Physician Resources

A new clinical report published in Pediatrics entitled "Management of Dental Trauma in a Primary Care Setting" expands the knowledge base for pediatricians who care for children in the primary care setting (2014;133:e466-e476). Recommendations for pediatricians go beyond caries preventive messages (brush, floss, limit juice consumption, no bottles in bed, first dental visit at 1 year of age) to include triage and screening for dental trauma in our patients.

Dental trauma is the second most common injury in children aged 0-6 years, and 25% of all school-age children experience dental trauma.

Recommendations to share with parents include anticipatory guidance in several key areas: household safety (gates on stairways, furniture protectors, removal of tripping hazards); mouth guards for competitive/contact sports; and management of dental injuries.

An estimated 20%-30% of all dental injures are sports-related injuries, and the preparticipation sports physical is an ideal time to incorporate injury prevention messages, such as the importance of wearing mouth guards during all practices and games. Custom-fit mouth guards offer the most protection, but use of any mouth guard is preferable to none. Although the U.S. National Collegiate Athletic Association requires mouth guards for only four sports (ice hockey, lacrosse, field hockey, and football), the American Dental Association recommends the use of mouth guards in 29 sports and activities, according to the report.

As pediatric primary care providers are often the first responders for dental injuries, the report provides guidance for initial assessment and recommendations for triage, basing urgency for dental evaluation on injury type. As survival of the tooth is time dependent, it is critical that first responders provide timely and appropriate care. Key skills include determining whether the injured tooth is a primary or permanent tooth (both age of the patient and size of the tooth are factors), and a recommendation to take a photo of the injured tooth. Clinical recommendations vary depending on whether a primary or permanent tooth has been traumatized. The guideline includes excellent photographs and drawings of dental trauma classifications, and denotes injuries that need immediate referral to a dentist versus those that can be managed by the primary care physician.

When evaluating dental injuries, it is imperative to adhere to a systematic approach to avoid an oversight. This includes, but is not limited to, the mechanism and nature of the dental injury, need for a tetanus booster, and consideration of both the possibility of head injury and child abuse.

Dental trauma can be classified into the following categories: concussion, subluxation, luxation, extrusion, intrusion, avulsions, and fractures. Primary teeth that avulse should not be replaced, due to concern for damaging the underlying permanent tooth. Permanent teeth that avulse should be immediately put back in place; these teeth need to be handled by the crown portion only and not the root, which contains fibroblasts necessary for reimplantation. Dirty avulsed permanent teeth can be placed in milk, a balanced salt solution, or saliva (but not water) until the patient can be seen by the dentist.

Conventional intraoral radiographs remain the optimal study for evaluating injured teeth, with less radiation exposure than a computed tomography scan. These studies will be performed at the dental office.

Prophylactic systemic antibiotics are not routinely warranted after dental trauma care, except following reimplantation of a primary avulsed tooth.

Encourage a soft diet and avoidance of non-nutritive sucking (digit or pacifier) for 10 days following most dental injuries

Potential trauma sequelae that should be discussed with caregivers include crown discoloration, root resorption, fixation of the tooth to the underlying bone, and pulpal necrosis.

These guidelines present new and important information for the primary care pediatrician, who will see many examples of dental trauma in their practice. Recommendations regarding care by the primary care physicians and immediate or routine referral to the dentist will be a helpful adjunct to comprehensive patient care.

Dr. Boulter is adjunct professor of pediatrics and community and family medicine at the Geisel School of Medicine at Dartmouth, Hanover, N.H. Dr. Clark is an associate professor of pediatrics at Albany (N.Y.) Medical College, and serves as the chief editor for both Smiles for Life: A National Oral Health Curriculum and Protecting All Children’s Teeth (PACT): AAP’s Pediatric Oral Health Training Program for Physicians. Both Dr. Boulter and Dr. Clark were members of the 2012-2013 AAP Section on Oral Health Executive Committee and involved in developing the clinical report.

A new clinical report published in Pediatrics entitled "Management of Dental Trauma in a Primary Care Setting" expands the knowledge base for pediatricians who care for children in the primary care setting (2014;133:e466-e476). Recommendations for pediatricians go beyond caries preventive messages (brush, floss, limit juice consumption, no bottles in bed, first dental visit at 1 year of age) to include triage and screening for dental trauma in our patients.

Dental trauma is the second most common injury in children aged 0-6 years, and 25% of all school-age children experience dental trauma.

Recommendations to share with parents include anticipatory guidance in several key areas: household safety (gates on stairways, furniture protectors, removal of tripping hazards); mouth guards for competitive/contact sports; and management of dental injuries.

An estimated 20%-30% of all dental injures are sports-related injuries, and the preparticipation sports physical is an ideal time to incorporate injury prevention messages, such as the importance of wearing mouth guards during all practices and games. Custom-fit mouth guards offer the most protection, but use of any mouth guard is preferable to none. Although the U.S. National Collegiate Athletic Association requires mouth guards for only four sports (ice hockey, lacrosse, field hockey, and football), the American Dental Association recommends the use of mouth guards in 29 sports and activities, according to the report.

As pediatric primary care providers are often the first responders for dental injuries, the report provides guidance for initial assessment and recommendations for triage, basing urgency for dental evaluation on injury type. As survival of the tooth is time dependent, it is critical that first responders provide timely and appropriate care. Key skills include determining whether the injured tooth is a primary or permanent tooth (both age of the patient and size of the tooth are factors), and a recommendation to take a photo of the injured tooth. Clinical recommendations vary depending on whether a primary or permanent tooth has been traumatized. The guideline includes excellent photographs and drawings of dental trauma classifications, and denotes injuries that need immediate referral to a dentist versus those that can be managed by the primary care physician.

When evaluating dental injuries, it is imperative to adhere to a systematic approach to avoid an oversight. This includes, but is not limited to, the mechanism and nature of the dental injury, need for a tetanus booster, and consideration of both the possibility of head injury and child abuse.

Dental trauma can be classified into the following categories: concussion, subluxation, luxation, extrusion, intrusion, avulsions, and fractures. Primary teeth that avulse should not be replaced, due to concern for damaging the underlying permanent tooth. Permanent teeth that avulse should be immediately put back in place; these teeth need to be handled by the crown portion only and not the root, which contains fibroblasts necessary for reimplantation. Dirty avulsed permanent teeth can be placed in milk, a balanced salt solution, or saliva (but not water) until the patient can be seen by the dentist.

Conventional intraoral radiographs remain the optimal study for evaluating injured teeth, with less radiation exposure than a computed tomography scan. These studies will be performed at the dental office.

Prophylactic systemic antibiotics are not routinely warranted after dental trauma care, except following reimplantation of a primary avulsed tooth.

Encourage a soft diet and avoidance of non-nutritive sucking (digit or pacifier) for 10 days following most dental injuries

Potential trauma sequelae that should be discussed with caregivers include crown discoloration, root resorption, fixation of the tooth to the underlying bone, and pulpal necrosis.

These guidelines present new and important information for the primary care pediatrician, who will see many examples of dental trauma in their practice. Recommendations regarding care by the primary care physicians and immediate or routine referral to the dentist will be a helpful adjunct to comprehensive patient care.

Dr. Boulter is adjunct professor of pediatrics and community and family medicine at the Geisel School of Medicine at Dartmouth, Hanover, N.H. Dr. Clark is an associate professor of pediatrics at Albany (N.Y.) Medical College, and serves as the chief editor for both Smiles for Life: A National Oral Health Curriculum and Protecting All Children’s Teeth (PACT): AAP’s Pediatric Oral Health Training Program for Physicians. Both Dr. Boulter and Dr. Clark were members of the 2012-2013 AAP Section on Oral Health Executive Committee and involved in developing the clinical report.

A new clinical report published in Pediatrics entitled "Management of Dental Trauma in a Primary Care Setting" expands the knowledge base for pediatricians who care for children in the primary care setting (2014;133:e466-e476). Recommendations for pediatricians go beyond caries preventive messages (brush, floss, limit juice consumption, no bottles in bed, first dental visit at 1 year of age) to include triage and screening for dental trauma in our patients.

Dental trauma is the second most common injury in children aged 0-6 years, and 25% of all school-age children experience dental trauma.

Recommendations to share with parents include anticipatory guidance in several key areas: household safety (gates on stairways, furniture protectors, removal of tripping hazards); mouth guards for competitive/contact sports; and management of dental injuries.

An estimated 20%-30% of all dental injures are sports-related injuries, and the preparticipation sports physical is an ideal time to incorporate injury prevention messages, such as the importance of wearing mouth guards during all practices and games. Custom-fit mouth guards offer the most protection, but use of any mouth guard is preferable to none. Although the U.S. National Collegiate Athletic Association requires mouth guards for only four sports (ice hockey, lacrosse, field hockey, and football), the American Dental Association recommends the use of mouth guards in 29 sports and activities, according to the report.

As pediatric primary care providers are often the first responders for dental injuries, the report provides guidance for initial assessment and recommendations for triage, basing urgency for dental evaluation on injury type. As survival of the tooth is time dependent, it is critical that first responders provide timely and appropriate care. Key skills include determining whether the injured tooth is a primary or permanent tooth (both age of the patient and size of the tooth are factors), and a recommendation to take a photo of the injured tooth. Clinical recommendations vary depending on whether a primary or permanent tooth has been traumatized. The guideline includes excellent photographs and drawings of dental trauma classifications, and denotes injuries that need immediate referral to a dentist versus those that can be managed by the primary care physician.

When evaluating dental injuries, it is imperative to adhere to a systematic approach to avoid an oversight. This includes, but is not limited to, the mechanism and nature of the dental injury, need for a tetanus booster, and consideration of both the possibility of head injury and child abuse.

Dental trauma can be classified into the following categories: concussion, subluxation, luxation, extrusion, intrusion, avulsions, and fractures. Primary teeth that avulse should not be replaced, due to concern for damaging the underlying permanent tooth. Permanent teeth that avulse should be immediately put back in place; these teeth need to be handled by the crown portion only and not the root, which contains fibroblasts necessary for reimplantation. Dirty avulsed permanent teeth can be placed in milk, a balanced salt solution, or saliva (but not water) until the patient can be seen by the dentist.

Conventional intraoral radiographs remain the optimal study for evaluating injured teeth, with less radiation exposure than a computed tomography scan. These studies will be performed at the dental office.

Prophylactic systemic antibiotics are not routinely warranted after dental trauma care, except following reimplantation of a primary avulsed tooth.

Encourage a soft diet and avoidance of non-nutritive sucking (digit or pacifier) for 10 days following most dental injuries

Potential trauma sequelae that should be discussed with caregivers include crown discoloration, root resorption, fixation of the tooth to the underlying bone, and pulpal necrosis.

These guidelines present new and important information for the primary care pediatrician, who will see many examples of dental trauma in their practice. Recommendations regarding care by the primary care physicians and immediate or routine referral to the dentist will be a helpful adjunct to comprehensive patient care.

Dr. Boulter is adjunct professor of pediatrics and community and family medicine at the Geisel School of Medicine at Dartmouth, Hanover, N.H. Dr. Clark is an associate professor of pediatrics at Albany (N.Y.) Medical College, and serves as the chief editor for both Smiles for Life: A National Oral Health Curriculum and Protecting All Children’s Teeth (PACT): AAP’s Pediatric Oral Health Training Program for Physicians. Both Dr. Boulter and Dr. Clark were members of the 2012-2013 AAP Section on Oral Health Executive Committee and involved in developing the clinical report.

The 2014 childhood and adolescent immunization schedule has been approved, with additions that include the use of one of the meningococcal conjugate vaccines (Menveo) in certain groups of high-risk infants and a list specifying the groups of people at increased risk of hepatitis A.

The schedule will be published in the February 2014 issue of Pediatrics, and is being made available online on Jan. 31 (Pediatrics 2014 [doi: 10.1542/peds.2013-3965]).

Guidance on the use of Menveo (Meningococcal Groups A, C, W-135, and Y Oligosaccharide Diphtheria CRM197 conjugate vaccine) for certain groups of infants at increased risk of disease starting at age 2 months has been added to the meningococcal vaccine footnote. This is based on the Food and Drug Administration licensure of Menveo for use starting at age 2 months in August 2013. Some of the high-risk categories include anatomic or functional asplenia, including sickle cell disease; children with persistent complement component deficiency; and those who travel to or live in an area hyperendemic area for meningococcal disease.

This is the first time that a meningococcal vaccine has been available for use starting at age 2 months, Dr. H. Cody Meissner, professor of pediatrics at Tufts University, Boston, pointed out in an interview.

The hepatitis A vaccine footnote now provides a list of groups at increased risk for hepatitis A. While these groups are well recognized, "it was useful to itemize these groups in the footnote," noted Dr. Meissner, who is a member of the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices work group on the harmonized immunization schedule.

The list includes people traveling to or working in countries where there is a high or intermediate endemicity of infection; men having sex with men; people with clotting factor disorders; people with chronic liver disease; users of injection and noninjection illicit drugs; and personal contacts – such as household contacts or regular babysitters – of international adoptees during the first 2 months of arrival in the United States "from a country with high or intermediate endemicity."

The footnote on the tetanus and diphtheria toxoids and acellular pertussis (Tdap) vaccine now states that a dose of the vaccine is recommended for pregnant adolescents every time they get pregnant – preferably during week 27 through week 36 of gestation. Last year, the American Academy of Pediatrics agreed that this vaccine should be given to a pregnant woman, but it withheld the recommendation to vaccinate during every pregnancy until more data became available, Dr. Meissner said. "Additional data now indicate the safety and efficacy of administration of Tdap each time a woman becomes pregnant." This will protect most infants during the first 2 months of life when pertussis can be most severe and until they receive their first DTaP dose at 2 months, he noted.

Other changes include clarification of the intervals between doses in the human papillomavirus (HPV) vaccines footnote, to avoid any misunderstanding of the schedule, said Dr. Meissner, who is also chief of pediatric infectious disease at the Floating Hospital for Children at Tufts Medical Center.

The recommendation for pneumococcal vaccines has not changed from last year, but the footnote provides clarification about the recommendations for PCV13 (Prevnar 13) and PPSV23 in children and adolescents, "which have been stratified according to age and according to degree of risk," he added.

The footnote on Haemophilus influenzae type b (Hib) conjugate vaccine now includes clarification of who should receive the vaccine if immunocompromised.

This is the second year that recommendations and footnotes for ages 0-18 years are included in one schedule, as opposed to previous years, when there were separate schedules and footnotes for 0-7 years and 8-18 years.

The 2014 schedules have been approved by the American Academy of Pediatrics, the Advisory Committee on Immunization Practices, the American Academy of Family Physicians, and the American College of Obstetricians and Gynecologists.

Dr. Meissner said he has no relevant financial disclosures.

You can view the 2014 schedule at our Resources section here.

[email protected]

The 2014 childhood and adolescent immunization schedule has been approved, with additions that include the use of one of the meningococcal conjugate vaccines (Menveo) in certain groups of high-risk infants and a list specifying the groups of people at increased risk of hepatitis A.

The schedule will be published in the February 2014 issue of Pediatrics, and is being made available online on Jan. 31 (Pediatrics 2014 [doi: 10.1542/peds.2013-3965]).

Guidance on the use of Menveo (Meningococcal Groups A, C, W-135, and Y Oligosaccharide Diphtheria CRM197 conjugate vaccine) for certain groups of infants at increased risk of disease starting at age 2 months has been added to the meningococcal vaccine footnote. This is based on the Food and Drug Administration licensure of Menveo for use starting at age 2 months in August 2013. Some of the high-risk categories include anatomic or functional asplenia, including sickle cell disease; children with persistent complement component deficiency; and those who travel to or live in an area hyperendemic area for meningococcal disease.

This is the first time that a meningococcal vaccine has been available for use starting at age 2 months, Dr. H. Cody Meissner, professor of pediatrics at Tufts University, Boston, pointed out in an interview.

The hepatitis A vaccine footnote now provides a list of groups at increased risk for hepatitis A. While these groups are well recognized, "it was useful to itemize these groups in the footnote," noted Dr. Meissner, who is a member of the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices work group on the harmonized immunization schedule.

The list includes people traveling to or working in countries where there is a high or intermediate endemicity of infection; men having sex with men; people with clotting factor disorders; people with chronic liver disease; users of injection and noninjection illicit drugs; and personal contacts – such as household contacts or regular babysitters – of international adoptees during the first 2 months of arrival in the United States "from a country with high or intermediate endemicity."

The footnote on the tetanus and diphtheria toxoids and acellular pertussis (Tdap) vaccine now states that a dose of the vaccine is recommended for pregnant adolescents every time they get pregnant – preferably during week 27 through week 36 of gestation. Last year, the American Academy of Pediatrics agreed that this vaccine should be given to a pregnant woman, but it withheld the recommendation to vaccinate during every pregnancy until more data became available, Dr. Meissner said. "Additional data now indicate the safety and efficacy of administration of Tdap each time a woman becomes pregnant." This will protect most infants during the first 2 months of life when pertussis can be most severe and until they receive their first DTaP dose at 2 months, he noted.

Other changes include clarification of the intervals between doses in the human papillomavirus (HPV) vaccines footnote, to avoid any misunderstanding of the schedule, said Dr. Meissner, who is also chief of pediatric infectious disease at the Floating Hospital for Children at Tufts Medical Center.

The recommendation for pneumococcal vaccines has not changed from last year, but the footnote provides clarification about the recommendations for PCV13 (Prevnar 13) and PPSV23 in children and adolescents, "which have been stratified according to age and according to degree of risk," he added.

The footnote on Haemophilus influenzae type b (Hib) conjugate vaccine now includes clarification of who should receive the vaccine if immunocompromised.

This is the second year that recommendations and footnotes for ages 0-18 years are included in one schedule, as opposed to previous years, when there were separate schedules and footnotes for 0-7 years and 8-18 years.

The 2014 schedules have been approved by the American Academy of Pediatrics, the Advisory Committee on Immunization Practices, the American Academy of Family Physicians, and the American College of Obstetricians and Gynecologists.

Dr. Meissner said he has no relevant financial disclosures.

You can view the 2014 schedule at our Resources section here.

[email protected]

The 2014 childhood and adolescent immunization schedule has been approved, with additions that include the use of one of the meningococcal conjugate vaccines (Menveo) in certain groups of high-risk infants and a list specifying the groups of people at increased risk of hepatitis A.

The schedule will be published in the February 2014 issue of Pediatrics, and is being made available online on Jan. 31 (Pediatrics 2014 [doi: 10.1542/peds.2013-3965]).

Guidance on the use of Menveo (Meningococcal Groups A, C, W-135, and Y Oligosaccharide Diphtheria CRM197 conjugate vaccine) for certain groups of infants at increased risk of disease starting at age 2 months has been added to the meningococcal vaccine footnote. This is based on the Food and Drug Administration licensure of Menveo for use starting at age 2 months in August 2013. Some of the high-risk categories include anatomic or functional asplenia, including sickle cell disease; children with persistent complement component deficiency; and those who travel to or live in an area hyperendemic area for meningococcal disease.

This is the first time that a meningococcal vaccine has been available for use starting at age 2 months, Dr. H. Cody Meissner, professor of pediatrics at Tufts University, Boston, pointed out in an interview.

The hepatitis A vaccine footnote now provides a list of groups at increased risk for hepatitis A. While these groups are well recognized, "it was useful to itemize these groups in the footnote," noted Dr. Meissner, who is a member of the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices work group on the harmonized immunization schedule.

The list includes people traveling to or working in countries where there is a high or intermediate endemicity of infection; men having sex with men; people with clotting factor disorders; people with chronic liver disease; users of injection and noninjection illicit drugs; and personal contacts – such as household contacts or regular babysitters – of international adoptees during the first 2 months of arrival in the United States "from a country with high or intermediate endemicity."

The footnote on the tetanus and diphtheria toxoids and acellular pertussis (Tdap) vaccine now states that a dose of the vaccine is recommended for pregnant adolescents every time they get pregnant – preferably during week 27 through week 36 of gestation. Last year, the American Academy of Pediatrics agreed that this vaccine should be given to a pregnant woman, but it withheld the recommendation to vaccinate during every pregnancy until more data became available, Dr. Meissner said. "Additional data now indicate the safety and efficacy of administration of Tdap each time a woman becomes pregnant." This will protect most infants during the first 2 months of life when pertussis can be most severe and until they receive their first DTaP dose at 2 months, he noted.

Other changes include clarification of the intervals between doses in the human papillomavirus (HPV) vaccines footnote, to avoid any misunderstanding of the schedule, said Dr. Meissner, who is also chief of pediatric infectious disease at the Floating Hospital for Children at Tufts Medical Center.

The recommendation for pneumococcal vaccines has not changed from last year, but the footnote provides clarification about the recommendations for PCV13 (Prevnar 13) and PPSV23 in children and adolescents, "which have been stratified according to age and according to degree of risk," he added.

The footnote on Haemophilus influenzae type b (Hib) conjugate vaccine now includes clarification of who should receive the vaccine if immunocompromised.

This is the second year that recommendations and footnotes for ages 0-18 years are included in one schedule, as opposed to previous years, when there were separate schedules and footnotes for 0-7 years and 8-18 years.

The 2014 schedules have been approved by the American Academy of Pediatrics, the Advisory Committee on Immunization Practices, the American Academy of Family Physicians, and the American College of Obstetricians and Gynecologists.

Dr. Meissner said he has no relevant financial disclosures.

You can view the 2014 schedule at our Resources section here.

[email protected]

ORLANDO – Pediatricians can do a great deal to help their patients and communities in the wake of tragedies involving violence affecting children, according to Dr. David Schonfeld.

Unfortunately, it appears that such events are increasing in frequency, as evidenced by the headlines in recent months and years, Dr. Schonfeld, director of the National Center for School Crisis and Bereavement at St. Christopher’s Hospital in Philadelphia said at the annual meeting of the American Academy of Pediatrics.

Courtesy Wikimedia Commons/Algr/Creative Commons License

It is important that when such events do occur, pediatricians work to address the impact of trauma on children; research suggests that supportive and nurturing adults can indeed mitigate the effects, said Dr. Schonfeld, a developmental and behavioral pediatrician and a member of the AAP Disaster Preparedness Advisory Council.

The available research, including both rat and human studies, highlights the role that nurturing by both mothers and other adults can play in protecting children.

In one set of experiments in rats, infants who experienced higher levels of maternal nurturing were less fearful and less reactive to stressful situations, and performed better on tasks thought to depend on optimal functioning of the hippocampus, Dr. Schonfeld explained.

Related studies showed that cross-fostering infant rats from mothers who provided less nurturing compensated for the lack of maternal nurturing.

This suggests that care and support provided by adults outside of the family can help promote the development and adjustment of children affected by a crisis, he said.

"These findings are directly applicable to humans. The National Collaborative Perinatal Project showed similar findings in humans at 8 months of age," he noted.

The project demonstrated that the degree of maternal nurturing in an experimental setting predicted the infants’ degree of emotional distress in adulthood.

An epigenetic phenomenon may explain how early parental nurturing results in less stress reactively in offspring in adulthood, he said, noting that this idea was supported by findings from recent postmortem analyses of the brains of suicide victims. Victims with a history of early-life adversity had lower levels of glucocorticoid receptor messenger RNA in their hippocampus and higher rates of DNA methylation in the same promoter region as in the rat model.

"A whole separate and growing body of research has also demonstrated that chronic severe stress, especially during critical periods of brain development, leads to long-term changes in brain function and structure," he said.

"If you take all of this together, it underscores the need to protect children from stressful situations as much as possible, to intervene quickly after stressful events occur, and to pay particular attention to minimizing subsequent stressors because of the particularly detrimental effects of chronic stress on children," he added.

He cautioned, however, that a child’s adjustment following a traumatic event is related not just to the trauma, but to what occurs as a result of the event.

For example, if a child loses a family member as a result of violence, difficulties experienced by the child may be a result of bereavement.

Dr. Schonfeld described one teen affected by the 2012 Aurora, Colo., shooting who was reluctant to return to school, and who declined offers of trauma counseling. Although many of his trauma-related symptoms – such as fidgeting and difficulty sleeping – had abated, he disclosed that he "just didn’t feel right, and felt sad and empty."

Further discussion revealed that his problem was one of bereavement; he had lost a close friend in the shooting.

"No one had suggested that might be an issue for him, and I have seen this in crisis event after crisis event when I’ve responded," Dr. Schonfeld said.

After a crisis, a "cascade of secondary losses" can occur, and any one of these can be the cause of difficulty for those affected, he added.

Also, keep in mind that even as such events seem to be occurring more often, children don’t "get used to it," he said.

"They simply learn that there is little benefit in asking for support or assistance from adults in these communities, because it is so infrequently offered to them," he said.

As a result, children may become fatalistic and engage in reactive risk-taking behaviors or counterphobic behaviors that place them at greater risk.

"But they don’t get used to it. And I would contend that neither should we," he said.

Pediatricians should, however, recognize and celebrate what they have done and can do every day to support children and families dealing with difficult situations.

"It makes a big difference. I don’t want you to get overwhelmed by all that could – and unfortunately does – happen, and the long-lasting and profound impact these violent events can have on children. Instead, I challenge you ... to commit to at least one strategy to advocate for violence prevention and/or readiness for your practice or your community to support those who have been impacted by these events," he said.

Such strategies can include:

• Working to decrease violence crisis and loss, and advocating for meaningful change.

• Giving voice to children impacted by these events, allowing them to tell their stories, and forcing a dialogue that can help move the agenda forward.

• Advocating for better systems and services for children affected by these events, and other adverse events in the lives of children, including poverty, exposure to urban violence, and food insecurity, for example.

• Becoming more skilled in supporting children who are grieving and traumatized.

• Ensuring that other professionals in positions to support children – such as teachers and other school staff – are better prepared, more skilled, and more effectively supported in helping children after these events (and introducing information that can help before such events occur).

• Inquiring about exposures and experiences routinely in the practice setting. (The Medical Home for Children Exposed to Violence project [MHCEV] is working to provide resources for identifying, treating, and referring affected children and youth.)

• Promptly identifying affected children at the time of an event, and facilitating discussion about the impact of the event, and offering "psychological first aid and psychoeducation." Attend to basic needs, provide triage and referral, and remember that services will be needed throughout the recovery period, which may be weeks, months, or years.

• Helping in one’s own community when events happen elsewhere, as communities struggle to understand and cope with the events, and deal with distress that can surface as a result of concerns and personal experience.

• Becoming aware of the resources and support efforts of the AAP with respect to disaster preparedness and response. The academy’s department of federal affairs has helped make the AAP one of the leading forces for positive change at the federal level, Dr. Schonfeld said.

"The [AAP] Friends of Children’s Fund in general, and specifically the disaster relief part of that fund, helps not only children, families, and communities recover, but also assists professionals with self-care after these events," he said, noting that it is important to recognize that "it is distressing to be with children in distress."

"Events that are troubling our patients and their families are troubling to us as pediatric health care providers, as well," he said.

Dr. Schonfeld recommended the following resources for additional information:

• The AAP Children and Disasters site.

• The AAP Children and Disasters site, Coping and Adjustment.

• The AAP Medical Home for Children Exposed to Violence.

• The National Center for School Crisis and Bereavement.

Dr. Schonfeld reported having no relevant financial disclosures.

ORLANDO – Pediatricians can do a great deal to help their patients and communities in the wake of tragedies involving violence affecting children, according to Dr. David Schonfeld.

Unfortunately, it appears that such events are increasing in frequency, as evidenced by the headlines in recent months and years, Dr. Schonfeld, director of the National Center for School Crisis and Bereavement at St. Christopher’s Hospital in Philadelphia said at the annual meeting of the American Academy of Pediatrics.

Courtesy Wikimedia Commons/Algr/Creative Commons License

It is important that when such events do occur, pediatricians work to address the impact of trauma on children; research suggests that supportive and nurturing adults can indeed mitigate the effects, said Dr. Schonfeld, a developmental and behavioral pediatrician and a member of the AAP Disaster Preparedness Advisory Council.

The available research, including both rat and human studies, highlights the role that nurturing by both mothers and other adults can play in protecting children.

In one set of experiments in rats, infants who experienced higher levels of maternal nurturing were less fearful and less reactive to stressful situations, and performed better on tasks thought to depend on optimal functioning of the hippocampus, Dr. Schonfeld explained.

Related studies showed that cross-fostering infant rats from mothers who provided less nurturing compensated for the lack of maternal nurturing.

This suggests that care and support provided by adults outside of the family can help promote the development and adjustment of children affected by a crisis, he said.

"These findings are directly applicable to humans. The National Collaborative Perinatal Project showed similar findings in humans at 8 months of age," he noted.

The project demonstrated that the degree of maternal nurturing in an experimental setting predicted the infants’ degree of emotional distress in adulthood.

An epigenetic phenomenon may explain how early parental nurturing results in less stress reactively in offspring in adulthood, he said, noting that this idea was supported by findings from recent postmortem analyses of the brains of suicide victims. Victims with a history of early-life adversity had lower levels of glucocorticoid receptor messenger RNA in their hippocampus and higher rates of DNA methylation in the same promoter region as in the rat model.

"A whole separate and growing body of research has also demonstrated that chronic severe stress, especially during critical periods of brain development, leads to long-term changes in brain function and structure," he said.

"If you take all of this together, it underscores the need to protect children from stressful situations as much as possible, to intervene quickly after stressful events occur, and to pay particular attention to minimizing subsequent stressors because of the particularly detrimental effects of chronic stress on children," he added.

He cautioned, however, that a child’s adjustment following a traumatic event is related not just to the trauma, but to what occurs as a result of the event.

For example, if a child loses a family member as a result of violence, difficulties experienced by the child may be a result of bereavement.

Dr. Schonfeld described one teen affected by the 2012 Aurora, Colo., shooting who was reluctant to return to school, and who declined offers of trauma counseling. Although many of his trauma-related symptoms – such as fidgeting and difficulty sleeping – had abated, he disclosed that he "just didn’t feel right, and felt sad and empty."

Further discussion revealed that his problem was one of bereavement; he had lost a close friend in the shooting.

"No one had suggested that might be an issue for him, and I have seen this in crisis event after crisis event when I’ve responded," Dr. Schonfeld said.

After a crisis, a "cascade of secondary losses" can occur, and any one of these can be the cause of difficulty for those affected, he added.

Also, keep in mind that even as such events seem to be occurring more often, children don’t "get used to it," he said.

"They simply learn that there is little benefit in asking for support or assistance from adults in these communities, because it is so infrequently offered to them," he said.

As a result, children may become fatalistic and engage in reactive risk-taking behaviors or counterphobic behaviors that place them at greater risk.

"But they don’t get used to it. And I would contend that neither should we," he said.

Pediatricians should, however, recognize and celebrate what they have done and can do every day to support children and families dealing with difficult situations.

"It makes a big difference. I don’t want you to get overwhelmed by all that could – and unfortunately does – happen, and the long-lasting and profound impact these violent events can have on children. Instead, I challenge you ... to commit to at least one strategy to advocate for violence prevention and/or readiness for your practice or your community to support those who have been impacted by these events," he said.

Such strategies can include:

• Working to decrease violence crisis and loss, and advocating for meaningful change.

• Giving voice to children impacted by these events, allowing them to tell their stories, and forcing a dialogue that can help move the agenda forward.

• Advocating for better systems and services for children affected by these events, and other adverse events in the lives of children, including poverty, exposure to urban violence, and food insecurity, for example.

• Becoming more skilled in supporting children who are grieving and traumatized.

• Ensuring that other professionals in positions to support children – such as teachers and other school staff – are better prepared, more skilled, and more effectively supported in helping children after these events (and introducing information that can help before such events occur).

• Inquiring about exposures and experiences routinely in the practice setting. (The Medical Home for Children Exposed to Violence project [MHCEV] is working to provide resources for identifying, treating, and referring affected children and youth.)

• Promptly identifying affected children at the time of an event, and facilitating discussion about the impact of the event, and offering "psychological first aid and psychoeducation." Attend to basic needs, provide triage and referral, and remember that services will be needed throughout the recovery period, which may be weeks, months, or years.

• Helping in one’s own community when events happen elsewhere, as communities struggle to understand and cope with the events, and deal with distress that can surface as a result of concerns and personal experience.

• Becoming aware of the resources and support efforts of the AAP with respect to disaster preparedness and response. The academy’s department of federal affairs has helped make the AAP one of the leading forces for positive change at the federal level, Dr. Schonfeld said.

"The [AAP] Friends of Children’s Fund in general, and specifically the disaster relief part of that fund, helps not only children, families, and communities recover, but also assists professionals with self-care after these events," he said, noting that it is important to recognize that "it is distressing to be with children in distress."

"Events that are troubling our patients and their families are troubling to us as pediatric health care providers, as well," he said.

Dr. Schonfeld recommended the following resources for additional information:

• The AAP Children and Disasters site.

• The AAP Children and Disasters site, Coping and Adjustment.

• The AAP Medical Home for Children Exposed to Violence.

• The National Center for School Crisis and Bereavement.

Dr. Schonfeld reported having no relevant financial disclosures.

ORLANDO – Pediatricians can do a great deal to help their patients and communities in the wake of tragedies involving violence affecting children, according to Dr. David Schonfeld.

Unfortunately, it appears that such events are increasing in frequency, as evidenced by the headlines in recent months and years, Dr. Schonfeld, director of the National Center for School Crisis and Bereavement at St. Christopher’s Hospital in Philadelphia said at the annual meeting of the American Academy of Pediatrics.

Courtesy Wikimedia Commons/Algr/Creative Commons License

It is important that when such events do occur, pediatricians work to address the impact of trauma on children; research suggests that supportive and nurturing adults can indeed mitigate the effects, said Dr. Schonfeld, a developmental and behavioral pediatrician and a member of the AAP Disaster Preparedness Advisory Council.

The available research, including both rat and human studies, highlights the role that nurturing by both mothers and other adults can play in protecting children.

In one set of experiments in rats, infants who experienced higher levels of maternal nurturing were less fearful and less reactive to stressful situations, and performed better on tasks thought to depend on optimal functioning of the hippocampus, Dr. Schonfeld explained.

Related studies showed that cross-fostering infant rats from mothers who provided less nurturing compensated for the lack of maternal nurturing.

This suggests that care and support provided by adults outside of the family can help promote the development and adjustment of children affected by a crisis, he said.

"These findings are directly applicable to humans. The National Collaborative Perinatal Project showed similar findings in humans at 8 months of age," he noted.

The project demonstrated that the degree of maternal nurturing in an experimental setting predicted the infants’ degree of emotional distress in adulthood.

An epigenetic phenomenon may explain how early parental nurturing results in less stress reactively in offspring in adulthood, he said, noting that this idea was supported by findings from recent postmortem analyses of the brains of suicide victims. Victims with a history of early-life adversity had lower levels of glucocorticoid receptor messenger RNA in their hippocampus and higher rates of DNA methylation in the same promoter region as in the rat model.

"A whole separate and growing body of research has also demonstrated that chronic severe stress, especially during critical periods of brain development, leads to long-term changes in brain function and structure," he said.

"If you take all of this together, it underscores the need to protect children from stressful situations as much as possible, to intervene quickly after stressful events occur, and to pay particular attention to minimizing subsequent stressors because of the particularly detrimental effects of chronic stress on children," he added.

He cautioned, however, that a child’s adjustment following a traumatic event is related not just to the trauma, but to what occurs as a result of the event.

For example, if a child loses a family member as a result of violence, difficulties experienced by the child may be a result of bereavement.

Dr. Schonfeld described one teen affected by the 2012 Aurora, Colo., shooting who was reluctant to return to school, and who declined offers of trauma counseling. Although many of his trauma-related symptoms – such as fidgeting and difficulty sleeping – had abated, he disclosed that he "just didn’t feel right, and felt sad and empty."

Further discussion revealed that his problem was one of bereavement; he had lost a close friend in the shooting.

"No one had suggested that might be an issue for him, and I have seen this in crisis event after crisis event when I’ve responded," Dr. Schonfeld said.

After a crisis, a "cascade of secondary losses" can occur, and any one of these can be the cause of difficulty for those affected, he added.

Also, keep in mind that even as such events seem to be occurring more often, children don’t "get used to it," he said.

"They simply learn that there is little benefit in asking for support or assistance from adults in these communities, because it is so infrequently offered to them," he said.

As a result, children may become fatalistic and engage in reactive risk-taking behaviors or counterphobic behaviors that place them at greater risk.

"But they don’t get used to it. And I would contend that neither should we," he said.

Pediatricians should, however, recognize and celebrate what they have done and can do every day to support children and families dealing with difficult situations.

"It makes a big difference. I don’t want you to get overwhelmed by all that could – and unfortunately does – happen, and the long-lasting and profound impact these violent events can have on children. Instead, I challenge you ... to commit to at least one strategy to advocate for violence prevention and/or readiness for your practice or your community to support those who have been impacted by these events," he said.

Such strategies can include:

• Working to decrease violence crisis and loss, and advocating for meaningful change.

• Giving voice to children impacted by these events, allowing them to tell their stories, and forcing a dialogue that can help move the agenda forward.

• Advocating for better systems and services for children affected by these events, and other adverse events in the lives of children, including poverty, exposure to urban violence, and food insecurity, for example.

• Becoming more skilled in supporting children who are grieving and traumatized.

• Ensuring that other professionals in positions to support children – such as teachers and other school staff – are better prepared, more skilled, and more effectively supported in helping children after these events (and introducing information that can help before such events occur).

• Inquiring about exposures and experiences routinely in the practice setting. (The Medical Home for Children Exposed to Violence project [MHCEV] is working to provide resources for identifying, treating, and referring affected children and youth.)

• Promptly identifying affected children at the time of an event, and facilitating discussion about the impact of the event, and offering "psychological first aid and psychoeducation." Attend to basic needs, provide triage and referral, and remember that services will be needed throughout the recovery period, which may be weeks, months, or years.

• Helping in one’s own community when events happen elsewhere, as communities struggle to understand and cope with the events, and deal with distress that can surface as a result of concerns and personal experience.

• Becoming aware of the resources and support efforts of the AAP with respect to disaster preparedness and response. The academy’s department of federal affairs has helped make the AAP one of the leading forces for positive change at the federal level, Dr. Schonfeld said.

"The [AAP] Friends of Children’s Fund in general, and specifically the disaster relief part of that fund, helps not only children, families, and communities recover, but also assists professionals with self-care after these events," he said, noting that it is important to recognize that "it is distressing to be with children in distress."

"Events that are troubling our patients and their families are troubling to us as pediatric health care providers, as well," he said.

Dr. Schonfeld recommended the following resources for additional information:

• The AAP Children and Disasters site.

• The AAP Children and Disasters site, Coping and Adjustment.

• The AAP Medical Home for Children Exposed to Violence.

• The National Center for School Crisis and Bereavement.

Dr. Schonfeld reported having no relevant financial disclosures.

Nearly 80% of office-based physicians had adopted some type of electronic health record system in 2013, according to figures from the Centers for Disease Control and Prevention.

Findings from the report, which is based on a survey of about 10,000 office-based physicians, show that adoption has skyrocketed over the past decade. Between 2001 and 2013, the use of any type of electronic health record (EHR) system jumped from 18% to 78%. And adoption climbed from 48% to 78% between 2009 and 2013, following the enactment of the Health Information Technology for Economic and Clinical Health (HITECH) Act in 2009, which allowed the federal government to make bonus payments to physicians for adopting certified EHR systems.

Even the use of more advanced systems that include a set of "basic" functionals has increased. Those basic systems include computerized orders for prescriptions, the ability to view laboratory and imaging results electronically, a comprehensive list of a patient’s medications and allergies, physician notes, problem lists, and patient history and demographics.

In 2013, nearly half (48%) of physicians reported having an EHR system that met the criteria for a basic system. That’s up from 11% in 2006, the first year that the CDC collected data on basic systems.

But adoption of EHRs varies greatly by geography. The lowest adoption rate for a basic EHR system was in New Jersey (21%), and the highest was in North Dakota (83%).

Physician interest in the Medicare and Medicaid Incentive Programs is also high, according to the survey results. But the ability to meet the "meaningful use" criteria lags behind the interest. In 2013, 69% of physicians reported that they intended to participate in the incentive programs. But only 13% of physicians both intended to participate in the programs and had an EHR system capable of meeting most of the Stage 2 core requirements of meaningful use.

But Dr. Karen DeSalvo, the new National Coordinator for Health Information Technology of the Department of Health and Human Services, said the survey results show that the incentive programs are "healthy and growing steadily." In a blog post about the survey, Dr. DeSalvo said even the fact that only 13% of physicians could meet Stage 2 requirements in 2013 is a good sign, since it means that they were ready for Stage 2 a year ahead of schedule.

"The deadline to begin attesting for Meaningful Use Stage 2 is October 2014 for the earliest adopters of Meaningful Use Stage 1, so more than one in ten physicians decided on their own to participate [in] Meaningful Use Stage 2 capabilities more than a year earlier than necessary," Dr. DeSalvo wrote. "These are early adopters who recognize the benefits of EHRs."

[email protected]

Nearly 80% of office-based physicians had adopted some type of electronic health record system in 2013, according to figures from the Centers for Disease Control and Prevention.

Findings from the report, which is based on a survey of about 10,000 office-based physicians, show that adoption has skyrocketed over the past decade. Between 2001 and 2013, the use of any type of electronic health record (EHR) system jumped from 18% to 78%. And adoption climbed from 48% to 78% between 2009 and 2013, following the enactment of the Health Information Technology for Economic and Clinical Health (HITECH) Act in 2009, which allowed the federal government to make bonus payments to physicians for adopting certified EHR systems.

Even the use of more advanced systems that include a set of "basic" functionals has increased. Those basic systems include computerized orders for prescriptions, the ability to view laboratory and imaging results electronically, a comprehensive list of a patient’s medications and allergies, physician notes, problem lists, and patient history and demographics.

In 2013, nearly half (48%) of physicians reported having an EHR system that met the criteria for a basic system. That’s up from 11% in 2006, the first year that the CDC collected data on basic systems.

But adoption of EHRs varies greatly by geography. The lowest adoption rate for a basic EHR system was in New Jersey (21%), and the highest was in North Dakota (83%).

Physician interest in the Medicare and Medicaid Incentive Programs is also high, according to the survey results. But the ability to meet the "meaningful use" criteria lags behind the interest. In 2013, 69% of physicians reported that they intended to participate in the incentive programs. But only 13% of physicians both intended to participate in the programs and had an EHR system capable of meeting most of the Stage 2 core requirements of meaningful use.

But Dr. Karen DeSalvo, the new National Coordinator for Health Information Technology of the Department of Health and Human Services, said the survey results show that the incentive programs are "healthy and growing steadily." In a blog post about the survey, Dr. DeSalvo said even the fact that only 13% of physicians could meet Stage 2 requirements in 2013 is a good sign, since it means that they were ready for Stage 2 a year ahead of schedule.

"The deadline to begin attesting for Meaningful Use Stage 2 is October 2014 for the earliest adopters of Meaningful Use Stage 1, so more than one in ten physicians decided on their own to participate [in] Meaningful Use Stage 2 capabilities more than a year earlier than necessary," Dr. DeSalvo wrote. "These are early adopters who recognize the benefits of EHRs."

[email protected]

Nearly 80% of office-based physicians had adopted some type of electronic health record system in 2013, according to figures from the Centers for Disease Control and Prevention.

Findings from the report, which is based on a survey of about 10,000 office-based physicians, show that adoption has skyrocketed over the past decade. Between 2001 and 2013, the use of any type of electronic health record (EHR) system jumped from 18% to 78%. And adoption climbed from 48% to 78% between 2009 and 2013, following the enactment of the Health Information Technology for Economic and Clinical Health (HITECH) Act in 2009, which allowed the federal government to make bonus payments to physicians for adopting certified EHR systems.

Even the use of more advanced systems that include a set of "basic" functionals has increased. Those basic systems include computerized orders for prescriptions, the ability to view laboratory and imaging results electronically, a comprehensive list of a patient’s medications and allergies, physician notes, problem lists, and patient history and demographics.

In 2013, nearly half (48%) of physicians reported having an EHR system that met the criteria for a basic system. That’s up from 11% in 2006, the first year that the CDC collected data on basic systems.

But adoption of EHRs varies greatly by geography. The lowest adoption rate for a basic EHR system was in New Jersey (21%), and the highest was in North Dakota (83%).

Physician interest in the Medicare and Medicaid Incentive Programs is also high, according to the survey results. But the ability to meet the "meaningful use" criteria lags behind the interest. In 2013, 69% of physicians reported that they intended to participate in the incentive programs. But only 13% of physicians both intended to participate in the programs and had an EHR system capable of meeting most of the Stage 2 core requirements of meaningful use.

But Dr. Karen DeSalvo, the new National Coordinator for Health Information Technology of the Department of Health and Human Services, said the survey results show that the incentive programs are "healthy and growing steadily." In a blog post about the survey, Dr. DeSalvo said even the fact that only 13% of physicians could meet Stage 2 requirements in 2013 is a good sign, since it means that they were ready for Stage 2 a year ahead of schedule.

"The deadline to begin attesting for Meaningful Use Stage 2 is October 2014 for the earliest adopters of Meaningful Use Stage 1, so more than one in ten physicians decided on their own to participate [in] Meaningful Use Stage 2 capabilities more than a year earlier than necessary," Dr. DeSalvo wrote. "These are early adopters who recognize the benefits of EHRs."

[email protected]

Currently in the United States, less than 0.5% of the population serves in the uniformed armed services. This small sliver of the population has borne a large burden over the past dozen years, as the United States engaged in wars in both Iraq and Afghanistan. While those in the armed services have traditionally been quite young themselves, Operation Iraqi Freedom and Operation Enduring Freedom saw many more Army Reservists and National Guardsmen deployed.

Many of those deployed are parents, coming from civilian communities and jobs rather than from military bases. While combat operations in Iraq and Afghanistan have officially ceased, there are many families still living with the effects of a military deployment, whether deployment is ongoing or the deployed parent recently returned; the effects of deployment include post-traumatic stress disorder (PTSD) or traumatic brain injury (TBI) in a returning parent, or even the death of a parent.

As many as 2 million children in the United States have lived through a parent’s deployment, with more than 800,000 living through two or more deployments. Pediatricians are in a unique position to provide useful information and support to the parents of these children, especially for those not on military bases, which have all of the built-in supports such a location may provide.

Supporting resilience in the families of our military service members can begin with a simple question, "Is someone in your family serving in the military?" Simply asking this question suggests you understand the range of risks, level of stress, and potential isolation of these "single" parents. Children with a deployed parent are at greater risk for anxiety and depression than their civilian peers are, and the risk goes up with longer or multiple deployments.

Somewhat counterintuitively, the risk can be higher for adolescents than for younger children. Adolescents have more complex needs to adjust and test their emerging identities with both parents, and they are faced with greater real-world risks given their many hours of unsupervised time, access to alcohol, and, if they are old enough, the ability to drive. It can be useful to find out if the child is functioning well at school, at home, and with peers, or if there have been any changes in function since the parent was deployed. This may be an ideal time to consider using a mental health screening instrument, such as the Pediatric Symptom Checklist (PSC) to check for functional impairment that may indicate a need for a mental health referral.

It is also important to ask the remaining parent how they are managing the deployment. The combined effect of their anxiety about their partner’s safety; sudden, single parenthood; and the financial strains that deployment can bring is often profound. Families with a deployed reservist are likely to experience some social isolation as they manage these challenges outside of the structure and organization of the military community. It can be meaningful for these parents to receive support from a pediatrician, and the suggestion that they make good use of all of their available supports, whether through the military, a faith organization, family, or community-service agencies.

On a practical level, it can be very helpful to consider how the family is managing communication around the deployment. How much should their children know about the details of the parent’s deployment? How is the child or adolescent dealing with the information? How anxious are they? What questions are they asking? Do the children feel they have enough information or would they prefer to know more? Are there certain things they don’t want to know? Do they know to ask a trusted adult if they have a specific worry or hear something worrisome at school, on television, or even at home? How is the parent himself or herself adjusting? Is she able to cope with the stress? Is he depressed or overwhelmed?

Similarly, it can be powerful for a parent to hear from their pediatrician that it is protective to preserve a child’s routines, rules, and responsibilities during a parent’s deployment. Even an adolescent will find it reassuring and organizing to have consistency in her schedule. School, extracurricular activities, homework, sports, and play dates should continue whenever possible, and parents may need to use their support network to help with this. They might focus on special rituals, such as holidays or birthdays, and document them so that they can be shared with the deployed parent, either in a care package or when they return.

While a parent’s return will be eagerly anticipated, it will also be a time of some unexpected changes and challenges. During deployment, usually 8 to 12 months, their children will have grown and changed, and the at-home parent will have adjusted to a different pace and routines. Simple questions can help the other parent anticipate and prepare for the challenge of reintegration into the home and community. What have they told their children about the return? Have they talked about what might be difficult? What has been surprising or easier during the parent’s deployment? What will be easier after that parent returns? How have they changed since their parent was deployed? What are they most curious about? What are they most worried about? Reintegration takes time, but as long as there are open lines of communication during the transition and supports to turn to in case of significant difficulties, it will be successful.

If a parent has recently returned, it is reasonable to ask if there have been any unexpected problems. While some injuries are visible, many returning soldiers will experience the "invisible wounds" of TBI or PTSD. There is ample evidence that many veterans will not seek care for PTSD, and those who do may experience significant barriers to accessing treatment. These conditions will affect a whole family, so asking a parent (and your patient) about concerning behaviors, such as anxiety, anger, avoidance, withdrawal, or substance abuse in a returned parent can be the first step to helping a family. Reminding parents that there are resources available to them, whether through the Department of Veterans Affairs, community service agencies, or even online (see below), can empower them to help the returning parent get the needed treatment and support.

Finally, the death of a parent during deployment is a subject worthy of its own column. Express your condolences while acknowledging that grief is a gradual process that is different for each individual and is especially different for children and spouses. Ask if they are taking good care of themselves and have enough personal support. You might remind a parent that some regressive behaviors, moodiness, or even seeming normalcy are all typical expressions of grief in children and require patience. Increased risk-taking behaviors in an adolescent or significant dysfunction (refusing to go to school or total withdrawal from friends and extracurricular activities) are concerning, though, and should be referred for additional evaluation and support. Assess the parent’s capacity during this difficult time, and see if the surviving parent and children have access to sufficient support or whether a referral for mental health services is needed. For a child to know that she can speak to another family member, teacher, or coach can be protective and allay guilt, as she can voice her grief or worries to an adult who is not grieving as intensely as her surviving parent. Finally, you might work with parents to locate the community resources that are available to them and their children as they manage this painful adjustment while also supporting their children’s healthiest development.

Some examples of online resources for the families of deployed or returned veterans:

• The Department of Veterans Affairs Mental Health page.

• The Veteran Parenting Toolkit.

• The Home Base Program.

Most of us are isolated from the difficulties that military families routinely face, and it is easy to forget the impact and the risks to children when parents are deployed. We should not forget their service and their needs.

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

Currently in the United States, less than 0.5% of the population serves in the uniformed armed services. This small sliver of the population has borne a large burden over the past dozen years, as the United States engaged in wars in both Iraq and Afghanistan. While those in the armed services have traditionally been quite young themselves, Operation Iraqi Freedom and Operation Enduring Freedom saw many more Army Reservists and National Guardsmen deployed.

Many of those deployed are parents, coming from civilian communities and jobs rather than from military bases. While combat operations in Iraq and Afghanistan have officially ceased, there are many families still living with the effects of a military deployment, whether deployment is ongoing or the deployed parent recently returned; the effects of deployment include post-traumatic stress disorder (PTSD) or traumatic brain injury (TBI) in a returning parent, or even the death of a parent.

As many as 2 million children in the United States have lived through a parent’s deployment, with more than 800,000 living through two or more deployments. Pediatricians are in a unique position to provide useful information and support to the parents of these children, especially for those not on military bases, which have all of the built-in supports such a location may provide.

Supporting resilience in the families of our military service members can begin with a simple question, "Is someone in your family serving in the military?" Simply asking this question suggests you understand the range of risks, level of stress, and potential isolation of these "single" parents. Children with a deployed parent are at greater risk for anxiety and depression than their civilian peers are, and the risk goes up with longer or multiple deployments.

Somewhat counterintuitively, the risk can be higher for adolescents than for younger children. Adolescents have more complex needs to adjust and test their emerging identities with both parents, and they are faced with greater real-world risks given their many hours of unsupervised time, access to alcohol, and, if they are old enough, the ability to drive. It can be useful to find out if the child is functioning well at school, at home, and with peers, or if there have been any changes in function since the parent was deployed. This may be an ideal time to consider using a mental health screening instrument, such as the Pediatric Symptom Checklist (PSC) to check for functional impairment that may indicate a need for a mental health referral.

It is also important to ask the remaining parent how they are managing the deployment. The combined effect of their anxiety about their partner’s safety; sudden, single parenthood; and the financial strains that deployment can bring is often profound. Families with a deployed reservist are likely to experience some social isolation as they manage these challenges outside of the structure and organization of the military community. It can be meaningful for these parents to receive support from a pediatrician, and the suggestion that they make good use of all of their available supports, whether through the military, a faith organization, family, or community-service agencies.

On a practical level, it can be very helpful to consider how the family is managing communication around the deployment. How much should their children know about the details of the parent’s deployment? How is the child or adolescent dealing with the information? How anxious are they? What questions are they asking? Do the children feel they have enough information or would they prefer to know more? Are there certain things they don’t want to know? Do they know to ask a trusted adult if they have a specific worry or hear something worrisome at school, on television, or even at home? How is the parent himself or herself adjusting? Is she able to cope with the stress? Is he depressed or overwhelmed?

Similarly, it can be powerful for a parent to hear from their pediatrician that it is protective to preserve a child’s routines, rules, and responsibilities during a parent’s deployment. Even an adolescent will find it reassuring and organizing to have consistency in her schedule. School, extracurricular activities, homework, sports, and play dates should continue whenever possible, and parents may need to use their support network to help with this. They might focus on special rituals, such as holidays or birthdays, and document them so that they can be shared with the deployed parent, either in a care package or when they return.

While a parent’s return will be eagerly anticipated, it will also be a time of some unexpected changes and challenges. During deployment, usually 8 to 12 months, their children will have grown and changed, and the at-home parent will have adjusted to a different pace and routines. Simple questions can help the other parent anticipate and prepare for the challenge of reintegration into the home and community. What have they told their children about the return? Have they talked about what might be difficult? What has been surprising or easier during the parent’s deployment? What will be easier after that parent returns? How have they changed since their parent was deployed? What are they most curious about? What are they most worried about? Reintegration takes time, but as long as there are open lines of communication during the transition and supports to turn to in case of significant difficulties, it will be successful.

If a parent has recently returned, it is reasonable to ask if there have been any unexpected problems. While some injuries are visible, many returning soldiers will experience the "invisible wounds" of TBI or PTSD. There is ample evidence that many veterans will not seek care for PTSD, and those who do may experience significant barriers to accessing treatment. These conditions will affect a whole family, so asking a parent (and your patient) about concerning behaviors, such as anxiety, anger, avoidance, withdrawal, or substance abuse in a returned parent can be the first step to helping a family. Reminding parents that there are resources available to them, whether through the Department of Veterans Affairs, community service agencies, or even online (see below), can empower them to help the returning parent get the needed treatment and support.

Finally, the death of a parent during deployment is a subject worthy of its own column. Express your condolences while acknowledging that grief is a gradual process that is different for each individual and is especially different for children and spouses. Ask if they are taking good care of themselves and have enough personal support. You might remind a parent that some regressive behaviors, moodiness, or even seeming normalcy are all typical expressions of grief in children and require patience. Increased risk-taking behaviors in an adolescent or significant dysfunction (refusing to go to school or total withdrawal from friends and extracurricular activities) are concerning, though, and should be referred for additional evaluation and support. Assess the parent’s capacity during this difficult time, and see if the surviving parent and children have access to sufficient support or whether a referral for mental health services is needed. For a child to know that she can speak to another family member, teacher, or coach can be protective and allay guilt, as she can voice her grief or worries to an adult who is not grieving as intensely as her surviving parent. Finally, you might work with parents to locate the community resources that are available to them and their children as they manage this painful adjustment while also supporting their children’s healthiest development.

Some examples of online resources for the families of deployed or returned veterans:

• The Department of Veterans Affairs Mental Health page.

• The Veteran Parenting Toolkit.

• The Home Base Program.

Most of us are isolated from the difficulties that military families routinely face, and it is easy to forget the impact and the risks to children when parents are deployed. We should not forget their service and their needs.

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

Currently in the United States, less than 0.5% of the population serves in the uniformed armed services. This small sliver of the population has borne a large burden over the past dozen years, as the United States engaged in wars in both Iraq and Afghanistan. While those in the armed services have traditionally been quite young themselves, Operation Iraqi Freedom and Operation Enduring Freedom saw many more Army Reservists and National Guardsmen deployed.

Many of those deployed are parents, coming from civilian communities and jobs rather than from military bases. While combat operations in Iraq and Afghanistan have officially ceased, there are many families still living with the effects of a military deployment, whether deployment is ongoing or the deployed parent recently returned; the effects of deployment include post-traumatic stress disorder (PTSD) or traumatic brain injury (TBI) in a returning parent, or even the death of a parent.

As many as 2 million children in the United States have lived through a parent’s deployment, with more than 800,000 living through two or more deployments. Pediatricians are in a unique position to provide useful information and support to the parents of these children, especially for those not on military bases, which have all of the built-in supports such a location may provide.

Supporting resilience in the families of our military service members can begin with a simple question, "Is someone in your family serving in the military?" Simply asking this question suggests you understand the range of risks, level of stress, and potential isolation of these "single" parents. Children with a deployed parent are at greater risk for anxiety and depression than their civilian peers are, and the risk goes up with longer or multiple deployments.

Somewhat counterintuitively, the risk can be higher for adolescents than for younger children. Adolescents have more complex needs to adjust and test their emerging identities with both parents, and they are faced with greater real-world risks given their many hours of unsupervised time, access to alcohol, and, if they are old enough, the ability to drive. It can be useful to find out if the child is functioning well at school, at home, and with peers, or if there have been any changes in function since the parent was deployed. This may be an ideal time to consider using a mental health screening instrument, such as the Pediatric Symptom Checklist (PSC) to check for functional impairment that may indicate a need for a mental health referral.

It is also important to ask the remaining parent how they are managing the deployment. The combined effect of their anxiety about their partner’s safety; sudden, single parenthood; and the financial strains that deployment can bring is often profound. Families with a deployed reservist are likely to experience some social isolation as they manage these challenges outside of the structure and organization of the military community. It can be meaningful for these parents to receive support from a pediatrician, and the suggestion that they make good use of all of their available supports, whether through the military, a faith organization, family, or community-service agencies.

On a practical level, it can be very helpful to consider how the family is managing communication around the deployment. How much should their children know about the details of the parent’s deployment? How is the child or adolescent dealing with the information? How anxious are they? What questions are they asking? Do the children feel they have enough information or would they prefer to know more? Are there certain things they don’t want to know? Do they know to ask a trusted adult if they have a specific worry or hear something worrisome at school, on television, or even at home? How is the parent himself or herself adjusting? Is she able to cope with the stress? Is he depressed or overwhelmed?

Similarly, it can be powerful for a parent to hear from their pediatrician that it is protective to preserve a child’s routines, rules, and responsibilities during a parent’s deployment. Even an adolescent will find it reassuring and organizing to have consistency in her schedule. School, extracurricular activities, homework, sports, and play dates should continue whenever possible, and parents may need to use their support network to help with this. They might focus on special rituals, such as holidays or birthdays, and document them so that they can be shared with the deployed parent, either in a care package or when they return.

While a parent’s return will be eagerly anticipated, it will also be a time of some unexpected changes and challenges. During deployment, usually 8 to 12 months, their children will have grown and changed, and the at-home parent will have adjusted to a different pace and routines. Simple questions can help the other parent anticipate and prepare for the challenge of reintegration into the home and community. What have they told their children about the return? Have they talked about what might be difficult? What has been surprising or easier during the parent’s deployment? What will be easier after that parent returns? How have they changed since their parent was deployed? What are they most curious about? What are they most worried about? Reintegration takes time, but as long as there are open lines of communication during the transition and supports to turn to in case of significant difficulties, it will be successful.

If a parent has recently returned, it is reasonable to ask if there have been any unexpected problems. While some injuries are visible, many returning soldiers will experience the "invisible wounds" of TBI or PTSD. There is ample evidence that many veterans will not seek care for PTSD, and those who do may experience significant barriers to accessing treatment. These conditions will affect a whole family, so asking a parent (and your patient) about concerning behaviors, such as anxiety, anger, avoidance, withdrawal, or substance abuse in a returned parent can be the first step to helping a family. Reminding parents that there are resources available to them, whether through the Department of Veterans Affairs, community service agencies, or even online (see below), can empower them to help the returning parent get the needed treatment and support.

Finally, the death of a parent during deployment is a subject worthy of its own column. Express your condolences while acknowledging that grief is a gradual process that is different for each individual and is especially different for children and spouses. Ask if they are taking good care of themselves and have enough personal support. You might remind a parent that some regressive behaviors, moodiness, or even seeming normalcy are all typical expressions of grief in children and require patience. Increased risk-taking behaviors in an adolescent or significant dysfunction (refusing to go to school or total withdrawal from friends and extracurricular activities) are concerning, though, and should be referred for additional evaluation and support. Assess the parent’s capacity during this difficult time, and see if the surviving parent and children have access to sufficient support or whether a referral for mental health services is needed. For a child to know that she can speak to another family member, teacher, or coach can be protective and allay guilt, as she can voice her grief or worries to an adult who is not grieving as intensely as her surviving parent. Finally, you might work with parents to locate the community resources that are available to them and their children as they manage this painful adjustment while also supporting their children’s healthiest development.

Some examples of online resources for the families of deployed or returned veterans:

• The Department of Veterans Affairs Mental Health page.

• The Veteran Parenting Toolkit.

• The Home Base Program.

Most of us are isolated from the difficulties that military families routinely face, and it is easy to forget the impact and the risks to children when parents are deployed. We should not forget their service and their needs.

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

The U.S. Preventive Services Task Force has determined, for the second time in 10 years, that there is not enough quality evidence to recommend – or not recommend – regular blood pressure screening as part of standard pediatric care.

The task force, chaired by Dr. Virginia A. Moyer, argues that the evidence to support routine screening for primary hypertension remains insufficient in a paper published online Oct. 7 in Pediatrics (2013;132:1-8 [doi:10.1542/peds.2013-2864]). The task force’s position on pediatric screening is little changed from 2003 when it issued recommendations on screening for both children and adults (Am. Fam. Physician 2003;68:2019-22).

©kzenon/iStockphoto.com

For its newest recommendation, however, the task force authors looked solely at the issue of screening in asymptomatic children and adolescents without a risk factor for hypertension, such as high body mass index.

It evaluated studies on diagnostic accuracy, the relationship of childhood primary hypertension with adult hypertension and cardiovascular disease, the effectiveness of treatment, and the harms related to screening or treatment. But the task force determined that it had not found enough quality evidence to weigh in.

One of the rationales for regular blood pressure screening in asymptomatic children 3 years and older – a practice that has been recommended for more than 35 years (Pediatrics 1977;59(suppl.):797-820)and is currently advocated by the American Academy of Pediatrics, the American Heart Association, and the National Heart, Lung, and Blood Institute – is to identify children at increased risk for adult hypertension and cardiovascular disease.

However, predictive values of childhood hypertension for adult hypertension "are at best modest," wrote the authors. A recent, related study also conducted by the task force found no direct evidence that screening for hypertension in children and adolescents reduces adverse cardiovascular outcomes in adults (Pediatrics 2013;131:490-525).

Some practitioners have criticized the USPSTF’s focus on primary hypertension and adult outcomes, saying that pediatricians have other reasons to screen children routinely for hypertension, including identifying asymptomatic secondary hypertension. Indeed, for some pediatricians, reducing adult cardiovascular events is not seen as the primary goal of screening. Dr. Bonita Falkner, then incoming chair of the International Pediatric Hypertension Association, clearly outlined this position in a letter to the editor published in Pediatrics in March 2013 in response to a review conducted for the USPSTF.

The task force emphasized that "clinical decisions involve more considerations than evidence alone," and noted that screening between the ages of 3 and 17 years is recommended by the AAP and other organizations.

Dr. Sarah de Ferranti, the director of the preventive cardiology clinic at Boston Children’s Hospital and a member of the AAP committee on nutrition, said in an interview that she, like the task force authors, would like to see more evidence on the relationship between childhood and adult hypertension, and that she would not dismiss the important question of risk or harms related to screening.

But she also said she had no intention of abandoning routine screening as part of her practice, and would counsel other pediatricians not to do so, either. "There are definitely patients identified as having other medical problems by blood pressure – such as kidney problems and endocrine problems. There are cases where the blood pressure is the identifying cause," she said.

"We still identify children with primary and secondary hypertension, and that is important in terms of outcomes," Dr. de Ferranti continued. Observational and longitudinal studies, she pointed out, have found evidence linking pediatric hypertension with adult arterial stiffness, subclinical atherosclerosis, and carotid intima-media thickness, and even with cardiovascular damage that occurs before adulthood.

Moreover, Dr. de Ferranti said, there are logistical barriers to obtaining the type of evidence the USPSTF seeks in its recommendations, such as a randomized controlled trial to determine whether blood pressure reduction improves adult outcomes. "Few parents would be interested in having their child take a placebo or dummy pill for 30 years to find out the answers to these questions," she said.

The U.S. Preventive Services Task Force has determined, for the second time in 10 years, that there is not enough quality evidence to recommend – or not recommend – regular blood pressure screening as part of standard pediatric care.

The task force, chaired by Dr. Virginia A. Moyer, argues that the evidence to support routine screening for primary hypertension remains insufficient in a paper published online Oct. 7 in Pediatrics (2013;132:1-8 [doi:10.1542/peds.2013-2864]). The task force’s position on pediatric screening is little changed from 2003 when it issued recommendations on screening for both children and adults (Am. Fam. Physician 2003;68:2019-22).

©kzenon/iStockphoto.com

For its newest recommendation, however, the task force authors looked solely at the issue of screening in asymptomatic children and adolescents without a risk factor for hypertension, such as high body mass index.

It evaluated studies on diagnostic accuracy, the relationship of childhood primary hypertension with adult hypertension and cardiovascular disease, the effectiveness of treatment, and the harms related to screening or treatment. But the task force determined that it had not found enough quality evidence to weigh in.

One of the rationales for regular blood pressure screening in asymptomatic children 3 years and older – a practice that has been recommended for more than 35 years (Pediatrics 1977;59(suppl.):797-820)and is currently advocated by the American Academy of Pediatrics, the American Heart Association, and the National Heart, Lung, and Blood Institute – is to identify children at increased risk for adult hypertension and cardiovascular disease.

However, predictive values of childhood hypertension for adult hypertension "are at best modest," wrote the authors. A recent, related study also conducted by the task force found no direct evidence that screening for hypertension in children and adolescents reduces adverse cardiovascular outcomes in adults (Pediatrics 2013;131:490-525).

Some practitioners have criticized the USPSTF’s focus on primary hypertension and adult outcomes, saying that pediatricians have other reasons to screen children routinely for hypertension, including identifying asymptomatic secondary hypertension. Indeed, for some pediatricians, reducing adult cardiovascular events is not seen as the primary goal of screening. Dr. Bonita Falkner, then incoming chair of the International Pediatric Hypertension Association, clearly outlined this position in a letter to the editor published in Pediatrics in March 2013 in response to a review conducted for the USPSTF.

The task force emphasized that "clinical decisions involve more considerations than evidence alone," and noted that screening between the ages of 3 and 17 years is recommended by the AAP and other organizations.

Dr. Sarah de Ferranti, the director of the preventive cardiology clinic at Boston Children’s Hospital and a member of the AAP committee on nutrition, said in an interview that she, like the task force authors, would like to see more evidence on the relationship between childhood and adult hypertension, and that she would not dismiss the important question of risk or harms related to screening.

But she also said she had no intention of abandoning routine screening as part of her practice, and would counsel other pediatricians not to do so, either. "There are definitely patients identified as having other medical problems by blood pressure – such as kidney problems and endocrine problems. There are cases where the blood pressure is the identifying cause," she said.

"We still identify children with primary and secondary hypertension, and that is important in terms of outcomes," Dr. de Ferranti continued. Observational and longitudinal studies, she pointed out, have found evidence linking pediatric hypertension with adult arterial stiffness, subclinical atherosclerosis, and carotid intima-media thickness, and even with cardiovascular damage that occurs before adulthood.

Moreover, Dr. de Ferranti said, there are logistical barriers to obtaining the type of evidence the USPSTF seeks in its recommendations, such as a randomized controlled trial to determine whether blood pressure reduction improves adult outcomes. "Few parents would be interested in having their child take a placebo or dummy pill for 30 years to find out the answers to these questions," she said.

The U.S. Preventive Services Task Force has determined, for the second time in 10 years, that there is not enough quality evidence to recommend – or not recommend – regular blood pressure screening as part of standard pediatric care.

The task force, chaired by Dr. Virginia A. Moyer, argues that the evidence to support routine screening for primary hypertension remains insufficient in a paper published online Oct. 7 in Pediatrics (2013;132:1-8 [doi:10.1542/peds.2013-2864]). The task force’s position on pediatric screening is little changed from 2003 when it issued recommendations on screening for both children and adults (Am. Fam. Physician 2003;68:2019-22).

©kzenon/iStockphoto.com

For its newest recommendation, however, the task force authors looked solely at the issue of screening in asymptomatic children and adolescents without a risk factor for hypertension, such as high body mass index.

It evaluated studies on diagnostic accuracy, the relationship of childhood primary hypertension with adult hypertension and cardiovascular disease, the effectiveness of treatment, and the harms related to screening or treatment. But the task force determined that it had not found enough quality evidence to weigh in.

One of the rationales for regular blood pressure screening in asymptomatic children 3 years and older – a practice that has been recommended for more than 35 years (Pediatrics 1977;59(suppl.):797-820)and is currently advocated by the American Academy of Pediatrics, the American Heart Association, and the National Heart, Lung, and Blood Institute – is to identify children at increased risk for adult hypertension and cardiovascular disease.

However, predictive values of childhood hypertension for adult hypertension "are at best modest," wrote the authors. A recent, related study also conducted by the task force found no direct evidence that screening for hypertension in children and adolescents reduces adverse cardiovascular outcomes in adults (Pediatrics 2013;131:490-525).

Some practitioners have criticized the USPSTF’s focus on primary hypertension and adult outcomes, saying that pediatricians have other reasons to screen children routinely for hypertension, including identifying asymptomatic secondary hypertension. Indeed, for some pediatricians, reducing adult cardiovascular events is not seen as the primary goal of screening. Dr. Bonita Falkner, then incoming chair of the International Pediatric Hypertension Association, clearly outlined this position in a letter to the editor published in Pediatrics in March 2013 in response to a review conducted for the USPSTF.

The task force emphasized that "clinical decisions involve more considerations than evidence alone," and noted that screening between the ages of 3 and 17 years is recommended by the AAP and other organizations.

Dr. Sarah de Ferranti, the director of the preventive cardiology clinic at Boston Children’s Hospital and a member of the AAP committee on nutrition, said in an interview that she, like the task force authors, would like to see more evidence on the relationship between childhood and adult hypertension, and that she would not dismiss the important question of risk or harms related to screening.

But she also said she had no intention of abandoning routine screening as part of her practice, and would counsel other pediatricians not to do so, either. "There are definitely patients identified as having other medical problems by blood pressure – such as kidney problems and endocrine problems. There are cases where the blood pressure is the identifying cause," she said.

"We still identify children with primary and secondary hypertension, and that is important in terms of outcomes," Dr. de Ferranti continued. Observational and longitudinal studies, she pointed out, have found evidence linking pediatric hypertension with adult arterial stiffness, subclinical atherosclerosis, and carotid intima-media thickness, and even with cardiovascular damage that occurs before adulthood.

Moreover, Dr. de Ferranti said, there are logistical barriers to obtaining the type of evidence the USPSTF seeks in its recommendations, such as a randomized controlled trial to determine whether blood pressure reduction improves adult outcomes. "Few parents would be interested in having their child take a placebo or dummy pill for 30 years to find out the answers to these questions," she said.

Giving clinicians the option to wait up to 3 days before treating the most common presentation of acute bacterial sinusitis is among the changes to the American Academy of Pediatrics’ updated clinical practice guidelines for treating these infections.

About 5%-10% of upper respiratory tract infections in children develop into acute bacterial sinusitis, according to the new guidelines, published in Pediatrics.

Other changes include a new presentation, and discouraging the use of x-rays to confirm diagnosis. The guidelines published online were written by Dr. Ellen R. Wald, chair of pediatrics at the University of Wisconsin, Madison, and her associates (Pediatrics 2013 June 24 [doi:10.1542/peds.2013-1071]). The guidelines incorporated data from an accompanying systematic review of the research published since the last guidelines were issued in 2001.

The added presentation is a worsening course, defined as "worsening or new onset of nasal discharge, daytime cough, or fever after initial improvement." This presentation joins the existing severe onset (a fever of at least 39° C [102.2° F] with at least 3 days of a purulent nasal discharge) and, most common, persistent illness lasting more than 10 days without improvement.

For those with symptoms of nasal discharge, daytime cough, or fever lasting more than 10 days, clinicians may discuss with the parent whether to treat right away or wait a few days. For severe onset and worsening symptoms, clinicians should prescribe antibiotic therapy right away. First-line treatment is amoxicillin with or without clavulanate, followed by a reassessment of initial management if the symptoms worsen or do not improve within 72 hours.

The guidelines do not recommend adjuvant therapies, including intranasal corticosteroids, saline nasal irrigation or lavage, topical or oral decongestants, mucolytics, and topical or oral antihistamines.

Among the four major changes to the guidelines, including the updated evidence, the option for delayed treatment in nonsevere cases and the recommendation not to use imaging are especially relevant for clinical practice, according to Dr. Wald, a pediatric infectious disease specialist.

"When the AAP writes about this, they’re talking about it as joint decision making," Dr. Wald said in an interview. "If the parent really wants treatment at that time, I think the doctor’s going to want to do it. It’s being a little bit more permissive in tolerating the symptoms for a few more days. The clinician is given the option to treat immediately or, with the parents’ consent, they can wait a few days to see if the child gets better spontaneously."

Dr. Wald noted that the decision to treat can involve a trade-off, so these guidelines offer the clinicians more latitude in making the cost-benefit analysis with the parent, taking into account the illness severity, the child’s quality of life, and the parents’ values and concerns.

"The reason we like to treat it is that kids get better faster," Dr. Wald said. "On the one hand, we want the kid to get better faster, but on the other hand, we don’t want to use the antibiotic if we don’t have to because we want to avoid side effects or, from a public health perspective, the increased antibiotic resistance for the population." The most common side effect of antibiotics is diarrhea, she said; fewer patients may experience a rash.

The guideline discouraging imaging stems from findings that imaging offers little clinical benefit. "In the past, a diagnostician would get a set of x-rays to see if the sinuses were cloudy and confirm the diagnosis if they found cloudy sinuses," Dr. Wald said. "However, x-rays are frequently abnormal even in children with uncomplicated colds, so the x-rays are not a help. Therefore, we’re encouraging people to make the diagnosis only on clinical grounds."

However, the guidelines do encourage clinicians to get a "contrast-enhanced CT scan of the paranasal sinuses and/or an MRI with contrast whenever a child is suspected of having orbital or central nervous system complications of acute bacterial sinusitis" because discovered abscesses may require surgical intervention.

The systematic review, conducted by Dr. Michael J. Smith, a pediatric infectious disease specialist at the University of Louisville (Ky.), included evidence from 17 randomized controlled trials in the treatment of sinusitis in children (Pediatrics 2013 June 24 [doi:10.1542/peds.2013-1072]. All published since 2001, these trials add to the evidence base from the 21 studies published between 1966 and 1999 that were used in the previous guidelines.

Among the 17 new trials, 4 were randomized, double-blind, placebo-controlled trials of antimicrobial therapy used on a combined 392 children, but they were too heterogenous in criteria and results (2 favored treatment and 2 found no significant difference between treatment and control) to use in conducting a formal meta-analysis. Comparisons were further complicated by the long time span over which they were conducted, the introduction of universal conjugate pneumococcal vaccination, the increase in prevalence of other bacterial infections, and the variance in placebo group clinical improvement, ranging from 14% to 79% across the studies.

Five other trials that compared antimicrobial therapies lacked placebo controls, three dealt with subacute sinusitis rather than acute, and six tested various ancillary treatments. These ancillary treatments included steroids, nasal spray, saline irrigation, and mucolytic agents, but with small study populations and mostly equivocal results.

"Greater severity of illness at the time of presentation seems to be associated with increased likelihood of antimicrobial efficacy," Dr. Smith said.

Dr. Smith identified several clinical questions that require additional research: definitions of acute, subacute, and recurrent acute sinusitis; the epidemiology of sinusitis in the pneumococcal conjugate vaccine era; the effectiveness of antimicrobial prophylaxis; accurate estimates for duration of symptoms; and clinical utility of various imaging types.

The guidelines and systematic review did not identify any external funding used. Dr. Smith has received research funding from Sanofi Pasteur and Novartis. Dr. Nelson is employed by McKesson Health Solutions. Dr. Wald, Dr. Shaikh, and Dr. Rosenfeld have published research related to sinusitis. No other disclosures were reported.

Giving clinicians the option to wait up to 3 days before treating the most common presentation of acute bacterial sinusitis is among the changes to the American Academy of Pediatrics’ updated clinical practice guidelines for treating these infections.

About 5%-10% of upper respiratory tract infections in children develop into acute bacterial sinusitis, according to the new guidelines, published in Pediatrics.

Other changes include a new presentation, and discouraging the use of x-rays to confirm diagnosis. The guidelines published online were written by Dr. Ellen R. Wald, chair of pediatrics at the University of Wisconsin, Madison, and her associates (Pediatrics 2013 June 24 [doi:10.1542/peds.2013-1071]). The guidelines incorporated data from an accompanying systematic review of the research published since the last guidelines were issued in 2001.

The added presentation is a worsening course, defined as "worsening or new onset of nasal discharge, daytime cough, or fever after initial improvement." This presentation joins the existing severe onset (a fever of at least 39° C [102.2° F] with at least 3 days of a purulent nasal discharge) and, most common, persistent illness lasting more than 10 days without improvement.

For those with symptoms of nasal discharge, daytime cough, or fever lasting more than 10 days, clinicians may discuss with the parent whether to treat right away or wait a few days. For severe onset and worsening symptoms, clinicians should prescribe antibiotic therapy right away. First-line treatment is amoxicillin with or without clavulanate, followed by a reassessment of initial management if the symptoms worsen or do not improve within 72 hours.

The guidelines do not recommend adjuvant therapies, including intranasal corticosteroids, saline nasal irrigation or lavage, topical or oral decongestants, mucolytics, and topical or oral antihistamines.

Among the four major changes to the guidelines, including the updated evidence, the option for delayed treatment in nonsevere cases and the recommendation not to use imaging are especially relevant for clinical practice, according to Dr. Wald, a pediatric infectious disease specialist.

"When the AAP writes about this, they’re talking about it as joint decision making," Dr. Wald said in an interview. "If the parent really wants treatment at that time, I think the doctor’s going to want to do it. It’s being a little bit more permissive in tolerating the symptoms for a few more days. The clinician is given the option to treat immediately or, with the parents’ consent, they can wait a few days to see if the child gets better spontaneously."

Dr. Wald noted that the decision to treat can involve a trade-off, so these guidelines offer the clinicians more latitude in making the cost-benefit analysis with the parent, taking into account the illness severity, the child’s quality of life, and the parents’ values and concerns.

"The reason we like to treat it is that kids get better faster," Dr. Wald said. "On the one hand, we want the kid to get better faster, but on the other hand, we don’t want to use the antibiotic if we don’t have to because we want to avoid side effects or, from a public health perspective, the increased antibiotic resistance for the population." The most common side effect of antibiotics is diarrhea, she said; fewer patients may experience a rash.

The guideline discouraging imaging stems from findings that imaging offers little clinical benefit. "In the past, a diagnostician would get a set of x-rays to see if the sinuses were cloudy and confirm the diagnosis if they found cloudy sinuses," Dr. Wald said. "However, x-rays are frequently abnormal even in children with uncomplicated colds, so the x-rays are not a help. Therefore, we’re encouraging people to make the diagnosis only on clinical grounds."

However, the guidelines do encourage clinicians to get a "contrast-enhanced CT scan of the paranasal sinuses and/or an MRI with contrast whenever a child is suspected of having orbital or central nervous system complications of acute bacterial sinusitis" because discovered abscesses may require surgical intervention.

The systematic review, conducted by Dr. Michael J. Smith, a pediatric infectious disease specialist at the University of Louisville (Ky.), included evidence from 17 randomized controlled trials in the treatment of sinusitis in children (Pediatrics 2013 June 24 [doi:10.1542/peds.2013-1072]. All published since 2001, these trials add to the evidence base from the 21 studies published between 1966 and 1999 that were used in the previous guidelines.

Among the 17 new trials, 4 were randomized, double-blind, placebo-controlled trials of antimicrobial therapy used on a combined 392 children, but they were too heterogenous in criteria and results (2 favored treatment and 2 found no significant difference between treatment and control) to use in conducting a formal meta-analysis. Comparisons were further complicated by the long time span over which they were conducted, the introduction of universal conjugate pneumococcal vaccination, the increase in prevalence of other bacterial infections, and the variance in placebo group clinical improvement, ranging from 14% to 79% across the studies.

Five other trials that compared antimicrobial therapies lacked placebo controls, three dealt with subacute sinusitis rather than acute, and six tested various ancillary treatments. These ancillary treatments included steroids, nasal spray, saline irrigation, and mucolytic agents, but with small study populations and mostly equivocal results.

"Greater severity of illness at the time of presentation seems to be associated with increased likelihood of antimicrobial efficacy," Dr. Smith said.

Dr. Smith identified several clinical questions that require additional research: definitions of acute, subacute, and recurrent acute sinusitis; the epidemiology of sinusitis in the pneumococcal conjugate vaccine era; the effectiveness of antimicrobial prophylaxis; accurate estimates for duration of symptoms; and clinical utility of various imaging types.

The guidelines and systematic review did not identify any external funding used. Dr. Smith has received research funding from Sanofi Pasteur and Novartis. Dr. Nelson is employed by McKesson Health Solutions. Dr. Wald, Dr. Shaikh, and Dr. Rosenfeld have published research related to sinusitis. No other disclosures were reported.

Giving clinicians the option to wait up to 3 days before treating the most common presentation of acute bacterial sinusitis is among the changes to the American Academy of Pediatrics’ updated clinical practice guidelines for treating these infections.

About 5%-10% of upper respiratory tract infections in children develop into acute bacterial sinusitis, according to the new guidelines, published in Pediatrics.

Other changes include a new presentation, and discouraging the use of x-rays to confirm diagnosis. The guidelines published online were written by Dr. Ellen R. Wald, chair of pediatrics at the University of Wisconsin, Madison, and her associates (Pediatrics 2013 June 24 [doi:10.1542/peds.2013-1071]). The guidelines incorporated data from an accompanying systematic review of the research published since the last guidelines were issued in 2001.

The added presentation is a worsening course, defined as "worsening or new onset of nasal discharge, daytime cough, or fever after initial improvement." This presentation joins the existing severe onset (a fever of at least 39° C [102.2° F] with at least 3 days of a purulent nasal discharge) and, most common, persistent illness lasting more than 10 days without improvement.

For those with symptoms of nasal discharge, daytime cough, or fever lasting more than 10 days, clinicians may discuss with the parent whether to treat right away or wait a few days. For severe onset and worsening symptoms, clinicians should prescribe antibiotic therapy right away. First-line treatment is amoxicillin with or without clavulanate, followed by a reassessment of initial management if the symptoms worsen or do not improve within 72 hours.

The guidelines do not recommend adjuvant therapies, including intranasal corticosteroids, saline nasal irrigation or lavage, topical or oral decongestants, mucolytics, and topical or oral antihistamines.

Among the four major changes to the guidelines, including the updated evidence, the option for delayed treatment in nonsevere cases and the recommendation not to use imaging are especially relevant for clinical practice, according to Dr. Wald, a pediatric infectious disease specialist.

"When the AAP writes about this, they’re talking about it as joint decision making," Dr. Wald said in an interview. "If the parent really wants treatment at that time, I think the doctor’s going to want to do it. It’s being a little bit more permissive in tolerating the symptoms for a few more days. The clinician is given the option to treat immediately or, with the parents’ consent, they can wait a few days to see if the child gets better spontaneously."

Dr. Wald noted that the decision to treat can involve a trade-off, so these guidelines offer the clinicians more latitude in making the cost-benefit analysis with the parent, taking into account the illness severity, the child’s quality of life, and the parents’ values and concerns.

"The reason we like to treat it is that kids get better faster," Dr. Wald said. "On the one hand, we want the kid to get better faster, but on the other hand, we don’t want to use the antibiotic if we don’t have to because we want to avoid side effects or, from a public health perspective, the increased antibiotic resistance for the population." The most common side effect of antibiotics is diarrhea, she said; fewer patients may experience a rash.

The guideline discouraging imaging stems from findings that imaging offers little clinical benefit. "In the past, a diagnostician would get a set of x-rays to see if the sinuses were cloudy and confirm the diagnosis if they found cloudy sinuses," Dr. Wald said. "However, x-rays are frequently abnormal even in children with uncomplicated colds, so the x-rays are not a help. Therefore, we’re encouraging people to make the diagnosis only on clinical grounds."

However, the guidelines do encourage clinicians to get a "contrast-enhanced CT scan of the paranasal sinuses and/or an MRI with contrast whenever a child is suspected of having orbital or central nervous system complications of acute bacterial sinusitis" because discovered abscesses may require surgical intervention.

The systematic review, conducted by Dr. Michael J. Smith, a pediatric infectious disease specialist at the University of Louisville (Ky.), included evidence from 17 randomized controlled trials in the treatment of sinusitis in children (Pediatrics 2013 June 24 [doi:10.1542/peds.2013-1072]. All published since 2001, these trials add to the evidence base from the 21 studies published between 1966 and 1999 that were used in the previous guidelines.

Among the 17 new trials, 4 were randomized, double-blind, placebo-controlled trials of antimicrobial therapy used on a combined 392 children, but they were too heterogenous in criteria and results (2 favored treatment and 2 found no significant difference between treatment and control) to use in conducting a formal meta-analysis. Comparisons were further complicated by the long time span over which they were conducted, the introduction of universal conjugate pneumococcal vaccination, the increase in prevalence of other bacterial infections, and the variance in placebo group clinical improvement, ranging from 14% to 79% across the studies.

Five other trials that compared antimicrobial therapies lacked placebo controls, three dealt with subacute sinusitis rather than acute, and six tested various ancillary treatments. These ancillary treatments included steroids, nasal spray, saline irrigation, and mucolytic agents, but with small study populations and mostly equivocal results.

"Greater severity of illness at the time of presentation seems to be associated with increased likelihood of antimicrobial efficacy," Dr. Smith said.

Dr. Smith identified several clinical questions that require additional research: definitions of acute, subacute, and recurrent acute sinusitis; the epidemiology of sinusitis in the pneumococcal conjugate vaccine era; the effectiveness of antimicrobial prophylaxis; accurate estimates for duration of symptoms; and clinical utility of various imaging types.

The guidelines and systematic review did not identify any external funding used. Dr. Smith has received research funding from Sanofi Pasteur and Novartis. Dr. Nelson is employed by McKesson Health Solutions. Dr. Wald, Dr. Shaikh, and Dr. Rosenfeld have published research related to sinusitis. No other disclosures were reported.

WASHINGTON – A little bit of education can go a long way toward helping new parents understand the value of vaccines, according to Dr. Sarah E. Williams.

Parents who described themselves as worried about vaccine safety reported significantly greater confidence after they watched an 8-minute video about vaccine safety, she said at the annual meeting of the Pediatric Academic Societies.

Source: Vanderbilt University School of Medicine

"This is important because the study shows that it is possible to modify perceptions of vaccine-hesitant parents, which is likely the first step in the behavior change process," Dr. Williams said in an interview. "A larger sample size will be needed to see the actual change in vaccination rates."

Dr. Williams, a pediatrician who specializes in vaccinology and vaccine-preventable diseases at Vanderbilt University, Nashville, Tenn., conducted a randomized controlled trial of a vaccine education program in two pediatric offices. The study included parents of 2-week-old infants who were coming in for their first well-child check.

More than 450 parents completed the 15-item Parent Attitudes about Childhood Vaccines (PACV) survey, which examines parent behavior toward vaccines, their concerns about safety and efficacy, and other general questions about vaccines. Parents who scored 25 or higher were considered vaccine hesitant and invited to participate in the study; 369 agreed.

The control group received routine care and counseling. The intervention group received two short printed handouts and watched the video, which was narrated by Dr. Kathryn Edwards, professor of pediatrics at Vanderbilt. In it, Dr. Edwards touches on the safety of each of the infant vaccines; each discussion also includes a parent discussing his or her firsthand experience with an unvaccinated child falling seriously ill –or even dying.

The primary outcome was the change in PACV scores immediately after the video and at the 2-month well-child check. The secondary outcome was vaccine uptake.

Most of the parents (80%) were mothers; their mean age was 32 years. The majority were white (79%), and half reported an annual income of at least $75,000. The mean baseline PACV score was 28.

At the 2-month visit, the intervention group had a significant decrease in PACV score compared with the control group (median difference of 6.7). This finding remained significant after adjustment for baseline PACV score, race/ethnicity, and income.

There was not a significant between-group difference in on-time receipt of vaccines (control group, 82%; intervention group, 83%). However, Dr. Williams noted, the PACV scores in the intervention group remained stable from right after the video and reading until the 2-month visit. "This shows that brief education can improve vaccine attitudes in vaccine-hesitant parents and that these changes appear to be stable for at least 2 months."

She added that she is now developing a Web-based, interactive intervention that will allow parents to re-evaluate their feelings and ask their own questions. The project will continue to evolve along with public opinion about vaccines, she said.

"There’s a shifting hypothesis among these parents. As soon as we knock down one theory with research, another [one] crops up, so we need to have the opportunities to address these as they develop."

Dr. Williams said she had no relevant financial disclosures.

[email protected]

WASHINGTON – A little bit of education can go a long way toward helping new parents understand the value of vaccines, according to Dr. Sarah E. Williams.

Parents who described themselves as worried about vaccine safety reported significantly greater confidence after they watched an 8-minute video about vaccine safety, she said at the annual meeting of the Pediatric Academic Societies.

Source: Vanderbilt University School of Medicine

"This is important because the study shows that it is possible to modify perceptions of vaccine-hesitant parents, which is likely the first step in the behavior change process," Dr. Williams said in an interview. "A larger sample size will be needed to see the actual change in vaccination rates."

Dr. Williams, a pediatrician who specializes in vaccinology and vaccine-preventable diseases at Vanderbilt University, Nashville, Tenn., conducted a randomized controlled trial of a vaccine education program in two pediatric offices. The study included parents of 2-week-old infants who were coming in for their first well-child check.

More than 450 parents completed the 15-item Parent Attitudes about Childhood Vaccines (PACV) survey, which examines parent behavior toward vaccines, their concerns about safety and efficacy, and other general questions about vaccines. Parents who scored 25 or higher were considered vaccine hesitant and invited to participate in the study; 369 agreed.

The control group received routine care and counseling. The intervention group received two short printed handouts and watched the video, which was narrated by Dr. Kathryn Edwards, professor of pediatrics at Vanderbilt. In it, Dr. Edwards touches on the safety of each of the infant vaccines; each discussion also includes a parent discussing his or her firsthand experience with an unvaccinated child falling seriously ill –or even dying.

The primary outcome was the change in PACV scores immediately after the video and at the 2-month well-child check. The secondary outcome was vaccine uptake.

Most of the parents (80%) were mothers; their mean age was 32 years. The majority were white (79%), and half reported an annual income of at least $75,000. The mean baseline PACV score was 28.

At the 2-month visit, the intervention group had a significant decrease in PACV score compared with the control group (median difference of 6.7). This finding remained significant after adjustment for baseline PACV score, race/ethnicity, and income.

There was not a significant between-group difference in on-time receipt of vaccines (control group, 82%; intervention group, 83%). However, Dr. Williams noted, the PACV scores in the intervention group remained stable from right after the video and reading until the 2-month visit. "This shows that brief education can improve vaccine attitudes in vaccine-hesitant parents and that these changes appear to be stable for at least 2 months."

She added that she is now developing a Web-based, interactive intervention that will allow parents to re-evaluate their feelings and ask their own questions. The project will continue to evolve along with public opinion about vaccines, she said.

"There’s a shifting hypothesis among these parents. As soon as we knock down one theory with research, another [one] crops up, so we need to have the opportunities to address these as they develop."

Dr. Williams said she had no relevant financial disclosures.

[email protected]

WASHINGTON – A little bit of education can go a long way toward helping new parents understand the value of vaccines, according to Dr. Sarah E. Williams.

Parents who described themselves as worried about vaccine safety reported significantly greater confidence after they watched an 8-minute video about vaccine safety, she said at the annual meeting of the Pediatric Academic Societies.

Source: Vanderbilt University School of Medicine

"This is important because the study shows that it is possible to modify perceptions of vaccine-hesitant parents, which is likely the first step in the behavior change process," Dr. Williams said in an interview. "A larger sample size will be needed to see the actual change in vaccination rates."

Dr. Williams, a pediatrician who specializes in vaccinology and vaccine-preventable diseases at Vanderbilt University, Nashville, Tenn., conducted a randomized controlled trial of a vaccine education program in two pediatric offices. The study included parents of 2-week-old infants who were coming in for their first well-child check.

More than 450 parents completed the 15-item Parent Attitudes about Childhood Vaccines (PACV) survey, which examines parent behavior toward vaccines, their concerns about safety and efficacy, and other general questions about vaccines. Parents who scored 25 or higher were considered vaccine hesitant and invited to participate in the study; 369 agreed.

The control group received routine care and counseling. The intervention group received two short printed handouts and watched the video, which was narrated by Dr. Kathryn Edwards, professor of pediatrics at Vanderbilt. In it, Dr. Edwards touches on the safety of each of the infant vaccines; each discussion also includes a parent discussing his or her firsthand experience with an unvaccinated child falling seriously ill –or even dying.

The primary outcome was the change in PACV scores immediately after the video and at the 2-month well-child check. The secondary outcome was vaccine uptake.

Most of the parents (80%) were mothers; their mean age was 32 years. The majority were white (79%), and half reported an annual income of at least $75,000. The mean baseline PACV score was 28.

At the 2-month visit, the intervention group had a significant decrease in PACV score compared with the control group (median difference of 6.7). This finding remained significant after adjustment for baseline PACV score, race/ethnicity, and income.

There was not a significant between-group difference in on-time receipt of vaccines (control group, 82%; intervention group, 83%). However, Dr. Williams noted, the PACV scores in the intervention group remained stable from right after the video and reading until the 2-month visit. "This shows that brief education can improve vaccine attitudes in vaccine-hesitant parents and that these changes appear to be stable for at least 2 months."

She added that she is now developing a Web-based, interactive intervention that will allow parents to re-evaluate their feelings and ask their own questions. The project will continue to evolve along with public opinion about vaccines, she said.

"There’s a shifting hypothesis among these parents. As soon as we knock down one theory with research, another [one] crops up, so we need to have the opportunities to address these as they develop."

Dr. Williams said she had no relevant financial disclosures.

[email protected]

VAIL, COLO. – The most recent American Academy of Pediatrics guidelines on management of urinary tract infections do an abrupt about-face by recommending that a voiding cystourethrogram no longer be routinely performed after a first febrile UTI in children aged 2 months to 2 years.

"This is confusing. On a dime, we have changed our recommendations regarding radiographic imaging," noted Dr. John W. Ogle, vice chair and director of pediatrics at Denver Health.

The previous 1999 AAP guidelines on UTIs stated unequivocally that "infants and children 2 months through 2 years of age who have the expected response to antimicrobials should have a sonogram and either voiding cystourethrogram or radionuclide scan at the earliest convenient time" (Pediatrics 1999;10[4 Pt 1]:843-52).

This sharp shift away from this stance in the current guidelines reflects new thinking regarding the pathogenesis of renal scarring, Dr. Ogle said at a conference on pediatric infectious diseases sponsored by Children’s Hospital Colorado.

"The assumption that has been made in the past is that UTI in the presence of reflux is the primary thing that leads to renal scarring. That’s not so clear anymore. Some of what we call scarring may be congenital cortical defects in the kidney that we discover because we’ve studied the child. There are good studies demonstrating that you can have scarring from pyelonephritis with complete absence of reflux," said Dr. Ogle, who is also a professor of pediatrics at the University of Colorado, Denver.

The operative hypothesis up until the current guidelines were released in 2011 (Pediatrics 2011;128:595-610) was that identifying reflux via a voiding cystourethrogram (VCUG) allowed physicians to intervene surgically or with prophylactic antimicrobials to prevent further reflux nephropathy with further scarring.

"The evidence seems to be quite clear now that the interventions don’t change those important outcomes of renal scarring. So why look for the reflux? Why do the study, with its cost and discomfort, if you don’t have data that an intervention is going to positively affect the child?" Dr. Ogle said.

A key piece of evidence that triggered the change in AAP recommendations was a Cochrane review of 11 studies totaling 1,148 children. The analysis concluded that correction of vesicoureteral reflux by surgery or medical interventions did not reduce the risk of renal scarring (Cochrane Database Syst. Rev. 2007 July 18;(3):CD001532).

The shift in the AAP guidelines has generated controversy among urologists, some of whom are in agreement with the change while others are opposed.

Copyright RadsWiki/Wikimedia Commons

"I think for pediatricians, adopting these guidelines is an easy step," according to Dr. Ogle. "Many pediatricians in office practice had already adopted this years ago. They have not routinely done a VCUG on every child that presented with a febrile UTI. So for them, the impact of the 2011 Academy guidelines has been to say, ‘What you’ve been doing for the last 10 years is probably appropriate.’ "

He predicted that the current guidelines won’t be the final word on the topic of imaging in patients with febrile UTIs.

"What the guidelines don’t tell us is who exactly you should worry about. They don’t tell you which first-time UTIs you should consider VCUG in, and what’s the strategy for second-time UTIs. So stay tuned, there’s going to be further debate with regard to this, and hopefully further evidence," Dr. Ogle said.

"Remember," he continued, "the great history of American medicine is that first we adopt strategies for interventions in medical conditions, then we study them to see if our interventions are right."

Dr. Ogle reported having no relevant financial conflicts.

VAIL, COLO. – The most recent American Academy of Pediatrics guidelines on management of urinary tract infections do an abrupt about-face by recommending that a voiding cystourethrogram no longer be routinely performed after a first febrile UTI in children aged 2 months to 2 years.

"This is confusing. On a dime, we have changed our recommendations regarding radiographic imaging," noted Dr. John W. Ogle, vice chair and director of pediatrics at Denver Health.

The previous 1999 AAP guidelines on UTIs stated unequivocally that "infants and children 2 months through 2 years of age who have the expected response to antimicrobials should have a sonogram and either voiding cystourethrogram or radionuclide scan at the earliest convenient time" (Pediatrics 1999;10[4 Pt 1]:843-52).

This sharp shift away from this stance in the current guidelines reflects new thinking regarding the pathogenesis of renal scarring, Dr. Ogle said at a conference on pediatric infectious diseases sponsored by Children’s Hospital Colorado.

"The assumption that has been made in the past is that UTI in the presence of reflux is the primary thing that leads to renal scarring. That’s not so clear anymore. Some of what we call scarring may be congenital cortical defects in the kidney that we discover because we’ve studied the child. There are good studies demonstrating that you can have scarring from pyelonephritis with complete absence of reflux," said Dr. Ogle, who is also a professor of pediatrics at the University of Colorado, Denver.

The operative hypothesis up until the current guidelines were released in 2011 (Pediatrics 2011;128:595-610) was that identifying reflux via a voiding cystourethrogram (VCUG) allowed physicians to intervene surgically or with prophylactic antimicrobials to prevent further reflux nephropathy with further scarring.

"The evidence seems to be quite clear now that the interventions don’t change those important outcomes of renal scarring. So why look for the reflux? Why do the study, with its cost and discomfort, if you don’t have data that an intervention is going to positively affect the child?" Dr. Ogle said.

A key piece of evidence that triggered the change in AAP recommendations was a Cochrane review of 11 studies totaling 1,148 children. The analysis concluded that correction of vesicoureteral reflux by surgery or medical interventions did not reduce the risk of renal scarring (Cochrane Database Syst. Rev. 2007 July 18;(3):CD001532).

The shift in the AAP guidelines has generated controversy among urologists, some of whom are in agreement with the change while others are opposed.

Copyright RadsWiki/Wikimedia Commons

"I think for pediatricians, adopting these guidelines is an easy step," according to Dr. Ogle. "Many pediatricians in office practice had already adopted this years ago. They have not routinely done a VCUG on every child that presented with a febrile UTI. So for them, the impact of the 2011 Academy guidelines has been to say, ‘What you’ve been doing for the last 10 years is probably appropriate.’ "

He predicted that the current guidelines won’t be the final word on the topic of imaging in patients with febrile UTIs.

"What the guidelines don’t tell us is who exactly you should worry about. They don’t tell you which first-time UTIs you should consider VCUG in, and what’s the strategy for second-time UTIs. So stay tuned, there’s going to be further debate with regard to this, and hopefully further evidence," Dr. Ogle said.

"Remember," he continued, "the great history of American medicine is that first we adopt strategies for interventions in medical conditions, then we study them to see if our interventions are right."

Dr. Ogle reported having no relevant financial conflicts.

VAIL, COLO. – The most recent American Academy of Pediatrics guidelines on management of urinary tract infections do an abrupt about-face by recommending that a voiding cystourethrogram no longer be routinely performed after a first febrile UTI in children aged 2 months to 2 years.

"This is confusing. On a dime, we have changed our recommendations regarding radiographic imaging," noted Dr. John W. Ogle, vice chair and director of pediatrics at Denver Health.

The previous 1999 AAP guidelines on UTIs stated unequivocally that "infants and children 2 months through 2 years of age who have the expected response to antimicrobials should have a sonogram and either voiding cystourethrogram or radionuclide scan at the earliest convenient time" (Pediatrics 1999;10[4 Pt 1]:843-52).

This sharp shift away from this stance in the current guidelines reflects new thinking regarding the pathogenesis of renal scarring, Dr. Ogle said at a conference on pediatric infectious diseases sponsored by Children’s Hospital Colorado.

"The assumption that has been made in the past is that UTI in the presence of reflux is the primary thing that leads to renal scarring. That’s not so clear anymore. Some of what we call scarring may be congenital cortical defects in the kidney that we discover because we’ve studied the child. There are good studies demonstrating that you can have scarring from pyelonephritis with complete absence of reflux," said Dr. Ogle, who is also a professor of pediatrics at the University of Colorado, Denver.

The operative hypothesis up until the current guidelines were released in 2011 (Pediatrics 2011;128:595-610) was that identifying reflux via a voiding cystourethrogram (VCUG) allowed physicians to intervene surgically or with prophylactic antimicrobials to prevent further reflux nephropathy with further scarring.

"The evidence seems to be quite clear now that the interventions don’t change those important outcomes of renal scarring. So why look for the reflux? Why do the study, with its cost and discomfort, if you don’t have data that an intervention is going to positively affect the child?" Dr. Ogle said.

A key piece of evidence that triggered the change in AAP recommendations was a Cochrane review of 11 studies totaling 1,148 children. The analysis concluded that correction of vesicoureteral reflux by surgery or medical interventions did not reduce the risk of renal scarring (Cochrane Database Syst. Rev. 2007 July 18;(3):CD001532).

The shift in the AAP guidelines has generated controversy among urologists, some of whom are in agreement with the change while others are opposed.

Copyright RadsWiki/Wikimedia Commons

"I think for pediatricians, adopting these guidelines is an easy step," according to Dr. Ogle. "Many pediatricians in office practice had already adopted this years ago. They have not routinely done a VCUG on every child that presented with a febrile UTI. So for them, the impact of the 2011 Academy guidelines has been to say, ‘What you’ve been doing for the last 10 years is probably appropriate.’ "

He predicted that the current guidelines won’t be the final word on the topic of imaging in patients with febrile UTIs.

"What the guidelines don’t tell us is who exactly you should worry about. They don’t tell you which first-time UTIs you should consider VCUG in, and what’s the strategy for second-time UTIs. So stay tuned, there’s going to be further debate with regard to this, and hopefully further evidence," Dr. Ogle said.

"Remember," he continued, "the great history of American medicine is that first we adopt strategies for interventions in medical conditions, then we study them to see if our interventions are right."

Dr. Ogle reported having no relevant financial conflicts.