, and better behavior (Pediatrics 2014 [doi:10.1542/peds.2014-1697]).

But beyond biologic cause for delayed sleep, social media, texting, and video games further impact the amount of sleep obtained, which leaves the majority of teens sleep deprived. Watching TV more than 3 hours per night impacts your ability not only to fall asleep, but to stay asleep, which again increases daytime sleepiness. Many may think that the “weekend catch-up” might ameliorate the deprivation, but studies show that the inconsistency of appropriate sleep further disrupts the wake-sleep cycles and further reduces the secretion of melatonin.

So how does sleep deprivation impact health? The obvious increased daytime sleepiness which results in poor concentration and focus is well known, and clearly contributes to the number of car accidents in this age group. But there are clear physiologic changes that occur when there is inadequate sleep that result in increased risk for diabetes, obesity, depression, cardiovascular disease, and even Alzheimer’s (Psychiatry Res. 2010;176:34-9; Sleep 2004;27:1351-8; Endocr. Dev. 2010;17:11-21). Lack of sleep has shown alterations in metabolic profiles, such as insulin, cortisol, and leptin, which lead to insulin resistance, increased sympathetic nervous system activity, increased hunger, and decreased satiety (Pediatrics 2014 [doi:10.1542/peds.2014-1697]).

The resulting lack of sleep in adolescence has cause increased intake of caffeine as well. Recent surveys show that caffeine use has skyrocketed this age group. If it is taken in the form of energy drinks, coffee, or soda, people who drink excessive caffeine are twice as likely to have sleep issues and shortened REM sleep (J. Adolesc. 2009;32:1189-207). It suppresses appetite and has withdrawal symptoms that further increase daytime sleepiness.

Adolescents also show increased use of sleep aids and stimulant drinks that have significant side effects of residual daytime sleepiness and tachycardia, respectively. So the treatment is further impacting the problem.

As physicians, we need to emphasize the physiologic impact of sleep deprivation and how it impacts many of the symptoms with which patients present. Many patients may overlook limited sleep as a cause of their symptoms.

Natural alternatives for improved sleep include chamomile, passionflower, or valerian, which come as a tea, capsule, liquid, or essential oil. Magnesium with or without calcium also is commonly used. Although all are deemed generally safe, there is no definitive effective dose in pediatrics, and they are not without side effects, so caution should be used when recommending these. Almond milk is a rich source of calcium, and calcium in the brain gets converted to melatonin.

Suggesting to parents that cellphones, video games, and computers be removed from the bedrooms by 9 p.m. will allow for the required 8.5 hours sleep. Avoiding sleeping until noon on weekends will improve sleep cycles. Avoiding caffeinated drinks and eating at late hours also will improve the quality of sleep and lessen daytime sleepiness. But the best advice to parents is for them to be good role models, and for them to get the appropriate amount of sleep, so that they also can avoid the hazards of sleep deprivation.

Dr. Pearce is a pediatrician in Frankfort, Ill. E-mail her at [email protected]. Scan this QR code or go to pediatricnews.com.

Our local daily paper, like most other print newspapers, is on its last legs. But I read it faithfully for the obituaries, and to see how my former patients are doing on their school sports teams. Of course, there is always the smattering of motor vehicle accident reports to keep me reading.

One doesn’t have to be an insurance adjuster or an actuary to realize that motor vehicle accident fatalities cluster into two groups: teenagers and older folks (70 plus). One group falls victim to inexperience and a delusional sense of immortality. Those in the other group are losing their ability to sense their environment and respond with sufficient speed. One group makes poor decisions. The other makes them too slowly.

Because my mother died in her early 60s and my father never had a driver’s license, I never faced the difficult task of telling my aging parents that they were too old to drive. But I have heard from some of my friends of how difficult it was to ask Mom and Dad to give up their car keys.

The American Medical Association announced recently that they have to decided to take on a similar challenge by agreeing to “spearhead an effort to create competency guidelines for assessing whether older physicians remain able to provide safe and effective care for patients” (“Aging MDs Prompt Call for Competency Tests at AMA Meeting,” Associated Press, June 8, 2015). Prompted by the reality that one in four physicians in this country is over the age of 65 years, the AMA is beginning to talk about the issue and formulate plans to convene a variety of councils and work groups.

I’m sure there are some older physicians whose clinical skills have eroded with age to a point that they pose a significant threat to the safety of their patients, but I don’t think the situation warrants a full-court press by the AMA or anyone else for that matter.

First, I suspect that most physicians who continue to practice after they turn 70 years are not doing so because they need the money. That might be true 10-15 years from now when today’s young physicians are facing retirement while they are still recovering from the monstrous educational debts they incurred in their 20s. At present, though, I suspect that most physicians continue to practice because they enjoy what they do. I have to believe that a physician whose primary motivation is the joy of seeing patients is, in general, going to be doing a good job of it – and his or her patients probably know it and appreciate it.

Second, we already have in place (or should have) systems for identifying and dealing with physicians who are practicing substandard care for variety of reasons, such as substance abuse, financial malfeasance, inadequate training, or outright incompetence. Do we really need another layer of screening for older physicians? It feels like just another example of profiling. For example, does the Transportation Security Administration need to strip search every male with a dark complexion named Hassan?

The problem is that in many situations our safety nets for identifying and addressing incompetent physicians have too many holes in them. One of the reasons for this inadequacy is the unofficial code of silence that physicians have followed for years. Unless a fellow physician’s behavior is three orders of magnitude beyond the pale, many of us feel uncomfortable about approaching him or her or even lodging an anonymous report to the state board of licensure.

Of course, as physicians age some will lose critical clinical skills. On the other hand, with age many older physicians have gained perspectives on health, life, and death that their younger colleagues need to hear. We don’t need to single out older physicians for closer scrutiny. We simply have to improve our current surveillance systems and attitudes for physicians of all ages. If anyone wants to look more closely at how older physicians practice, the first question to ask should not be “What are they doing wrong?” but “What are these folks doing right that allows them to continue to enjoy practicing medicine at age 75?”

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.”

Our local daily paper, like most other print newspapers, is on its last legs. But I read it faithfully for the obituaries, and to see how my former patients are doing on their school sports teams. Of course, there is always the smattering of motor vehicle accident reports to keep me reading.

One doesn’t have to be an insurance adjuster or an actuary to realize that motor vehicle accident fatalities cluster into two groups: teenagers and older folks (70 plus). One group falls victim to inexperience and a delusional sense of immortality. Those in the other group are losing their ability to sense their environment and respond with sufficient speed. One group makes poor decisions. The other makes them too slowly.

Because my mother died in her early 60s and my father never had a driver’s license, I never faced the difficult task of telling my aging parents that they were too old to drive. But I have heard from some of my friends of how difficult it was to ask Mom and Dad to give up their car keys.

The American Medical Association announced recently that they have to decided to take on a similar challenge by agreeing to “spearhead an effort to create competency guidelines for assessing whether older physicians remain able to provide safe and effective care for patients” (“Aging MDs Prompt Call for Competency Tests at AMA Meeting,” Associated Press, June 8, 2015). Prompted by the reality that one in four physicians in this country is over the age of 65 years, the AMA is beginning to talk about the issue and formulate plans to convene a variety of councils and work groups.

I’m sure there are some older physicians whose clinical skills have eroded with age to a point that they pose a significant threat to the safety of their patients, but I don’t think the situation warrants a full-court press by the AMA or anyone else for that matter.

First, I suspect that most physicians who continue to practice after they turn 70 years are not doing so because they need the money. That might be true 10-15 years from now when today’s young physicians are facing retirement while they are still recovering from the monstrous educational debts they incurred in their 20s. At present, though, I suspect that most physicians continue to practice because they enjoy what they do. I have to believe that a physician whose primary motivation is the joy of seeing patients is, in general, going to be doing a good job of it – and his or her patients probably know it and appreciate it.

Second, we already have in place (or should have) systems for identifying and dealing with physicians who are practicing substandard care for variety of reasons, such as substance abuse, financial malfeasance, inadequate training, or outright incompetence. Do we really need another layer of screening for older physicians? It feels like just another example of profiling. For example, does the Transportation Security Administration need to strip search every male with a dark complexion named Hassan?

The problem is that in many situations our safety nets for identifying and addressing incompetent physicians have too many holes in them. One of the reasons for this inadequacy is the unofficial code of silence that physicians have followed for years. Unless a fellow physician’s behavior is three orders of magnitude beyond the pale, many of us feel uncomfortable about approaching him or her or even lodging an anonymous report to the state board of licensure.

Of course, as physicians age some will lose critical clinical skills. On the other hand, with age many older physicians have gained perspectives on health, life, and death that their younger colleagues need to hear. We don’t need to single out older physicians for closer scrutiny. We simply have to improve our current surveillance systems and attitudes for physicians of all ages. If anyone wants to look more closely at how older physicians practice, the first question to ask should not be “What are they doing wrong?” but “What are these folks doing right that allows them to continue to enjoy practicing medicine at age 75?”

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.”

Our local daily paper, like most other print newspapers, is on its last legs. But I read it faithfully for the obituaries, and to see how my former patients are doing on their school sports teams. Of course, there is always the smattering of motor vehicle accident reports to keep me reading.

One doesn’t have to be an insurance adjuster or an actuary to realize that motor vehicle accident fatalities cluster into two groups: teenagers and older folks (70 plus). One group falls victim to inexperience and a delusional sense of immortality. Those in the other group are losing their ability to sense their environment and respond with sufficient speed. One group makes poor decisions. The other makes them too slowly.

Because my mother died in her early 60s and my father never had a driver’s license, I never faced the difficult task of telling my aging parents that they were too old to drive. But I have heard from some of my friends of how difficult it was to ask Mom and Dad to give up their car keys.

The American Medical Association announced recently that they have to decided to take on a similar challenge by agreeing to “spearhead an effort to create competency guidelines for assessing whether older physicians remain able to provide safe and effective care for patients” (“Aging MDs Prompt Call for Competency Tests at AMA Meeting,” Associated Press, June 8, 2015). Prompted by the reality that one in four physicians in this country is over the age of 65 years, the AMA is beginning to talk about the issue and formulate plans to convene a variety of councils and work groups.

I’m sure there are some older physicians whose clinical skills have eroded with age to a point that they pose a significant threat to the safety of their patients, but I don’t think the situation warrants a full-court press by the AMA or anyone else for that matter.

First, I suspect that most physicians who continue to practice after they turn 70 years are not doing so because they need the money. That might be true 10-15 years from now when today’s young physicians are facing retirement while they are still recovering from the monstrous educational debts they incurred in their 20s. At present, though, I suspect that most physicians continue to practice because they enjoy what they do. I have to believe that a physician whose primary motivation is the joy of seeing patients is, in general, going to be doing a good job of it – and his or her patients probably know it and appreciate it.

Second, we already have in place (or should have) systems for identifying and dealing with physicians who are practicing substandard care for variety of reasons, such as substance abuse, financial malfeasance, inadequate training, or outright incompetence. Do we really need another layer of screening for older physicians? It feels like just another example of profiling. For example, does the Transportation Security Administration need to strip search every male with a dark complexion named Hassan?

The problem is that in many situations our safety nets for identifying and addressing incompetent physicians have too many holes in them. One of the reasons for this inadequacy is the unofficial code of silence that physicians have followed for years. Unless a fellow physician’s behavior is three orders of magnitude beyond the pale, many of us feel uncomfortable about approaching him or her or even lodging an anonymous report to the state board of licensure.

Of course, as physicians age some will lose critical clinical skills. On the other hand, with age many older physicians have gained perspectives on health, life, and death that their younger colleagues need to hear. We don’t need to single out older physicians for closer scrutiny. We simply have to improve our current surveillance systems and attitudes for physicians of all ages. If anyone wants to look more closely at how older physicians practice, the first question to ask should not be “What are they doing wrong?” but “What are these folks doing right that allows them to continue to enjoy practicing medicine at age 75?”

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.”

For you, the first visits with a newborn are a busy balancing act of gentle physical exam and empathic parent reassurance and education. It’s difficult to imagine that much else could fit into these visits. But your providing weekly and then monthly checks on a newborn puts you in a unique position to detect postpartum depression in that baby’s mother (as are obstetricians at the 6-week follow up). Postpartum depression is relatively common and very treatable, but it can go untreated because of the silence that is often grounded in shame and stigma. A few days of “baby blues” secondary to being tired and hormonal changes is quite different from persistent postpartum depression. Early detection of postpartum depression and referral to a psychiatrist can relieve extraordinary suffering in a parent and stress in a family, and can protect the critical relationship developing between mother and baby.

Postpartum depression was rarely discussed as recently as 30 years ago; it was not formally recognized by psychiatrists as a distinct illness in the Diagnostic and Statistical Manual of Mental Disorders (DSM) until its fourth edition, released in 1994. It is only slightly more common than depression in nonpregnant women of childbearing age: the Centers for Disease Control and Prevention estimated that depression affects 13% of women in the postpartum period, compared with 11% of age-matched controls. It is, however, more likely to be severe than depression in the nonperipartum woman (Gen. Hosp. Psychiatry 2004;26:289-95).Teenage mothers, women with a personal or family history of depression, women giving birth to twins or triplets, women with a history of miscarriage or stillbirth, and women who experienced premature labor and delivery all appear to be at elevated risk for postpartum depression. While other stressors such as marital conflict, single parenthood, or financial strain are challenging for new mothers, they have not been shown to significantly increase the risk of postpartum depression. It also should be noted that a history of previous deliveries without a postpartum mood disorder is not protective or predictive.

The diagnostic criteria for postpartum depression are the same as for a major depressive episode, except that symptoms start in the 4 weeks after the delivery of a baby (although they may be present during the pregnancy or may not be noted until weeks or months later). This can make it easy to mistake depression for the “baby blues” – a period of weepiness, anxiety, moodiness, and exhaustion that commonly occurs to new mothers. These symptoms affect as many as 75% of mothers in the first few days after delivery and can be very unsettling, but the symptoms always improve within 2 weeks, whereas postpartum depression will persist or worsen. Although it can be severe, postpartum depression will improve with treatment, typically psychotherapy and possibly medication. Without treatment, postpartum depression can persist for months. It may remit spontaneously after a substantial period, but it also may worsen. Untreated postpartum depression can (rarely) deteriorate into postpartum psychosis, which usually requires hospitalization and more significant psychopharmacologic intervention. Failure to detect and treat depression in new mothers can lead to a number of complications for the mother, ranging from difficulty with breastfeeding and forming an attachment with her newborn to an inability to return to work. It also raises the risk for suicide, which accounts for 20% of all deaths in the postpartum population (Arch. Womens Ment. Health 2005;8:77-87).The catastrophe of infanticide is diminishingly rare, but almost always associated with untreated postpartum depression or psychosis.

The complications of untreated depression do not affect only the symptomatic mother. There have been many studies that have demonstrated the negative developmental effects of maternal depression on children of all ages, from infancy through adolescence. Maternal depression in the newborn period can be especially disruptive of development, as it can interfere with healthy attachment and an infant’s development of the fundamentals of self-regulation. Infants of depressed mothers are more likely to be passive, withdrawn, and dysregulated. Cognitive development in infants and toddlers of depressed mothers is frequently delayed. Toddler children of depressed mothers more frequently display internalizing (depressed and anxious) and externalizing (disruptive) behavioral symptoms. Mood, anxiety, conduct disorders, and attention-deficit/hyperactivity disorder are more common in the school-age and adolescent children of depressed mothers than in peers whose mothers are not depressed (Paediatr. Child Health 2004;9:575-83). Clearly, the consequences of untreated depression in a mother on even the youngest children can be profound and persistent. And, most importantly, they are preventable.

Why would new mothers experiencing such uncomfortable symptoms fail to actively seek help? There are many reasons for their silent suffering. Many new mothers assume that their symptoms are the “baby blues,” a normal part of the monumental adjustment from pregnancy to motherhood. When their symptoms fail to improve in the first few weeks as promised by friends or clinicians, they often assume that they are personally inadequate, not up to the task of parenting. Such feelings of worthlessness and guilt are actually common symptoms of depression, and contribute to the shame and silence that accompany depressive disorders. (This is one of the reasons depression is described as an “internalizing” disorder.) These feelings (or symptoms) of guilt often are heightened by popular expectations that new mothers should be experiencing delight and joy in the new child. While all of the attention was on the mother during her pregnancy, the focus of friends, family, and clinicians usually shifts entirely to the infant after delivery. Although the reality of postpartum depression is more comfortably and openly discussed now than a generation ago, these forces continue to compel most women suffering from depression to remain silent.

This is where you are in a unique position to facilitate the recognition and treatment of postpartum depression. While a new mother may have one follow-up visit with her obstetrician, she often will visit you weekly for the first month and monthly for the first 6 months of her infant’s life. These visits are structured around questions about routines of sleeping and eating, the mechanics of breastfeeding, and growing connection with the newborn. You are in a natural position to ask nonjudgmentally about these things, and to follow-up on suggestions that a mother’s sleep, appetite, and energy are problematic with a few screening questions. If it sounds to you like there may be postpartum depression, you are in a powerful position to point out that these feelings do not reflect inadequacy, but rather a common and treatable problem in new mothers. You are uniquely qualified to suggest to the guilt-ridden mother that it is not selfish to seek her own treatment, but it is critical to the healthy development of her newborn and other children, much like the routine airline warning that parents must put on their own oxygen masks before attempting to place the masks on their children. Indeed, the American Academy of Pediatrics recommended in a 2010 report that pediatricians screen new mothers for postpartum depression at the 1-, 2-, and 4-month check-ups of their newborns (Pediatrics 2010;126:1032).

So how best to screen during a busy check-up? The AAP recommends the Edinburgh Postnatal Depression Screen (EPDS), an extensively validated 10-item questionnaire that a mother can fill out in the waiting room. Scoring is relatively fast and a cut-off at or above 10 points suggests a high risk of depression. The AAP also suggests using a “yes” answer to either of the following questions as a positive screen:

1. Over the past 2 weeks have you ever felt down, depressed, or hopeless?

2. Over the past 2 weeks have you felt little interest or pleasure in doing things?

Even without using specific questions or instruments, you can be vigilant for certain red flags. If a new mother reports that she is having difficulty falling asleep (despite the sleep deprivation that usually accompanies life with a newborn); if her appetite is decreasing despite breastfeeding; if she describes intense worries or doubts about the baby or motherhood that have persisted for more than a few days or that interfere with her function; if she reports that she is experiencing no feelings of happiness or pleasure with her infant; or if she describes feelings of hopelessness or recurring thoughts about death and dying, then you should be concerned that she may be suffering from postpartum depression. You might then suggest to the mother that these feelings may reflect postpartum depression, reassuring her that this is a common and treatable condition. When you calmly and comfortably discusses this topic, you provide hope and relief, dissolving some of the stigma that can surround psychiatric illness for mothers.

What to do once you have noted that a new mother may be suffering from postpartum depression? The problem is common enough that you may want to find a psychiatrist with an interest in postpartum depression and develop a collegial working relationship. It can be helpful to find out if the mother has ever seen a psychiatrist or therapist, as this can be an easy and effective referral for a comprehensive evaluation. If she does not already have a mental health provider, referring her to her primary care provider can be an efficient way to access a psychiatric evaluation. Many mothers will want to have more specialized treatment, especially as they consider the safety of medications while breastfeeding. Many academic medical centers will have psychiatrists who specialize in women’s health. Some states have created programs to facilitate access to treatment for mothers, such as Massachusetts Child Psychiatry Access Project (MCPAP) for Moms. There are several national organizations that provide online information about clinicians and other resources, such as Postpartum Support International, the American Psychological Association, and the CDC.

Finally, we have addressed depression in new mothers. But the rates of depression in new fathers also are higher than in age-matched controls. When a father is the primary parent and suggests problems with sleep and mood, asking the same questions, showing concern, and providing referral information can be just as important.

Remember, 13% of new mothers have postpartum depression, and the suffering of parent, family, and newborn is treatable. Unfortunately, many mothers do not get the help they need, as this condition has not been a priority of our health care system. You, the pediatrician or family physician, are in a unique position to make this a priority. You can detect depression in new parents, providing a critical link to treatment and relief for them, and protecting their children from potentially serious and preventable complications.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) program at the Vernon Cancer Center, Newton (Mass.) Wellesley Hospital. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. E-mail them at [email protected].

For you, the first visits with a newborn are a busy balancing act of gentle physical exam and empathic parent reassurance and education. It’s difficult to imagine that much else could fit into these visits. But your providing weekly and then monthly checks on a newborn puts you in a unique position to detect postpartum depression in that baby’s mother (as are obstetricians at the 6-week follow up). Postpartum depression is relatively common and very treatable, but it can go untreated because of the silence that is often grounded in shame and stigma. A few days of “baby blues” secondary to being tired and hormonal changes is quite different from persistent postpartum depression. Early detection of postpartum depression and referral to a psychiatrist can relieve extraordinary suffering in a parent and stress in a family, and can protect the critical relationship developing between mother and baby.

Postpartum depression was rarely discussed as recently as 30 years ago; it was not formally recognized by psychiatrists as a distinct illness in the Diagnostic and Statistical Manual of Mental Disorders (DSM) until its fourth edition, released in 1994. It is only slightly more common than depression in nonpregnant women of childbearing age: the Centers for Disease Control and Prevention estimated that depression affects 13% of women in the postpartum period, compared with 11% of age-matched controls. It is, however, more likely to be severe than depression in the nonperipartum woman (Gen. Hosp. Psychiatry 2004;26:289-95).Teenage mothers, women with a personal or family history of depression, women giving birth to twins or triplets, women with a history of miscarriage or stillbirth, and women who experienced premature labor and delivery all appear to be at elevated risk for postpartum depression. While other stressors such as marital conflict, single parenthood, or financial strain are challenging for new mothers, they have not been shown to significantly increase the risk of postpartum depression. It also should be noted that a history of previous deliveries without a postpartum mood disorder is not protective or predictive.

The diagnostic criteria for postpartum depression are the same as for a major depressive episode, except that symptoms start in the 4 weeks after the delivery of a baby (although they may be present during the pregnancy or may not be noted until weeks or months later). This can make it easy to mistake depression for the “baby blues” – a period of weepiness, anxiety, moodiness, and exhaustion that commonly occurs to new mothers. These symptoms affect as many as 75% of mothers in the first few days after delivery and can be very unsettling, but the symptoms always improve within 2 weeks, whereas postpartum depression will persist or worsen. Although it can be severe, postpartum depression will improve with treatment, typically psychotherapy and possibly medication. Without treatment, postpartum depression can persist for months. It may remit spontaneously after a substantial period, but it also may worsen. Untreated postpartum depression can (rarely) deteriorate into postpartum psychosis, which usually requires hospitalization and more significant psychopharmacologic intervention. Failure to detect and treat depression in new mothers can lead to a number of complications for the mother, ranging from difficulty with breastfeeding and forming an attachment with her newborn to an inability to return to work. It also raises the risk for suicide, which accounts for 20% of all deaths in the postpartum population (Arch. Womens Ment. Health 2005;8:77-87).The catastrophe of infanticide is diminishingly rare, but almost always associated with untreated postpartum depression or psychosis.

The complications of untreated depression do not affect only the symptomatic mother. There have been many studies that have demonstrated the negative developmental effects of maternal depression on children of all ages, from infancy through adolescence. Maternal depression in the newborn period can be especially disruptive of development, as it can interfere with healthy attachment and an infant’s development of the fundamentals of self-regulation. Infants of depressed mothers are more likely to be passive, withdrawn, and dysregulated. Cognitive development in infants and toddlers of depressed mothers is frequently delayed. Toddler children of depressed mothers more frequently display internalizing (depressed and anxious) and externalizing (disruptive) behavioral symptoms. Mood, anxiety, conduct disorders, and attention-deficit/hyperactivity disorder are more common in the school-age and adolescent children of depressed mothers than in peers whose mothers are not depressed (Paediatr. Child Health 2004;9:575-83). Clearly, the consequences of untreated depression in a mother on even the youngest children can be profound and persistent. And, most importantly, they are preventable.

Why would new mothers experiencing such uncomfortable symptoms fail to actively seek help? There are many reasons for their silent suffering. Many new mothers assume that their symptoms are the “baby blues,” a normal part of the monumental adjustment from pregnancy to motherhood. When their symptoms fail to improve in the first few weeks as promised by friends or clinicians, they often assume that they are personally inadequate, not up to the task of parenting. Such feelings of worthlessness and guilt are actually common symptoms of depression, and contribute to the shame and silence that accompany depressive disorders. (This is one of the reasons depression is described as an “internalizing” disorder.) These feelings (or symptoms) of guilt often are heightened by popular expectations that new mothers should be experiencing delight and joy in the new child. While all of the attention was on the mother during her pregnancy, the focus of friends, family, and clinicians usually shifts entirely to the infant after delivery. Although the reality of postpartum depression is more comfortably and openly discussed now than a generation ago, these forces continue to compel most women suffering from depression to remain silent.

This is where you are in a unique position to facilitate the recognition and treatment of postpartum depression. While a new mother may have one follow-up visit with her obstetrician, she often will visit you weekly for the first month and monthly for the first 6 months of her infant’s life. These visits are structured around questions about routines of sleeping and eating, the mechanics of breastfeeding, and growing connection with the newborn. You are in a natural position to ask nonjudgmentally about these things, and to follow-up on suggestions that a mother’s sleep, appetite, and energy are problematic with a few screening questions. If it sounds to you like there may be postpartum depression, you are in a powerful position to point out that these feelings do not reflect inadequacy, but rather a common and treatable problem in new mothers. You are uniquely qualified to suggest to the guilt-ridden mother that it is not selfish to seek her own treatment, but it is critical to the healthy development of her newborn and other children, much like the routine airline warning that parents must put on their own oxygen masks before attempting to place the masks on their children. Indeed, the American Academy of Pediatrics recommended in a 2010 report that pediatricians screen new mothers for postpartum depression at the 1-, 2-, and 4-month check-ups of their newborns (Pediatrics 2010;126:1032).

So how best to screen during a busy check-up? The AAP recommends the Edinburgh Postnatal Depression Screen (EPDS), an extensively validated 10-item questionnaire that a mother can fill out in the waiting room. Scoring is relatively fast and a cut-off at or above 10 points suggests a high risk of depression. The AAP also suggests using a “yes” answer to either of the following questions as a positive screen:

1. Over the past 2 weeks have you ever felt down, depressed, or hopeless?

2. Over the past 2 weeks have you felt little interest or pleasure in doing things?

Even without using specific questions or instruments, you can be vigilant for certain red flags. If a new mother reports that she is having difficulty falling asleep (despite the sleep deprivation that usually accompanies life with a newborn); if her appetite is decreasing despite breastfeeding; if she describes intense worries or doubts about the baby or motherhood that have persisted for more than a few days or that interfere with her function; if she reports that she is experiencing no feelings of happiness or pleasure with her infant; or if she describes feelings of hopelessness or recurring thoughts about death and dying, then you should be concerned that she may be suffering from postpartum depression. You might then suggest to the mother that these feelings may reflect postpartum depression, reassuring her that this is a common and treatable condition. When you calmly and comfortably discusses this topic, you provide hope and relief, dissolving some of the stigma that can surround psychiatric illness for mothers.

What to do once you have noted that a new mother may be suffering from postpartum depression? The problem is common enough that you may want to find a psychiatrist with an interest in postpartum depression and develop a collegial working relationship. It can be helpful to find out if the mother has ever seen a psychiatrist or therapist, as this can be an easy and effective referral for a comprehensive evaluation. If she does not already have a mental health provider, referring her to her primary care provider can be an efficient way to access a psychiatric evaluation. Many mothers will want to have more specialized treatment, especially as they consider the safety of medications while breastfeeding. Many academic medical centers will have psychiatrists who specialize in women’s health. Some states have created programs to facilitate access to treatment for mothers, such as Massachusetts Child Psychiatry Access Project (MCPAP) for Moms. There are several national organizations that provide online information about clinicians and other resources, such as Postpartum Support International, the American Psychological Association, and the CDC.

Finally, we have addressed depression in new mothers. But the rates of depression in new fathers also are higher than in age-matched controls. When a father is the primary parent and suggests problems with sleep and mood, asking the same questions, showing concern, and providing referral information can be just as important.

Remember, 13% of new mothers have postpartum depression, and the suffering of parent, family, and newborn is treatable. Unfortunately, many mothers do not get the help they need, as this condition has not been a priority of our health care system. You, the pediatrician or family physician, are in a unique position to make this a priority. You can detect depression in new parents, providing a critical link to treatment and relief for them, and protecting their children from potentially serious and preventable complications.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) program at the Vernon Cancer Center, Newton (Mass.) Wellesley Hospital. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. E-mail them at [email protected].

For you, the first visits with a newborn are a busy balancing act of gentle physical exam and empathic parent reassurance and education. It’s difficult to imagine that much else could fit into these visits. But your providing weekly and then monthly checks on a newborn puts you in a unique position to detect postpartum depression in that baby’s mother (as are obstetricians at the 6-week follow up). Postpartum depression is relatively common and very treatable, but it can go untreated because of the silence that is often grounded in shame and stigma. A few days of “baby blues” secondary to being tired and hormonal changes is quite different from persistent postpartum depression. Early detection of postpartum depression and referral to a psychiatrist can relieve extraordinary suffering in a parent and stress in a family, and can protect the critical relationship developing between mother and baby.

Postpartum depression was rarely discussed as recently as 30 years ago; it was not formally recognized by psychiatrists as a distinct illness in the Diagnostic and Statistical Manual of Mental Disorders (DSM) until its fourth edition, released in 1994. It is only slightly more common than depression in nonpregnant women of childbearing age: the Centers for Disease Control and Prevention estimated that depression affects 13% of women in the postpartum period, compared with 11% of age-matched controls. It is, however, more likely to be severe than depression in the nonperipartum woman (Gen. Hosp. Psychiatry 2004;26:289-95).Teenage mothers, women with a personal or family history of depression, women giving birth to twins or triplets, women with a history of miscarriage or stillbirth, and women who experienced premature labor and delivery all appear to be at elevated risk for postpartum depression. While other stressors such as marital conflict, single parenthood, or financial strain are challenging for new mothers, they have not been shown to significantly increase the risk of postpartum depression. It also should be noted that a history of previous deliveries without a postpartum mood disorder is not protective or predictive.

The diagnostic criteria for postpartum depression are the same as for a major depressive episode, except that symptoms start in the 4 weeks after the delivery of a baby (although they may be present during the pregnancy or may not be noted until weeks or months later). This can make it easy to mistake depression for the “baby blues” – a period of weepiness, anxiety, moodiness, and exhaustion that commonly occurs to new mothers. These symptoms affect as many as 75% of mothers in the first few days after delivery and can be very unsettling, but the symptoms always improve within 2 weeks, whereas postpartum depression will persist or worsen. Although it can be severe, postpartum depression will improve with treatment, typically psychotherapy and possibly medication. Without treatment, postpartum depression can persist for months. It may remit spontaneously after a substantial period, but it also may worsen. Untreated postpartum depression can (rarely) deteriorate into postpartum psychosis, which usually requires hospitalization and more significant psychopharmacologic intervention. Failure to detect and treat depression in new mothers can lead to a number of complications for the mother, ranging from difficulty with breastfeeding and forming an attachment with her newborn to an inability to return to work. It also raises the risk for suicide, which accounts for 20% of all deaths in the postpartum population (Arch. Womens Ment. Health 2005;8:77-87).The catastrophe of infanticide is diminishingly rare, but almost always associated with untreated postpartum depression or psychosis.

The complications of untreated depression do not affect only the symptomatic mother. There have been many studies that have demonstrated the negative developmental effects of maternal depression on children of all ages, from infancy through adolescence. Maternal depression in the newborn period can be especially disruptive of development, as it can interfere with healthy attachment and an infant’s development of the fundamentals of self-regulation. Infants of depressed mothers are more likely to be passive, withdrawn, and dysregulated. Cognitive development in infants and toddlers of depressed mothers is frequently delayed. Toddler children of depressed mothers more frequently display internalizing (depressed and anxious) and externalizing (disruptive) behavioral symptoms. Mood, anxiety, conduct disorders, and attention-deficit/hyperactivity disorder are more common in the school-age and adolescent children of depressed mothers than in peers whose mothers are not depressed (Paediatr. Child Health 2004;9:575-83). Clearly, the consequences of untreated depression in a mother on even the youngest children can be profound and persistent. And, most importantly, they are preventable.

Why would new mothers experiencing such uncomfortable symptoms fail to actively seek help? There are many reasons for their silent suffering. Many new mothers assume that their symptoms are the “baby blues,” a normal part of the monumental adjustment from pregnancy to motherhood. When their symptoms fail to improve in the first few weeks as promised by friends or clinicians, they often assume that they are personally inadequate, not up to the task of parenting. Such feelings of worthlessness and guilt are actually common symptoms of depression, and contribute to the shame and silence that accompany depressive disorders. (This is one of the reasons depression is described as an “internalizing” disorder.) These feelings (or symptoms) of guilt often are heightened by popular expectations that new mothers should be experiencing delight and joy in the new child. While all of the attention was on the mother during her pregnancy, the focus of friends, family, and clinicians usually shifts entirely to the infant after delivery. Although the reality of postpartum depression is more comfortably and openly discussed now than a generation ago, these forces continue to compel most women suffering from depression to remain silent.

This is where you are in a unique position to facilitate the recognition and treatment of postpartum depression. While a new mother may have one follow-up visit with her obstetrician, she often will visit you weekly for the first month and monthly for the first 6 months of her infant’s life. These visits are structured around questions about routines of sleeping and eating, the mechanics of breastfeeding, and growing connection with the newborn. You are in a natural position to ask nonjudgmentally about these things, and to follow-up on suggestions that a mother’s sleep, appetite, and energy are problematic with a few screening questions. If it sounds to you like there may be postpartum depression, you are in a powerful position to point out that these feelings do not reflect inadequacy, but rather a common and treatable problem in new mothers. You are uniquely qualified to suggest to the guilt-ridden mother that it is not selfish to seek her own treatment, but it is critical to the healthy development of her newborn and other children, much like the routine airline warning that parents must put on their own oxygen masks before attempting to place the masks on their children. Indeed, the American Academy of Pediatrics recommended in a 2010 report that pediatricians screen new mothers for postpartum depression at the 1-, 2-, and 4-month check-ups of their newborns (Pediatrics 2010;126:1032).

So how best to screen during a busy check-up? The AAP recommends the Edinburgh Postnatal Depression Screen (EPDS), an extensively validated 10-item questionnaire that a mother can fill out in the waiting room. Scoring is relatively fast and a cut-off at or above 10 points suggests a high risk of depression. The AAP also suggests using a “yes” answer to either of the following questions as a positive screen:

1. Over the past 2 weeks have you ever felt down, depressed, or hopeless?

2. Over the past 2 weeks have you felt little interest or pleasure in doing things?

Even without using specific questions or instruments, you can be vigilant for certain red flags. If a new mother reports that she is having difficulty falling asleep (despite the sleep deprivation that usually accompanies life with a newborn); if her appetite is decreasing despite breastfeeding; if she describes intense worries or doubts about the baby or motherhood that have persisted for more than a few days or that interfere with her function; if she reports that she is experiencing no feelings of happiness or pleasure with her infant; or if she describes feelings of hopelessness or recurring thoughts about death and dying, then you should be concerned that she may be suffering from postpartum depression. You might then suggest to the mother that these feelings may reflect postpartum depression, reassuring her that this is a common and treatable condition. When you calmly and comfortably discusses this topic, you provide hope and relief, dissolving some of the stigma that can surround psychiatric illness for mothers.

What to do once you have noted that a new mother may be suffering from postpartum depression? The problem is common enough that you may want to find a psychiatrist with an interest in postpartum depression and develop a collegial working relationship. It can be helpful to find out if the mother has ever seen a psychiatrist or therapist, as this can be an easy and effective referral for a comprehensive evaluation. If she does not already have a mental health provider, referring her to her primary care provider can be an efficient way to access a psychiatric evaluation. Many mothers will want to have more specialized treatment, especially as they consider the safety of medications while breastfeeding. Many academic medical centers will have psychiatrists who specialize in women’s health. Some states have created programs to facilitate access to treatment for mothers, such as Massachusetts Child Psychiatry Access Project (MCPAP) for Moms. There are several national organizations that provide online information about clinicians and other resources, such as Postpartum Support International, the American Psychological Association, and the CDC.

Finally, we have addressed depression in new mothers. But the rates of depression in new fathers also are higher than in age-matched controls. When a father is the primary parent and suggests problems with sleep and mood, asking the same questions, showing concern, and providing referral information can be just as important.

Remember, 13% of new mothers have postpartum depression, and the suffering of parent, family, and newborn is treatable. Unfortunately, many mothers do not get the help they need, as this condition has not been a priority of our health care system. You, the pediatrician or family physician, are in a unique position to make this a priority. You can detect depression in new parents, providing a critical link to treatment and relief for them, and protecting their children from potentially serious and preventable complications.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) program at the Vernon Cancer Center, Newton (Mass.) Wellesley Hospital. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. E-mail them at [email protected].

The Internet has changed many facets of modern life, and the practice of medicine has not gone untouched. Consider, for better or worse, the reliance of many patients on WebMD and various other sites for self-diagnosis before consulting with a physician. Even before the Internet, patients would self-diagnose their skin type (more than 80% of them get it wrong). The Internet allows them access to most cosmeceutical brands, the misuse of which leads to unintended consequences that can affect skin health. Clearly, patients who receive advice from a trained medical professional have better outcomes. One reason for this is that the doctor (or aesthetician) spends time with the patient, explaining what products to use and in which order to use them, and follows up with the patient to assess the outcome and adjust the regimen as needed. The problem arises when these patients decide to purchase the products from a source other than their treating physician. Only about 30% of patients buy refills from their doctor for second purchases, and just 15% purchase products from their doctor the third time around. Why is this? It is likely the convenience and the low cost that drive patients to purchase from sources other than their physician or aesthetician. This desire to save money carries significant risks. Many the products online are expired or counterfeit, or are old containers refilled with a different formulation. Patients should be cautioned to only buy products from a source they trust.

I have had dozens of patients bringing in counterfeit products in the last few months. It seems that the problem is becoming more common. I interviewed several companies about this to see whether others were experiencing the same trend. This is what I found:

Some companies report that they have seen their samples and trade size containers being sold on eBay. Joe Ragosta of Topix Pharmaceuticals reports that when his company has asked such sellers if they are obtaining these products – marked as samples – from the company, they hear a range of defensive responses, including: “I got it at a show” or “My doctor gave me samples, and I decided to sell them” and “I work at a doctor’s office, and they let me take products as needed.” Make sure that no one on your staff is taking samples and selling them online.

One example: NeoStrata is concerned about the fraudulent use of their products. They recommend that patients purchase their products only from a known physician, ideally from the physician’s office rather than the website. The company understands that customers may want to save money wherever they can and might prefer to buy products online. NeoStrata urges customers who opt to buy online to make such purchases through physician-affiliated websites, where the doctor is clearly identified. At the very least, the company urges patients to choose only sites where they can contact someone and obtain the name of a physician. Further, they strongly discourage using eBay or other auction sites, which do not vouch for the safety and authenticity of products sold through their services.

Other potential problems with skin care products sold online include the following.

Counterfeit products

Several reports have indicated that counterfeit skin products originating in other countries have made their way into the United States and, according to the article published on the website Fact Based Skin Care, pharmaceuticals and personal care products, including cosmetics, are among the top five types of products seized by U.S. Customs and Border Patrol agents (Coy, C. Dangers of Counterfeit Cosmetics, Aug. 4, 2014). Such products include old bottles refilled with inexpensive imitation creams or bottles made to look like legitimate products that in fact contain imitation creams. I once had a patient present with an adverse reaction to a retinol product, which she brought with her to the visit. I sent the bottle to the company, which confirmed my suspicion that the product was counterfeit – a different bottle with a similar label.

In February 2014, CBS New York ran a segment on the potential inclusion of carcinogenic and other harmful ingredients found in online personal care products touted for their low prices (CBS New York. Counterfeit Cosmetics May Be Harmful To Your Health. Feb. 27, 2014). Not even 2 weeks later, CNN reported on the arrest of two brothers in New York alleged to have masterminded a multimillion-dollar counterfeit health and beauty product ring (CNN. Zulueta A. Massive Fake Health and Beauty Supplies Ring Busted. March 9, 2014). ABC’s Good Morning America followed suit with a segment in April 2014 that exposed aspects of the use of knock-off cosmetic products (ABC News, Good Morning America. Online Beauty Bargains: Is It the Real Deal? April 3, 2014).

The Federal Bureau of Investigation has posted memos concerning counterfeit and potentially compromised and hazardous cosmetics and fragrances, offering tips aimed at readily identifying or avoiding unauthorized products.

Torie Hardee of EltaMD summarized that counterfeit products can sometimes be identified by lack of an expiration date on the bottle, discoloration or slightly different fonts on bottles and packaging, and the manufacturer’s address on the bottle.

Jan Marini Company representative Stuart Mohr noted that their company has received returns of products that they had not manufactured, as well as their own current or discontinued products returned years after the expiration date. The Jan Marini Co., and most other companies, will not guarantee any product purchased via nonauthorized resellers, because the authenticity and safety of such products cannot be verified.

“These unauthorized resellers are sophisticated, often even working in rings, and find it easy to hide their real identity,” said Mr. Mohr. “Addresses are often hidden or vague; emails are not linked to any specific person; and it’s easy to use false names. If a person is caught in an unauthorized online transaction, it’s easy to change the email address or name and start again,” he added.

©Ingram Publishing/Thinkstockphotos.com

FBI’s tips for spotting counterfeit cosmetics and fragrances

• The product is a sample size.

• The packaging differs slightly from the authentic brand (different color or font).

• The product’s wrapping appears haphazard.

• The product is being advertised as a “limited edition” even though the authentic manufacturer doesn’t offer it as a limited edition.

• The product is not listed on the manufacturer’s website.

• The price is drastically lower than the MSRP.

• The product’s consistency or texture doesn’t feel or look like the authentic brand.

• For fragrances, something seems off about the scent, and the color of the fluid in the bottle might be different than the original.

• They are being sold at nonauthorized retailers, including flea markets and discount stores.

• The label does not contain lot number, bar code, manufacturer’s address, or expiration date.

Expired products

Unscrupulous online retailers may slash prices on expired products and remove the expiration date from the package. In my practice, a patient experiencing an erythematous reaction brought in the “SkinMedica” product bottle, which looked suspicious to me. The packaging that the product was in had been discontinued 8 years earlier. It is important to remember that ingredients, particularly retinol, degrade with exposure to air, sun, and heat, and over time. This is most likely what caused my patient’s adverse reaction, and her initial savings from the product caused her several weeks of irritated skin.

Diverted products

SkinMedica reports that diverted products are a trickier issue than counterfeit products, because their packaging and formulas are sufficiently complex to make counterfeiting too difficult to be profitable. Instead, their products have been sold on the so-called gray market below the manufacturer suggested retail price (MSRP), typically online. In these cases, the company cannot help patients with returns or complaints because they cannot verify the chain of custody of the purchased product. They are addressing this problem, though, with an awareness campaign called “Authentic and Authorized.” Its goal is to alert patients and the physicians who dispense their products of the benefits of a physician-dispensed model of skin care, with best outcomes achieved when doctors are prescribing a skin care regimen. SkinMedica emphasizes that no website can guarantee outcomes comparable to a skin care professional and product quality and safety can only be enforced when dispensed through authorized channels.

Potentially illegal or toxic ingredients

Several products that have entered the United States marketed as skin lighteners, antiaging agents, and acne treatment products have been found to contain mercury, according to a consumer update from the FDA. Arsenic, lead, beryllium, and other harmful toxins as well as allergy-inducing fragrances or preservatives not approved as safe in the U.S. may also be found in such products of dubious origin.

Improper storage

Products purveyed online are often stored in hot warehouses. As mentioned above, heat degrades and alters ingredients, rendering compounds such as retinol, benzoyl peroxide, peptides, and ascorbic acid worthless. Extreme cold can also damage the chemical integrity of products. Notably, organic products are more vulnerable because they lack preservatives to gird them against temperature variations and microbes that grow in hot, damp environments.

Lookalike imposters

Generic formulations are packaged to piggyback onto the success of well-known products. Such products found in drugstores may be packaged to look like Cetaphil or Aveeno items, but cost less, and deliver less. While the ingredients on the copycats are identical to those found in the branded preparations, the order in which ingredients are added, the temperature, pH, and even when and how fast ingredients are stirred are part of the proprietary recipe of the company and play a significant role in the potential of the end product and the actions the product exerts on the skin.

Conclusion

Whether or not you sell skin care products in your office, there is much you can do to educate your patients about skin care product safety. Namely, the farther a consumer gets from the source of the product or from reliable endorsers of products, the greater the opportunity for encountering fraudulent or counterfeit products. Patients are best served by sources they can trust, such as their dermatologist. If you sell products in your office, encourage your patients to buy refills from you so they can be assured of the proper formulations. Finally, encourage your patients not to skimp when it comes to the health of their skin, reminding them that it may cost them much more in terms of time, skin irritation, improper treatment, and all related expenses to buy products cheaply from unreliable sources.

Give your patients a copy of this article so that they will understand the enormity of the problem.

Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in the Design District in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote the textbook “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and a book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). She has contributed to the Cosmeceutical Critique column in Dermatology News since January 2001. Her latest book, “Cosmeceuticals and Cosmetic Ingredients,” was published in November 2014. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Evolus, Galderma, GlaxoSmithKline, Kythera Biopharmaceuticals, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy, Topix Pharmaceuticals, and Unilever.

The Internet has changed many facets of modern life, and the practice of medicine has not gone untouched. Consider, for better or worse, the reliance of many patients on WebMD and various other sites for self-diagnosis before consulting with a physician. Even before the Internet, patients would self-diagnose their skin type (more than 80% of them get it wrong). The Internet allows them access to most cosmeceutical brands, the misuse of which leads to unintended consequences that can affect skin health. Clearly, patients who receive advice from a trained medical professional have better outcomes. One reason for this is that the doctor (or aesthetician) spends time with the patient, explaining what products to use and in which order to use them, and follows up with the patient to assess the outcome and adjust the regimen as needed. The problem arises when these patients decide to purchase the products from a source other than their treating physician. Only about 30% of patients buy refills from their doctor for second purchases, and just 15% purchase products from their doctor the third time around. Why is this? It is likely the convenience and the low cost that drive patients to purchase from sources other than their physician or aesthetician. This desire to save money carries significant risks. Many the products online are expired or counterfeit, or are old containers refilled with a different formulation. Patients should be cautioned to only buy products from a source they trust.

I have had dozens of patients bringing in counterfeit products in the last few months. It seems that the problem is becoming more common. I interviewed several companies about this to see whether others were experiencing the same trend. This is what I found:

Some companies report that they have seen their samples and trade size containers being sold on eBay. Joe Ragosta of Topix Pharmaceuticals reports that when his company has asked such sellers if they are obtaining these products – marked as samples – from the company, they hear a range of defensive responses, including: “I got it at a show” or “My doctor gave me samples, and I decided to sell them” and “I work at a doctor’s office, and they let me take products as needed.” Make sure that no one on your staff is taking samples and selling them online.

One example: NeoStrata is concerned about the fraudulent use of their products. They recommend that patients purchase their products only from a known physician, ideally from the physician’s office rather than the website. The company understands that customers may want to save money wherever they can and might prefer to buy products online. NeoStrata urges customers who opt to buy online to make such purchases through physician-affiliated websites, where the doctor is clearly identified. At the very least, the company urges patients to choose only sites where they can contact someone and obtain the name of a physician. Further, they strongly discourage using eBay or other auction sites, which do not vouch for the safety and authenticity of products sold through their services.

Other potential problems with skin care products sold online include the following.

Counterfeit products

Several reports have indicated that counterfeit skin products originating in other countries have made their way into the United States and, according to the article published on the website Fact Based Skin Care, pharmaceuticals and personal care products, including cosmetics, are among the top five types of products seized by U.S. Customs and Border Patrol agents (Coy, C. Dangers of Counterfeit Cosmetics, Aug. 4, 2014). Such products include old bottles refilled with inexpensive imitation creams or bottles made to look like legitimate products that in fact contain imitation creams. I once had a patient present with an adverse reaction to a retinol product, which she brought with her to the visit. I sent the bottle to the company, which confirmed my suspicion that the product was counterfeit – a different bottle with a similar label.

In February 2014, CBS New York ran a segment on the potential inclusion of carcinogenic and other harmful ingredients found in online personal care products touted for their low prices (CBS New York. Counterfeit Cosmetics May Be Harmful To Your Health. Feb. 27, 2014). Not even 2 weeks later, CNN reported on the arrest of two brothers in New York alleged to have masterminded a multimillion-dollar counterfeit health and beauty product ring (CNN. Zulueta A. Massive Fake Health and Beauty Supplies Ring Busted. March 9, 2014). ABC’s Good Morning America followed suit with a segment in April 2014 that exposed aspects of the use of knock-off cosmetic products (ABC News, Good Morning America. Online Beauty Bargains: Is It the Real Deal? April 3, 2014).

The Federal Bureau of Investigation has posted memos concerning counterfeit and potentially compromised and hazardous cosmetics and fragrances, offering tips aimed at readily identifying or avoiding unauthorized products.

Torie Hardee of EltaMD summarized that counterfeit products can sometimes be identified by lack of an expiration date on the bottle, discoloration or slightly different fonts on bottles and packaging, and the manufacturer’s address on the bottle.

Jan Marini Company representative Stuart Mohr noted that their company has received returns of products that they had not manufactured, as well as their own current or discontinued products returned years after the expiration date. The Jan Marini Co., and most other companies, will not guarantee any product purchased via nonauthorized resellers, because the authenticity and safety of such products cannot be verified.

“These unauthorized resellers are sophisticated, often even working in rings, and find it easy to hide their real identity,” said Mr. Mohr. “Addresses are often hidden or vague; emails are not linked to any specific person; and it’s easy to use false names. If a person is caught in an unauthorized online transaction, it’s easy to change the email address or name and start again,” he added.

©Ingram Publishing/Thinkstockphotos.com

FBI’s tips for spotting counterfeit cosmetics and fragrances

• The product is a sample size.

• The packaging differs slightly from the authentic brand (different color or font).

• The product’s wrapping appears haphazard.

• The product is being advertised as a “limited edition” even though the authentic manufacturer doesn’t offer it as a limited edition.

• The product is not listed on the manufacturer’s website.

• The price is drastically lower than the MSRP.

• The product’s consistency or texture doesn’t feel or look like the authentic brand.

• For fragrances, something seems off about the scent, and the color of the fluid in the bottle might be different than the original.

• They are being sold at nonauthorized retailers, including flea markets and discount stores.

• The label does not contain lot number, bar code, manufacturer’s address, or expiration date.

Expired products

Unscrupulous online retailers may slash prices on expired products and remove the expiration date from the package. In my practice, a patient experiencing an erythematous reaction brought in the “SkinMedica” product bottle, which looked suspicious to me. The packaging that the product was in had been discontinued 8 years earlier. It is important to remember that ingredients, particularly retinol, degrade with exposure to air, sun, and heat, and over time. This is most likely what caused my patient’s adverse reaction, and her initial savings from the product caused her several weeks of irritated skin.

Diverted products

SkinMedica reports that diverted products are a trickier issue than counterfeit products, because their packaging and formulas are sufficiently complex to make counterfeiting too difficult to be profitable. Instead, their products have been sold on the so-called gray market below the manufacturer suggested retail price (MSRP), typically online. In these cases, the company cannot help patients with returns or complaints because they cannot verify the chain of custody of the purchased product. They are addressing this problem, though, with an awareness campaign called “Authentic and Authorized.” Its goal is to alert patients and the physicians who dispense their products of the benefits of a physician-dispensed model of skin care, with best outcomes achieved when doctors are prescribing a skin care regimen. SkinMedica emphasizes that no website can guarantee outcomes comparable to a skin care professional and product quality and safety can only be enforced when dispensed through authorized channels.

Potentially illegal or toxic ingredients

Several products that have entered the United States marketed as skin lighteners, antiaging agents, and acne treatment products have been found to contain mercury, according to a consumer update from the FDA. Arsenic, lead, beryllium, and other harmful toxins as well as allergy-inducing fragrances or preservatives not approved as safe in the U.S. may also be found in such products of dubious origin.

Improper storage

Products purveyed online are often stored in hot warehouses. As mentioned above, heat degrades and alters ingredients, rendering compounds such as retinol, benzoyl peroxide, peptides, and ascorbic acid worthless. Extreme cold can also damage the chemical integrity of products. Notably, organic products are more vulnerable because they lack preservatives to gird them against temperature variations and microbes that grow in hot, damp environments.

Lookalike imposters

Generic formulations are packaged to piggyback onto the success of well-known products. Such products found in drugstores may be packaged to look like Cetaphil or Aveeno items, but cost less, and deliver less. While the ingredients on the copycats are identical to those found in the branded preparations, the order in which ingredients are added, the temperature, pH, and even when and how fast ingredients are stirred are part of the proprietary recipe of the company and play a significant role in the potential of the end product and the actions the product exerts on the skin.

Conclusion

Whether or not you sell skin care products in your office, there is much you can do to educate your patients about skin care product safety. Namely, the farther a consumer gets from the source of the product or from reliable endorsers of products, the greater the opportunity for encountering fraudulent or counterfeit products. Patients are best served by sources they can trust, such as their dermatologist. If you sell products in your office, encourage your patients to buy refills from you so they can be assured of the proper formulations. Finally, encourage your patients not to skimp when it comes to the health of their skin, reminding them that it may cost them much more in terms of time, skin irritation, improper treatment, and all related expenses to buy products cheaply from unreliable sources.

Give your patients a copy of this article so that they will understand the enormity of the problem.

Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in the Design District in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote the textbook “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and a book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). She has contributed to the Cosmeceutical Critique column in Dermatology News since January 2001. Her latest book, “Cosmeceuticals and Cosmetic Ingredients,” was published in November 2014. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Evolus, Galderma, GlaxoSmithKline, Kythera Biopharmaceuticals, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy, Topix Pharmaceuticals, and Unilever.

The Internet has changed many facets of modern life, and the practice of medicine has not gone untouched. Consider, for better or worse, the reliance of many patients on WebMD and various other sites for self-diagnosis before consulting with a physician. Even before the Internet, patients would self-diagnose their skin type (more than 80% of them get it wrong). The Internet allows them access to most cosmeceutical brands, the misuse of which leads to unintended consequences that can affect skin health. Clearly, patients who receive advice from a trained medical professional have better outcomes. One reason for this is that the doctor (or aesthetician) spends time with the patient, explaining what products to use and in which order to use them, and follows up with the patient to assess the outcome and adjust the regimen as needed. The problem arises when these patients decide to purchase the products from a source other than their treating physician. Only about 30% of patients buy refills from their doctor for second purchases, and just 15% purchase products from their doctor the third time around. Why is this? It is likely the convenience and the low cost that drive patients to purchase from sources other than their physician or aesthetician. This desire to save money carries significant risks. Many the products online are expired or counterfeit, or are old containers refilled with a different formulation. Patients should be cautioned to only buy products from a source they trust.

I have had dozens of patients bringing in counterfeit products in the last few months. It seems that the problem is becoming more common. I interviewed several companies about this to see whether others were experiencing the same trend. This is what I found:

Some companies report that they have seen their samples and trade size containers being sold on eBay. Joe Ragosta of Topix Pharmaceuticals reports that when his company has asked such sellers if they are obtaining these products – marked as samples – from the company, they hear a range of defensive responses, including: “I got it at a show” or “My doctor gave me samples, and I decided to sell them” and “I work at a doctor’s office, and they let me take products as needed.” Make sure that no one on your staff is taking samples and selling them online.

One example: NeoStrata is concerned about the fraudulent use of their products. They recommend that patients purchase their products only from a known physician, ideally from the physician’s office rather than the website. The company understands that customers may want to save money wherever they can and might prefer to buy products online. NeoStrata urges customers who opt to buy online to make such purchases through physician-affiliated websites, where the doctor is clearly identified. At the very least, the company urges patients to choose only sites where they can contact someone and obtain the name of a physician. Further, they strongly discourage using eBay or other auction sites, which do not vouch for the safety and authenticity of products sold through their services.

Other potential problems with skin care products sold online include the following.

Counterfeit products

Several reports have indicated that counterfeit skin products originating in other countries have made their way into the United States and, according to the article published on the website Fact Based Skin Care, pharmaceuticals and personal care products, including cosmetics, are among the top five types of products seized by U.S. Customs and Border Patrol agents (Coy, C. Dangers of Counterfeit Cosmetics, Aug. 4, 2014). Such products include old bottles refilled with inexpensive imitation creams or bottles made to look like legitimate products that in fact contain imitation creams. I once had a patient present with an adverse reaction to a retinol product, which she brought with her to the visit. I sent the bottle to the company, which confirmed my suspicion that the product was counterfeit – a different bottle with a similar label.

In February 2014, CBS New York ran a segment on the potential inclusion of carcinogenic and other harmful ingredients found in online personal care products touted for their low prices (CBS New York. Counterfeit Cosmetics May Be Harmful To Your Health. Feb. 27, 2014). Not even 2 weeks later, CNN reported on the arrest of two brothers in New York alleged to have masterminded a multimillion-dollar counterfeit health and beauty product ring (CNN. Zulueta A. Massive Fake Health and Beauty Supplies Ring Busted. March 9, 2014). ABC’s Good Morning America followed suit with a segment in April 2014 that exposed aspects of the use of knock-off cosmetic products (ABC News, Good Morning America. Online Beauty Bargains: Is It the Real Deal? April 3, 2014).

The Federal Bureau of Investigation has posted memos concerning counterfeit and potentially compromised and hazardous cosmetics and fragrances, offering tips aimed at readily identifying or avoiding unauthorized products.

Torie Hardee of EltaMD summarized that counterfeit products can sometimes be identified by lack of an expiration date on the bottle, discoloration or slightly different fonts on bottles and packaging, and the manufacturer’s address on the bottle.

Jan Marini Company representative Stuart Mohr noted that their company has received returns of products that they had not manufactured, as well as their own current or discontinued products returned years after the expiration date. The Jan Marini Co., and most other companies, will not guarantee any product purchased via nonauthorized resellers, because the authenticity and safety of such products cannot be verified.

“These unauthorized resellers are sophisticated, often even working in rings, and find it easy to hide their real identity,” said Mr. Mohr. “Addresses are often hidden or vague; emails are not linked to any specific person; and it’s easy to use false names. If a person is caught in an unauthorized online transaction, it’s easy to change the email address or name and start again,” he added.

©Ingram Publishing/Thinkstockphotos.com

FBI’s tips for spotting counterfeit cosmetics and fragrances

• The product is a sample size.

• The packaging differs slightly from the authentic brand (different color or font).

• The product’s wrapping appears haphazard.

• The product is being advertised as a “limited edition” even though the authentic manufacturer doesn’t offer it as a limited edition.

• The product is not listed on the manufacturer’s website.

• The price is drastically lower than the MSRP.

• The product’s consistency or texture doesn’t feel or look like the authentic brand.

• For fragrances, something seems off about the scent, and the color of the fluid in the bottle might be different than the original.

• They are being sold at nonauthorized retailers, including flea markets and discount stores.

• The label does not contain lot number, bar code, manufacturer’s address, or expiration date.

Expired products

Unscrupulous online retailers may slash prices on expired products and remove the expiration date from the package. In my practice, a patient experiencing an erythematous reaction brought in the “SkinMedica” product bottle, which looked suspicious to me. The packaging that the product was in had been discontinued 8 years earlier. It is important to remember that ingredients, particularly retinol, degrade with exposure to air, sun, and heat, and over time. This is most likely what caused my patient’s adverse reaction, and her initial savings from the product caused her several weeks of irritated skin.

Diverted products

SkinMedica reports that diverted products are a trickier issue than counterfeit products, because their packaging and formulas are sufficiently complex to make counterfeiting too difficult to be profitable. Instead, their products have been sold on the so-called gray market below the manufacturer suggested retail price (MSRP), typically online. In these cases, the company cannot help patients with returns or complaints because they cannot verify the chain of custody of the purchased product. They are addressing this problem, though, with an awareness campaign called “Authentic and Authorized.” Its goal is to alert patients and the physicians who dispense their products of the benefits of a physician-dispensed model of skin care, with best outcomes achieved when doctors are prescribing a skin care regimen. SkinMedica emphasizes that no website can guarantee outcomes comparable to a skin care professional and product quality and safety can only be enforced when dispensed through authorized channels.

Potentially illegal or toxic ingredients

Several products that have entered the United States marketed as skin lighteners, antiaging agents, and acne treatment products have been found to contain mercury, according to a consumer update from the FDA. Arsenic, lead, beryllium, and other harmful toxins as well as allergy-inducing fragrances or preservatives not approved as safe in the U.S. may also be found in such products of dubious origin.

Improper storage

Products purveyed online are often stored in hot warehouses. As mentioned above, heat degrades and alters ingredients, rendering compounds such as retinol, benzoyl peroxide, peptides, and ascorbic acid worthless. Extreme cold can also damage the chemical integrity of products. Notably, organic products are more vulnerable because they lack preservatives to gird them against temperature variations and microbes that grow in hot, damp environments.

Lookalike imposters

Generic formulations are packaged to piggyback onto the success of well-known products. Such products found in drugstores may be packaged to look like Cetaphil or Aveeno items, but cost less, and deliver less. While the ingredients on the copycats are identical to those found in the branded preparations, the order in which ingredients are added, the temperature, pH, and even when and how fast ingredients are stirred are part of the proprietary recipe of the company and play a significant role in the potential of the end product and the actions the product exerts on the skin.

Conclusion

Whether or not you sell skin care products in your office, there is much you can do to educate your patients about skin care product safety. Namely, the farther a consumer gets from the source of the product or from reliable endorsers of products, the greater the opportunity for encountering fraudulent or counterfeit products. Patients are best served by sources they can trust, such as their dermatologist. If you sell products in your office, encourage your patients to buy refills from you so they can be assured of the proper formulations. Finally, encourage your patients not to skimp when it comes to the health of their skin, reminding them that it may cost them much more in terms of time, skin irritation, improper treatment, and all related expenses to buy products cheaply from unreliable sources.

Give your patients a copy of this article so that they will understand the enormity of the problem.

Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in the Design District in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote the textbook “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and a book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). She has contributed to the Cosmeceutical Critique column in Dermatology News since January 2001. Her latest book, “Cosmeceuticals and Cosmetic Ingredients,” was published in November 2014. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Evolus, Galderma, GlaxoSmithKline, Kythera Biopharmaceuticals, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy, Topix Pharmaceuticals, and Unilever.

While much has been written about the Center for Medicare & Medicaid Services (CMS) plan to shift its payment system away from fee for service and toward a “value-based” structure, most physicians in small and solo private settings have given little, if any, thought to its potential impact on their practices. That is about to change.

The principal vehicle for the CMS plan is something called the Value-Based Payment Modifier (VBM), a component of the Affordable Care Act (ACA). The VBM has been off the radar of smaller private practices, because up until now it has applied only to groups with more than 10 providers. Starting this year, it applies to everyone. If you accept Medicare patients, regardless of the size of your practice, VBM will become part of your life – because your 2017 Medicare payments will be adjusted based on your 2015 VBM “score.”

That score will be based on your “quality of care” (as defined by the CMS) and how much your care costs the system, compared with care provided by other physicians. The quality component will be calculated from measures reported through the Physician Quality Reporting System (PQRS). Your practice will then be “tiered” to determine whether your performance is statistically better, the same, or worse than the national mean. The CMS has not shared all the details of its “quality tiering” formula, but you can get an idea of their general criteria by reviewing the recently released “Quality Benchmarks for the 2015 Value Modifier” at CMS.org.

To calculate the cost component, the CMS will evaluate measures that include total overall costs per beneficiary, and total costs for a composite of chronic conditions, such as (for internists) chronic obstructive pulmonary disease, heart failure, coronary artery disease, and diabetes; no one has speculated on which diseases might be used for dermatology. Practitioners are eligible for a 1% bonus if their average score is in the top 25% of all scores nationwide. You can get some sense of where you stand in the national hierarchy by studying your Quality Resource and Use Report (QRUR), which gathers information about each practice’s quality and performance rates for the VBM. Reports for the first half of 2014 were released by the CMS in April, and can be downloaded from the QRUR section of CMS.gov.

The ACA requires that the program be budget neutral – which means that all bonuses to physicians in the highest 25% must be offset by penalties – “negative adjustments” – to those in the lowest 25%. The good news is that groups with two to nine providers, and solo practitioners who report successfully for PQRS, receive only the upward or neutral adjustment for 2017, with no downward adjustments. That means you will have at least one penalty-free year to determine where you stand in the VBM pecking order – and perhaps earn a bonus.

So in summary, here is what you have to do now, in 2015, to maximize your chances of earning that upward adjustment in 2017:

• If you haven’t already, make sure your practice data are correct in the Medicare Provider Enrollment, Chain, and Ownership System (PECOS). This is where CMS will gather data for the VBM and the Physician Feedback Reports.

• Study the Quality Benchmarks and download your practice’s QRUR, as mentioned.

• Report successfully for PQRS in 2015, which will also avoid an automatic penalty of 4% in 2017.

Are there serious potential consequences inherent in this unprecedented new system? I think so. For all the talk that the transition from fee-for-service to “value-based” reimbursement would result in better care at a lower cost, there is little evidence that care is improving, and even less that costs are decreasing.

In essence, the VBM establishes arbitrary practice standards and spending ceilings. It creates new incentives to practice “cookbook” medicine, and new disincentives to order tests, consults, or medications, even when doing so would clearly be in a patient’s best interest. Physicians who have the temerity to practice medicine as they see fit, irrespective of the costs involved, will be punished.

Patients will certainly not welcome their physicians’ new reluctance to recommend appropriate interventions for fear of generating excessive costs, and should a less-than-thorough work-up lead to a missed diagnosis, the ACA offers no protection at all from any resulting malpractice litigation.

All of that said, the VBM is a reality, and can no longer be ignored if you treat Medicare patients.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters.

While much has been written about the Center for Medicare & Medicaid Services (CMS) plan to shift its payment system away from fee for service and toward a “value-based” structure, most physicians in small and solo private settings have given little, if any, thought to its potential impact on their practices. That is about to change.

The principal vehicle for the CMS plan is something called the Value-Based Payment Modifier (VBM), a component of the Affordable Care Act (ACA). The VBM has been off the radar of smaller private practices, because up until now it has applied only to groups with more than 10 providers. Starting this year, it applies to everyone. If you accept Medicare patients, regardless of the size of your practice, VBM will become part of your life – because your 2017 Medicare payments will be adjusted based on your 2015 VBM “score.”

That score will be based on your “quality of care” (as defined by the CMS) and how much your care costs the system, compared with care provided by other physicians. The quality component will be calculated from measures reported through the Physician Quality Reporting System (PQRS). Your practice will then be “tiered” to determine whether your performance is statistically better, the same, or worse than the national mean. The CMS has not shared all the details of its “quality tiering” formula, but you can get an idea of their general criteria by reviewing the recently released “Quality Benchmarks for the 2015 Value Modifier” at CMS.org.

To calculate the cost component, the CMS will evaluate measures that include total overall costs per beneficiary, and total costs for a composite of chronic conditions, such as (for internists) chronic obstructive pulmonary disease, heart failure, coronary artery disease, and diabetes; no one has speculated on which diseases might be used for dermatology. Practitioners are eligible for a 1% bonus if their average score is in the top 25% of all scores nationwide. You can get some sense of where you stand in the national hierarchy by studying your Quality Resource and Use Report (QRUR), which gathers information about each practice’s quality and performance rates for the VBM. Reports for the first half of 2014 were released by the CMS in April, and can be downloaded from the QRUR section of CMS.gov.

The ACA requires that the program be budget neutral – which means that all bonuses to physicians in the highest 25% must be offset by penalties – “negative adjustments” – to those in the lowest 25%. The good news is that groups with two to nine providers, and solo practitioners who report successfully for PQRS, receive only the upward or neutral adjustment for 2017, with no downward adjustments. That means you will have at least one penalty-free year to determine where you stand in the VBM pecking order – and perhaps earn a bonus.

So in summary, here is what you have to do now, in 2015, to maximize your chances of earning that upward adjustment in 2017:

• If you haven’t already, make sure your practice data are correct in the Medicare Provider Enrollment, Chain, and Ownership System (PECOS). This is where CMS will gather data for the VBM and the Physician Feedback Reports.

• Study the Quality Benchmarks and download your practice’s QRUR, as mentioned.

• Report successfully for PQRS in 2015, which will also avoid an automatic penalty of 4% in 2017.

Are there serious potential consequences inherent in this unprecedented new system? I think so. For all the talk that the transition from fee-for-service to “value-based” reimbursement would result in better care at a lower cost, there is little evidence that care is improving, and even less that costs are decreasing.

In essence, the VBM establishes arbitrary practice standards and spending ceilings. It creates new incentives to practice “cookbook” medicine, and new disincentives to order tests, consults, or medications, even when doing so would clearly be in a patient’s best interest. Physicians who have the temerity to practice medicine as they see fit, irrespective of the costs involved, will be punished.

Patients will certainly not welcome their physicians’ new reluctance to recommend appropriate interventions for fear of generating excessive costs, and should a less-than-thorough work-up lead to a missed diagnosis, the ACA offers no protection at all from any resulting malpractice litigation.

All of that said, the VBM is a reality, and can no longer be ignored if you treat Medicare patients.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters.

While much has been written about the Center for Medicare & Medicaid Services (CMS) plan to shift its payment system away from fee for service and toward a “value-based” structure, most physicians in small and solo private settings have given little, if any, thought to its potential impact on their practices. That is about to change.

The principal vehicle for the CMS plan is something called the Value-Based Payment Modifier (VBM), a component of the Affordable Care Act (ACA). The VBM has been off the radar of smaller private practices, because up until now it has applied only to groups with more than 10 providers. Starting this year, it applies to everyone. If you accept Medicare patients, regardless of the size of your practice, VBM will become part of your life – because your 2017 Medicare payments will be adjusted based on your 2015 VBM “score.”

That score will be based on your “quality of care” (as defined by the CMS) and how much your care costs the system, compared with care provided by other physicians. The quality component will be calculated from measures reported through the Physician Quality Reporting System (PQRS). Your practice will then be “tiered” to determine whether your performance is statistically better, the same, or worse than the national mean. The CMS has not shared all the details of its “quality tiering” formula, but you can get an idea of their general criteria by reviewing the recently released “Quality Benchmarks for the 2015 Value Modifier” at CMS.org.

To calculate the cost component, the CMS will evaluate measures that include total overall costs per beneficiary, and total costs for a composite of chronic conditions, such as (for internists) chronic obstructive pulmonary disease, heart failure, coronary artery disease, and diabetes; no one has speculated on which diseases might be used for dermatology. Practitioners are eligible for a 1% bonus if their average score is in the top 25% of all scores nationwide. You can get some sense of where you stand in the national hierarchy by studying your Quality Resource and Use Report (QRUR), which gathers information about each practice’s quality and performance rates for the VBM. Reports for the first half of 2014 were released by the CMS in April, and can be downloaded from the QRUR section of CMS.gov.

The ACA requires that the program be budget neutral – which means that all bonuses to physicians in the highest 25% must be offset by penalties – “negative adjustments” – to those in the lowest 25%. The good news is that groups with two to nine providers, and solo practitioners who report successfully for PQRS, receive only the upward or neutral adjustment for 2017, with no downward adjustments. That means you will have at least one penalty-free year to determine where you stand in the VBM pecking order – and perhaps earn a bonus.

So in summary, here is what you have to do now, in 2015, to maximize your chances of earning that upward adjustment in 2017:

• If you haven’t already, make sure your practice data are correct in the Medicare Provider Enrollment, Chain, and Ownership System (PECOS). This is where CMS will gather data for the VBM and the Physician Feedback Reports.

• Study the Quality Benchmarks and download your practice’s QRUR, as mentioned.

• Report successfully for PQRS in 2015, which will also avoid an automatic penalty of 4% in 2017.

Are there serious potential consequences inherent in this unprecedented new system? I think so. For all the talk that the transition from fee-for-service to “value-based” reimbursement would result in better care at a lower cost, there is little evidence that care is improving, and even less that costs are decreasing.

In essence, the VBM establishes arbitrary practice standards and spending ceilings. It creates new incentives to practice “cookbook” medicine, and new disincentives to order tests, consults, or medications, even when doing so would clearly be in a patient’s best interest. Physicians who have the temerity to practice medicine as they see fit, irrespective of the costs involved, will be punished.

Patients will certainly not welcome their physicians’ new reluctance to recommend appropriate interventions for fear of generating excessive costs, and should a less-than-thorough work-up lead to a missed diagnosis, the ACA offers no protection at all from any resulting malpractice litigation.

All of that said, the VBM is a reality, and can no longer be ignored if you treat Medicare patients.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters.