Commentary

It is widely known and taught that maternal blood lipid levels increase slightly during pregnancy. Lipid values throughout pregnancy, however, have not been well described, making it difficult to ascertain which changes are normal and which changes may be potentially troubling for the mother and/or the baby.

Similarly, the association between pregnancy outcomes and lipid levels prior to conception and during pregnancy has been studied only minimally. In both areas, more research is needed.

Yet despite the need for more research, it now appears that the mother’s lipid profile – particularly her triglyceride levels before and during pregnancy – warrants our attention. Results from several clinical studies suggest that elevated maternal triglyceride (TG) levels may be associated with gestational diabetes mellitus (GDM) and preeclampsia. Since these conditions can contribute to the development of peri- and postpartum complications and increase the mother’s risk of developing subsequent type 2 diabetes and systemic hypertension, a mother’s lipid profile – just like her glucose levels – may help us define who is at high risk of pregnancy complications and later adverse effects.

Research findings

In addition to assessing fetal health during pregnancy, ob.gyns. routinely measure and monitor maternal blood pressure, weight gain, and blood sugar, which fluctuate during normal pregnancies.

We have found that lipid levels, notably maternal TG, total cholesterol, and the major particles of high-density lipoproteins (HDLs) and low-density lipoproteins (LDLs) also vary during pregnancy, with a nadir during the first trimester, followed by a gradual increase and a peaking before delivery.

It is well known that severely elevated blood pressure, gestational weight, or glucose can signify a pregnancy at risk for adverse outcomes. However, our research has shown that high levels of TGs, but not the levels of HDLs, LDLs, or total cholesterol, during pregnancy also are associated with an increased risk for preeclampsia and gestational diabetes mellitus (Am. J. Obstet. Gynecol. 2009;201:482.e1-8).

In our study, the rate of preeclampsia or GDM increased with maternal TG level, from 7.2% in women who had the lowest levels (<25^th percentile) to 19.8% in women who had the highest levels (>75^th percentile).

We found that TG levels in the upper quartile also were associated with a significantly higher risk of preeclampsia, compared with the lower quartile (relative risk, 1.87).

Similarly, among women without diagnosed GDM, those with TG levels in the upper quartile were more likely to have a fasting glucose level of 100 mg/dL or more, compared with the intermediate group (TG level between the 25^th and 75^th percentiles) and the lower quartile. Women with the highest TG levels also were more likely to have infants classified as large for gestational age.

Our findings are consistent with a review that showed a positive association between elevated maternal TG and the risk of preeclampsia (BJOG 2006;113:379-86), as well as a cohort study that found plasma TG levels in the first trimester were independently and linearly associated with pregnancy-induced hypertension, preeclampsia, and large-for-gestational age (J. Clin. Endocrinol. Metab. 2012;97:3917-25).

Interestingly, the cohort study did not show an association between elevated maternal TG levels, adverse pregnancy outcomes, and body mass index. This suggests that weight gain and TG may be independent risk factors.

In practice

At this point in time, without defined cut-off values and well-tested interventions, there is no recommendation regarding maternal lipid measurement during pregnancy. We have shown, however, that maternal TG levels above 140 mg/dL at 3 months’ gestation and TG levels of 200 mg/dL or more at 6 months’ gestation are very high and may indicate a high-risk pregnancy.

Like all ob.gyns., we advise women before pregnancy to lose weight and to normalize blood glucose levels before attempting to conceive to reduce pregnancy complications, but we also encourage our patients to lower their TG levels. Given the observed associations between higher TG levels and adverse pregnancy outcomes, we now routinely measure maternal lipids as well as blood glucose in our pregnant patients. We also test lipid levels in pregnant women who have other risk factors such as GDM in a prior pregnancy or chronic high blood pressure.

It is possible that lifestyle programs (such as those involving diet, weight reduction, and physical activity) prior to and during pregnancy, with a focus not only on maintaining a healthy weight but also on lowering TG levels, may help to further prevent complications during pregnancy and adverse birth outcomes. Although more research is needed, lowering TGs with cholesterol-reducing drugs also may help improve pregnancy outcomes. Indeed, there is currently a study investigating the pharmacologic treatment of high lipids during pregnancy.

For now, we should advise our patients who have higher TG levels in pregnancy to improve their diets and levels of physical activity. We also should monitor these patients for the increased likelihood of developing GDM and preeclampsia because higher lipid profiles appear to equate to a higher risk of adverse outcomes.

Finally, our attention to lipid profiles should extend beyond birth, since the long-term risk of cardiovascular disease may be influenced by preeclampsia and potentially by the lipid changes that escalate with the condition.

Dr. Wiznitzer reported having no financial disclosures related to this Master Class.

It is widely known and taught that maternal blood lipid levels increase slightly during pregnancy. Lipid values throughout pregnancy, however, have not been well described, making it difficult to ascertain which changes are normal and which changes may be potentially troubling for the mother and/or the baby.

Similarly, the association between pregnancy outcomes and lipid levels prior to conception and during pregnancy has been studied only minimally. In both areas, more research is needed.

Yet despite the need for more research, it now appears that the mother’s lipid profile – particularly her triglyceride levels before and during pregnancy – warrants our attention. Results from several clinical studies suggest that elevated maternal triglyceride (TG) levels may be associated with gestational diabetes mellitus (GDM) and preeclampsia. Since these conditions can contribute to the development of peri- and postpartum complications and increase the mother’s risk of developing subsequent type 2 diabetes and systemic hypertension, a mother’s lipid profile – just like her glucose levels – may help us define who is at high risk of pregnancy complications and later adverse effects.

Research findings

In addition to assessing fetal health during pregnancy, ob.gyns. routinely measure and monitor maternal blood pressure, weight gain, and blood sugar, which fluctuate during normal pregnancies.

We have found that lipid levels, notably maternal TG, total cholesterol, and the major particles of high-density lipoproteins (HDLs) and low-density lipoproteins (LDLs) also vary during pregnancy, with a nadir during the first trimester, followed by a gradual increase and a peaking before delivery.

It is well known that severely elevated blood pressure, gestational weight, or glucose can signify a pregnancy at risk for adverse outcomes. However, our research has shown that high levels of TGs, but not the levels of HDLs, LDLs, or total cholesterol, during pregnancy also are associated with an increased risk for preeclampsia and gestational diabetes mellitus (Am. J. Obstet. Gynecol. 2009;201:482.e1-8).

In our study, the rate of preeclampsia or GDM increased with maternal TG level, from 7.2% in women who had the lowest levels (<25^th percentile) to 19.8% in women who had the highest levels (>75^th percentile).

We found that TG levels in the upper quartile also were associated with a significantly higher risk of preeclampsia, compared with the lower quartile (relative risk, 1.87).

Similarly, among women without diagnosed GDM, those with TG levels in the upper quartile were more likely to have a fasting glucose level of 100 mg/dL or more, compared with the intermediate group (TG level between the 25^th and 75^th percentiles) and the lower quartile. Women with the highest TG levels also were more likely to have infants classified as large for gestational age.

Our findings are consistent with a review that showed a positive association between elevated maternal TG and the risk of preeclampsia (BJOG 2006;113:379-86), as well as a cohort study that found plasma TG levels in the first trimester were independently and linearly associated with pregnancy-induced hypertension, preeclampsia, and large-for-gestational age (J. Clin. Endocrinol. Metab. 2012;97:3917-25).

Interestingly, the cohort study did not show an association between elevated maternal TG levels, adverse pregnancy outcomes, and body mass index. This suggests that weight gain and TG may be independent risk factors.

In practice

At this point in time, without defined cut-off values and well-tested interventions, there is no recommendation regarding maternal lipid measurement during pregnancy. We have shown, however, that maternal TG levels above 140 mg/dL at 3 months’ gestation and TG levels of 200 mg/dL or more at 6 months’ gestation are very high and may indicate a high-risk pregnancy.

Like all ob.gyns., we advise women before pregnancy to lose weight and to normalize blood glucose levels before attempting to conceive to reduce pregnancy complications, but we also encourage our patients to lower their TG levels. Given the observed associations between higher TG levels and adverse pregnancy outcomes, we now routinely measure maternal lipids as well as blood glucose in our pregnant patients. We also test lipid levels in pregnant women who have other risk factors such as GDM in a prior pregnancy or chronic high blood pressure.

It is possible that lifestyle programs (such as those involving diet, weight reduction, and physical activity) prior to and during pregnancy, with a focus not only on maintaining a healthy weight but also on lowering TG levels, may help to further prevent complications during pregnancy and adverse birth outcomes. Although more research is needed, lowering TGs with cholesterol-reducing drugs also may help improve pregnancy outcomes. Indeed, there is currently a study investigating the pharmacologic treatment of high lipids during pregnancy.

For now, we should advise our patients who have higher TG levels in pregnancy to improve their diets and levels of physical activity. We also should monitor these patients for the increased likelihood of developing GDM and preeclampsia because higher lipid profiles appear to equate to a higher risk of adverse outcomes.

Finally, our attention to lipid profiles should extend beyond birth, since the long-term risk of cardiovascular disease may be influenced by preeclampsia and potentially by the lipid changes that escalate with the condition.

Dr. Wiznitzer reported having no financial disclosures related to this Master Class.

It is widely known and taught that maternal blood lipid levels increase slightly during pregnancy. Lipid values throughout pregnancy, however, have not been well described, making it difficult to ascertain which changes are normal and which changes may be potentially troubling for the mother and/or the baby.

Similarly, the association between pregnancy outcomes and lipid levels prior to conception and during pregnancy has been studied only minimally. In both areas, more research is needed.

Yet despite the need for more research, it now appears that the mother’s lipid profile – particularly her triglyceride levels before and during pregnancy – warrants our attention. Results from several clinical studies suggest that elevated maternal triglyceride (TG) levels may be associated with gestational diabetes mellitus (GDM) and preeclampsia. Since these conditions can contribute to the development of peri- and postpartum complications and increase the mother’s risk of developing subsequent type 2 diabetes and systemic hypertension, a mother’s lipid profile – just like her glucose levels – may help us define who is at high risk of pregnancy complications and later adverse effects.

Research findings

In addition to assessing fetal health during pregnancy, ob.gyns. routinely measure and monitor maternal blood pressure, weight gain, and blood sugar, which fluctuate during normal pregnancies.

We have found that lipid levels, notably maternal TG, total cholesterol, and the major particles of high-density lipoproteins (HDLs) and low-density lipoproteins (LDLs) also vary during pregnancy, with a nadir during the first trimester, followed by a gradual increase and a peaking before delivery.

It is well known that severely elevated blood pressure, gestational weight, or glucose can signify a pregnancy at risk for adverse outcomes. However, our research has shown that high levels of TGs, but not the levels of HDLs, LDLs, or total cholesterol, during pregnancy also are associated with an increased risk for preeclampsia and gestational diabetes mellitus (Am. J. Obstet. Gynecol. 2009;201:482.e1-8).

In our study, the rate of preeclampsia or GDM increased with maternal TG level, from 7.2% in women who had the lowest levels (<25^th percentile) to 19.8% in women who had the highest levels (>75^th percentile).

We found that TG levels in the upper quartile also were associated with a significantly higher risk of preeclampsia, compared with the lower quartile (relative risk, 1.87).

Similarly, among women without diagnosed GDM, those with TG levels in the upper quartile were more likely to have a fasting glucose level of 100 mg/dL or more, compared with the intermediate group (TG level between the 25^th and 75^th percentiles) and the lower quartile. Women with the highest TG levels also were more likely to have infants classified as large for gestational age.

Our findings are consistent with a review that showed a positive association between elevated maternal TG and the risk of preeclampsia (BJOG 2006;113:379-86), as well as a cohort study that found plasma TG levels in the first trimester were independently and linearly associated with pregnancy-induced hypertension, preeclampsia, and large-for-gestational age (J. Clin. Endocrinol. Metab. 2012;97:3917-25).

Interestingly, the cohort study did not show an association between elevated maternal TG levels, adverse pregnancy outcomes, and body mass index. This suggests that weight gain and TG may be independent risk factors.

In practice

At this point in time, without defined cut-off values and well-tested interventions, there is no recommendation regarding maternal lipid measurement during pregnancy. We have shown, however, that maternal TG levels above 140 mg/dL at 3 months’ gestation and TG levels of 200 mg/dL or more at 6 months’ gestation are very high and may indicate a high-risk pregnancy.

Like all ob.gyns., we advise women before pregnancy to lose weight and to normalize blood glucose levels before attempting to conceive to reduce pregnancy complications, but we also encourage our patients to lower their TG levels. Given the observed associations between higher TG levels and adverse pregnancy outcomes, we now routinely measure maternal lipids as well as blood glucose in our pregnant patients. We also test lipid levels in pregnant women who have other risk factors such as GDM in a prior pregnancy or chronic high blood pressure.

It is possible that lifestyle programs (such as those involving diet, weight reduction, and physical activity) prior to and during pregnancy, with a focus not only on maintaining a healthy weight but also on lowering TG levels, may help to further prevent complications during pregnancy and adverse birth outcomes. Although more research is needed, lowering TGs with cholesterol-reducing drugs also may help improve pregnancy outcomes. Indeed, there is currently a study investigating the pharmacologic treatment of high lipids during pregnancy.

For now, we should advise our patients who have higher TG levels in pregnancy to improve their diets and levels of physical activity. We also should monitor these patients for the increased likelihood of developing GDM and preeclampsia because higher lipid profiles appear to equate to a higher risk of adverse outcomes.

Finally, our attention to lipid profiles should extend beyond birth, since the long-term risk of cardiovascular disease may be influenced by preeclampsia and potentially by the lipid changes that escalate with the condition.

Dr. Wiznitzer reported having no financial disclosures related to this Master Class.

As ob.gyns., we often focus on optimizing our patients’ reproductive health. Research has shown, however, that the condition of a woman’s health prior to conception can be just as – if not more – important to her pregnancy and her lifelong well-being. For example, we have established that women who take the daily recommended dose of folic acid (400 mcg), even outside of pregnancy, have a reduced risk for neural tube defects in their infants.

Last year, we devoted a series of Master Class columns to the crucial need to properly manage maternal weight gain and blood sugar levels before, during, and after gestation to improve pregnancy outcomes. We also have seen that intensive glycemic and weight control in women can reduce their risk of fetal and maternal complications.

However, the leading causes of morbidity and mortality remain cardiovascular diseases, both in the developing and developed world. One of the key contributors to poor heart and vascular health is high cholesterol. Although the body needs cholesterol, just as it needs sugar, excess lipids in the blood can lead to infarction and stroke.

According to the U.S. Centers for Disease Control and Prevention, the desirable total cholesterol levels, including low- and high-density lipids and triglycerides, for men and nonpregnant women fall below 200 mg/dL. What remain less clear are the desired lipid levels for pregnant women.

We have known for decades that cholesterol concentrations increase during pregnancy, possibly by as much as 50%. We do not, however, have a firm understanding of what may constitute normally higher lipid concentrations and what may signal risk to the health of the baby or mother. Additionally, while we may run a lipid panel when we order a blood test, ob.gyns. do not routinely monitor a women’s cholesterol.

Since excess lipids, obesity, and heart disease often occur in the same patient and have become increasingly prevalent in our society, it may be time to reexamine any correlations between maternal lipid levels and adverse pregnancy outcomes.

To comment on this reemerging area, we invited Dr. Arnon Wiznitzer, professor and chairman of the department of obstetrics and gynecology at Helen Schneider Hospital for Women and deputy director of the Rabin Medical Center, Sackler Faculty of Medicine, Tel Aviv University. Dr. Wiznitzer’s extensive experience working with women who have diabetes in pregnancy led him to examine other comorbidities, including lipids, which might confound good pregnancy outcomes.

Dr. Reece, who specializes in maternal-fetal medicine, is vice president for medical affairs at the University of Maryland, Baltimore, as well as the John Z. and Akiko K. Bowers Distinguished Professor and dean of the school of medicine. Dr. Reece said he had no relevant financial disclosures. He is the medical editor of this column. Contact him at [email protected].

As ob.gyns., we often focus on optimizing our patients’ reproductive health. Research has shown, however, that the condition of a woman’s health prior to conception can be just as – if not more – important to her pregnancy and her lifelong well-being. For example, we have established that women who take the daily recommended dose of folic acid (400 mcg), even outside of pregnancy, have a reduced risk for neural tube defects in their infants.

Last year, we devoted a series of Master Class columns to the crucial need to properly manage maternal weight gain and blood sugar levels before, during, and after gestation to improve pregnancy outcomes. We also have seen that intensive glycemic and weight control in women can reduce their risk of fetal and maternal complications.

However, the leading causes of morbidity and mortality remain cardiovascular diseases, both in the developing and developed world. One of the key contributors to poor heart and vascular health is high cholesterol. Although the body needs cholesterol, just as it needs sugar, excess lipids in the blood can lead to infarction and stroke.

According to the U.S. Centers for Disease Control and Prevention, the desirable total cholesterol levels, including low- and high-density lipids and triglycerides, for men and nonpregnant women fall below 200 mg/dL. What remain less clear are the desired lipid levels for pregnant women.

We have known for decades that cholesterol concentrations increase during pregnancy, possibly by as much as 50%. We do not, however, have a firm understanding of what may constitute normally higher lipid concentrations and what may signal risk to the health of the baby or mother. Additionally, while we may run a lipid panel when we order a blood test, ob.gyns. do not routinely monitor a women’s cholesterol.

Since excess lipids, obesity, and heart disease often occur in the same patient and have become increasingly prevalent in our society, it may be time to reexamine any correlations between maternal lipid levels and adverse pregnancy outcomes.

To comment on this reemerging area, we invited Dr. Arnon Wiznitzer, professor and chairman of the department of obstetrics and gynecology at Helen Schneider Hospital for Women and deputy director of the Rabin Medical Center, Sackler Faculty of Medicine, Tel Aviv University. Dr. Wiznitzer’s extensive experience working with women who have diabetes in pregnancy led him to examine other comorbidities, including lipids, which might confound good pregnancy outcomes.

Dr. Reece, who specializes in maternal-fetal medicine, is vice president for medical affairs at the University of Maryland, Baltimore, as well as the John Z. and Akiko K. Bowers Distinguished Professor and dean of the school of medicine. Dr. Reece said he had no relevant financial disclosures. He is the medical editor of this column. Contact him at [email protected].

As ob.gyns., we often focus on optimizing our patients’ reproductive health. Research has shown, however, that the condition of a woman’s health prior to conception can be just as – if not more – important to her pregnancy and her lifelong well-being. For example, we have established that women who take the daily recommended dose of folic acid (400 mcg), even outside of pregnancy, have a reduced risk for neural tube defects in their infants.

Last year, we devoted a series of Master Class columns to the crucial need to properly manage maternal weight gain and blood sugar levels before, during, and after gestation to improve pregnancy outcomes. We also have seen that intensive glycemic and weight control in women can reduce their risk of fetal and maternal complications.

However, the leading causes of morbidity and mortality remain cardiovascular diseases, both in the developing and developed world. One of the key contributors to poor heart and vascular health is high cholesterol. Although the body needs cholesterol, just as it needs sugar, excess lipids in the blood can lead to infarction and stroke.

According to the U.S. Centers for Disease Control and Prevention, the desirable total cholesterol levels, including low- and high-density lipids and triglycerides, for men and nonpregnant women fall below 200 mg/dL. What remain less clear are the desired lipid levels for pregnant women.

We have known for decades that cholesterol concentrations increase during pregnancy, possibly by as much as 50%. We do not, however, have a firm understanding of what may constitute normally higher lipid concentrations and what may signal risk to the health of the baby or mother. Additionally, while we may run a lipid panel when we order a blood test, ob.gyns. do not routinely monitor a women’s cholesterol.

Since excess lipids, obesity, and heart disease often occur in the same patient and have become increasingly prevalent in our society, it may be time to reexamine any correlations between maternal lipid levels and adverse pregnancy outcomes.

To comment on this reemerging area, we invited Dr. Arnon Wiznitzer, professor and chairman of the department of obstetrics and gynecology at Helen Schneider Hospital for Women and deputy director of the Rabin Medical Center, Sackler Faculty of Medicine, Tel Aviv University. Dr. Wiznitzer’s extensive experience working with women who have diabetes in pregnancy led him to examine other comorbidities, including lipids, which might confound good pregnancy outcomes.

Dr. Reece, who specializes in maternal-fetal medicine, is vice president for medical affairs at the University of Maryland, Baltimore, as well as the John Z. and Akiko K. Bowers Distinguished Professor and dean of the school of medicine. Dr. Reece said he had no relevant financial disclosures. He is the medical editor of this column. Contact him at [email protected].

I was 7 years old when my family got its first television. I can’t recall the year, but I know that we were one of the last houses in our neighborhood to have a color TV. As parents, my wife and I kept our children on a moderate viewing diet, mostly “Captain Kangaroo” and “Sesame Street” when they were young. Until they were teenagers, they believed that only televisions in motel rooms received cartoons. Now, as parents, they are more restrictive with their children than we were with them. One family doesn’t even own a television.

A few years ago, my wife and I cut back our cable service to “basic” and, other than a few sporting events and a rare show on PBS, our TV sits unused in our living room. Five months out of the year, we have no television at all – when we’re in our cottage by the ocean.

Our trajectory from being enthusiastic viewers to television abstainers seems to be not that unusual among our peers. At dinner parties, I often hear, “There is nothing worth watching on television. It’s all junk and commercials.” Could the same condemnation be voiced about television for young children? Could there be some benefit for preschoolers in watching an “educational” show such as “Sesame Street”? Or is it all garbage, even for the very young?

A recently and much ballyhooed study by two economists suggests that, at least as “Sesame Street” is concerned, television can have a positive effect on young children. You may have read the headline: “Study: Kids can learn as much from ‘Sesame Street’ as from preschool” (Washington Post, June 7, 2015).

The researchers exploited a quirk of the precable landscape when some markets could not tune into some shows, including “Sesame Street,” because they were receiving only a UHF signal. Analyzing the data over several years, the economists found that, in communities where children had the opportunity to watch “Sesame Street,” those children had a “14% drop in the likelihood of being behind in school.” That association appeared to fade by the time the children reached high school. To claim that “Sesame Street” is at least as good as preschool based on these numbers seems to me to be a bit of a stretch. It may be that UHF-watching kids watched more professional wrestling, and this encouraged them to be more disruptive in school.

We must remember that these researchers are economists, and we should take anything they conclude with a grain of salt. But let’s say that there may be something to their conclusion that there is an association between “Sesame Street” viewing and school readiness. Does this mean that we should be developing more shows on the “Sesame Street” model, and that young children should be watching educational television several hours a day? Is there a dose effect? Or does this apparent association simply suggest that we should be improving preschools?

For decades, pediatricians and the American Academy of Pediatrics were focused on content and giving too little attention to the amount of screen time. This has improved slightly in the last few years, but the fact remains that television is a passive and sedentary activity that is threatening the health of our nation. It is robbing millions of Americans of precious hours of restorative sleep. It is giving even more millions an easy and addictive way to avoid doing something else. Instead, the addicts spend hours each day watching other people doing something. I always have suspected that the introduction of color to television is the culprit. Black-and-white TV was interesting to a point, but I don’t recall it being addictive. Most of us will watch for hours anything that is colorful and moves.

“Sesame Street” is and has been a wonderful show, and I suspect it has helped millions of children learn things they may not have been exposed to at home. But in one sense, educational programming could be considered a gateway drug. Once the set goes on, many parents don’t have the fortitude to shut it off. We should think twice before claiming that it is on a par with preschool.

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.”

I was 7 years old when my family got its first television. I can’t recall the year, but I know that we were one of the last houses in our neighborhood to have a color TV. As parents, my wife and I kept our children on a moderate viewing diet, mostly “Captain Kangaroo” and “Sesame Street” when they were young. Until they were teenagers, they believed that only televisions in motel rooms received cartoons. Now, as parents, they are more restrictive with their children than we were with them. One family doesn’t even own a television.

A few years ago, my wife and I cut back our cable service to “basic” and, other than a few sporting events and a rare show on PBS, our TV sits unused in our living room. Five months out of the year, we have no television at all – when we’re in our cottage by the ocean.

Our trajectory from being enthusiastic viewers to television abstainers seems to be not that unusual among our peers. At dinner parties, I often hear, “There is nothing worth watching on television. It’s all junk and commercials.” Could the same condemnation be voiced about television for young children? Could there be some benefit for preschoolers in watching an “educational” show such as “Sesame Street”? Or is it all garbage, even for the very young?

A recently and much ballyhooed study by two economists suggests that, at least as “Sesame Street” is concerned, television can have a positive effect on young children. You may have read the headline: “Study: Kids can learn as much from ‘Sesame Street’ as from preschool” (Washington Post, June 7, 2015).

The researchers exploited a quirk of the precable landscape when some markets could not tune into some shows, including “Sesame Street,” because they were receiving only a UHF signal. Analyzing the data over several years, the economists found that, in communities where children had the opportunity to watch “Sesame Street,” those children had a “14% drop in the likelihood of being behind in school.” That association appeared to fade by the time the children reached high school. To claim that “Sesame Street” is at least as good as preschool based on these numbers seems to me to be a bit of a stretch. It may be that UHF-watching kids watched more professional wrestling, and this encouraged them to be more disruptive in school.

We must remember that these researchers are economists, and we should take anything they conclude with a grain of salt. But let’s say that there may be something to their conclusion that there is an association between “Sesame Street” viewing and school readiness. Does this mean that we should be developing more shows on the “Sesame Street” model, and that young children should be watching educational television several hours a day? Is there a dose effect? Or does this apparent association simply suggest that we should be improving preschools?

For decades, pediatricians and the American Academy of Pediatrics were focused on content and giving too little attention to the amount of screen time. This has improved slightly in the last few years, but the fact remains that television is a passive and sedentary activity that is threatening the health of our nation. It is robbing millions of Americans of precious hours of restorative sleep. It is giving even more millions an easy and addictive way to avoid doing something else. Instead, the addicts spend hours each day watching other people doing something. I always have suspected that the introduction of color to television is the culprit. Black-and-white TV was interesting to a point, but I don’t recall it being addictive. Most of us will watch for hours anything that is colorful and moves.

“Sesame Street” is and has been a wonderful show, and I suspect it has helped millions of children learn things they may not have been exposed to at home. But in one sense, educational programming could be considered a gateway drug. Once the set goes on, many parents don’t have the fortitude to shut it off. We should think twice before claiming that it is on a par with preschool.

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.”

I was 7 years old when my family got its first television. I can’t recall the year, but I know that we were one of the last houses in our neighborhood to have a color TV. As parents, my wife and I kept our children on a moderate viewing diet, mostly “Captain Kangaroo” and “Sesame Street” when they were young. Until they were teenagers, they believed that only televisions in motel rooms received cartoons. Now, as parents, they are more restrictive with their children than we were with them. One family doesn’t even own a television.

A few years ago, my wife and I cut back our cable service to “basic” and, other than a few sporting events and a rare show on PBS, our TV sits unused in our living room. Five months out of the year, we have no television at all – when we’re in our cottage by the ocean.

Our trajectory from being enthusiastic viewers to television abstainers seems to be not that unusual among our peers. At dinner parties, I often hear, “There is nothing worth watching on television. It’s all junk and commercials.” Could the same condemnation be voiced about television for young children? Could there be some benefit for preschoolers in watching an “educational” show such as “Sesame Street”? Or is it all garbage, even for the very young?

A recently and much ballyhooed study by two economists suggests that, at least as “Sesame Street” is concerned, television can have a positive effect on young children. You may have read the headline: “Study: Kids can learn as much from ‘Sesame Street’ as from preschool” (Washington Post, June 7, 2015).

The researchers exploited a quirk of the precable landscape when some markets could not tune into some shows, including “Sesame Street,” because they were receiving only a UHF signal. Analyzing the data over several years, the economists found that, in communities where children had the opportunity to watch “Sesame Street,” those children had a “14% drop in the likelihood of being behind in school.” That association appeared to fade by the time the children reached high school. To claim that “Sesame Street” is at least as good as preschool based on these numbers seems to me to be a bit of a stretch. It may be that UHF-watching kids watched more professional wrestling, and this encouraged them to be more disruptive in school.

We must remember that these researchers are economists, and we should take anything they conclude with a grain of salt. But let’s say that there may be something to their conclusion that there is an association between “Sesame Street” viewing and school readiness. Does this mean that we should be developing more shows on the “Sesame Street” model, and that young children should be watching educational television several hours a day? Is there a dose effect? Or does this apparent association simply suggest that we should be improving preschools?

For decades, pediatricians and the American Academy of Pediatrics were focused on content and giving too little attention to the amount of screen time. This has improved slightly in the last few years, but the fact remains that television is a passive and sedentary activity that is threatening the health of our nation. It is robbing millions of Americans of precious hours of restorative sleep. It is giving even more millions an easy and addictive way to avoid doing something else. Instead, the addicts spend hours each day watching other people doing something. I always have suspected that the introduction of color to television is the culprit. Black-and-white TV was interesting to a point, but I don’t recall it being addictive. Most of us will watch for hours anything that is colorful and moves.

“Sesame Street” is and has been a wonderful show, and I suspect it has helped millions of children learn things they may not have been exposed to at home. But in one sense, educational programming could be considered a gateway drug. Once the set goes on, many parents don’t have the fortitude to shut it off. We should think twice before claiming that it is on a par with preschool.

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.”

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.”