Sherry Boschert

SAN FRANCISCO — Placing a nicotine patch behind a patient's ear before radical retropubic prostatectomy or placing lidocaine patches on each side of the surgical wound could reduce postoperative pain or narcotic use, results of two studies suggest.

The lidocaine patch significantly reduced pain after surgery, and the nicotine patch significantly reduced cumulative morphine consumption 24 hours after surgery, Dr. Ashraf S. Habib and associates reported in two separate poster presentations at the annual meeting of the American Society of Anesthesiologists (ASA).

Both prospective, randomized, double-blind, placebo-controlled studies of patients undergoing radical retropubic prostatectomy used standardized postoperative analgesia via patient-controlled morphine administration and six hourly 15-mg IV doses of ketorolac.

In what may be the first reported study of the treatment of acute postoperative pain with 5% lidocaine patches, surgeons placed a patch on either side of the wound at the end of surgery on 36 patients and a placebo patch on 34 patients. The two groups were similar in age, height, weight, ASA class, length of surgery, and amount of intraoperative opiates received.

Postoperative pain scores on coughing were significantly lower in the lidocaine group than in the placebo group in the postanesthesia care unit (PACU) and at 6, 12, and 24 hours post surgery, after investigators accounted for a significant effect of morphine. Pain scores at rest were significantly lower in the lidocaine group than in the placebo group up to 6 hours after surgery, and were not significantly different at 12 and 24 hours, said Dr. Habib, director of quality improvement at Duke University Medical Center, Durham, N.C.

There were no significant differences between groups in cumulative morphine consumption or in duration of stay in the PACU or in the hospital.

In the other study, a 7-mg nicotine patch was applied behind the ear of 44 patients 30–60 minutes before anesthesia induction, and a placebo patch behind the ear of 46 patients. By 24 hours after surgery, patients in the nicotine group had used a mean of 33 mg of morphine, significantly less than the mean 45 mg used by the placebo group, Dr. Habib said.

There were no significant differences between groups at any time points in pain scores on coughing or at rest, or in incidence of nausea and vomiting.

There were significant negative correlations between serum nicotine levels at 4 hours and cumulative morphine consumption at 24 hours, and between serum nicotine levels at 24 hours and morphine consumption at all time points (in the PACU and at 6, 12, and 24 hours after surgery).

Dr. Habib has no association with the companies that make the lidocaine or nicotine patches.

The nicotine group used 33 mg of morphine, significantly less than the 45 mg used by the placebo group. DR. HABIB

SAN FRANCISCO — Placing a nicotine patch behind a patient's ear before radical retropubic prostatectomy or placing lidocaine patches on each side of the surgical wound could reduce postoperative pain or narcotic use, results of two studies suggest.

The lidocaine patch significantly reduced pain after surgery, and the nicotine patch significantly reduced cumulative morphine consumption 24 hours after surgery, Dr. Ashraf S. Habib and associates reported in two separate poster presentations at the annual meeting of the American Society of Anesthesiologists (ASA).

Both prospective, randomized, double-blind, placebo-controlled studies of patients undergoing radical retropubic prostatectomy used standardized postoperative analgesia via patient-controlled morphine administration and six hourly 15-mg IV doses of ketorolac.

In what may be the first reported study of the treatment of acute postoperative pain with 5% lidocaine patches, surgeons placed a patch on either side of the wound at the end of surgery on 36 patients and a placebo patch on 34 patients. The two groups were similar in age, height, weight, ASA class, length of surgery, and amount of intraoperative opiates received.

Postoperative pain scores on coughing were significantly lower in the lidocaine group than in the placebo group in the postanesthesia care unit (PACU) and at 6, 12, and 24 hours post surgery, after investigators accounted for a significant effect of morphine. Pain scores at rest were significantly lower in the lidocaine group than in the placebo group up to 6 hours after surgery, and were not significantly different at 12 and 24 hours, said Dr. Habib, director of quality improvement at Duke University Medical Center, Durham, N.C.

There were no significant differences between groups in cumulative morphine consumption or in duration of stay in the PACU or in the hospital.

In the other study, a 7-mg nicotine patch was applied behind the ear of 44 patients 30–60 minutes before anesthesia induction, and a placebo patch behind the ear of 46 patients. By 24 hours after surgery, patients in the nicotine group had used a mean of 33 mg of morphine, significantly less than the mean 45 mg used by the placebo group, Dr. Habib said.

There were no significant differences between groups at any time points in pain scores on coughing or at rest, or in incidence of nausea and vomiting.

There were significant negative correlations between serum nicotine levels at 4 hours and cumulative morphine consumption at 24 hours, and between serum nicotine levels at 24 hours and morphine consumption at all time points (in the PACU and at 6, 12, and 24 hours after surgery).

Dr. Habib has no association with the companies that make the lidocaine or nicotine patches.

The nicotine group used 33 mg of morphine, significantly less than the 45 mg used by the placebo group. DR. HABIB

SAN FRANCISCO — Placing a nicotine patch behind a patient's ear before radical retropubic prostatectomy or placing lidocaine patches on each side of the surgical wound could reduce postoperative pain or narcotic use, results of two studies suggest.

The lidocaine patch significantly reduced pain after surgery, and the nicotine patch significantly reduced cumulative morphine consumption 24 hours after surgery, Dr. Ashraf S. Habib and associates reported in two separate poster presentations at the annual meeting of the American Society of Anesthesiologists (ASA).

Both prospective, randomized, double-blind, placebo-controlled studies of patients undergoing radical retropubic prostatectomy used standardized postoperative analgesia via patient-controlled morphine administration and six hourly 15-mg IV doses of ketorolac.

In what may be the first reported study of the treatment of acute postoperative pain with 5% lidocaine patches, surgeons placed a patch on either side of the wound at the end of surgery on 36 patients and a placebo patch on 34 patients. The two groups were similar in age, height, weight, ASA class, length of surgery, and amount of intraoperative opiates received.

Postoperative pain scores on coughing were significantly lower in the lidocaine group than in the placebo group in the postanesthesia care unit (PACU) and at 6, 12, and 24 hours post surgery, after investigators accounted for a significant effect of morphine. Pain scores at rest were significantly lower in the lidocaine group than in the placebo group up to 6 hours after surgery, and were not significantly different at 12 and 24 hours, said Dr. Habib, director of quality improvement at Duke University Medical Center, Durham, N.C.

There were no significant differences between groups in cumulative morphine consumption or in duration of stay in the PACU or in the hospital.

In the other study, a 7-mg nicotine patch was applied behind the ear of 44 patients 30–60 minutes before anesthesia induction, and a placebo patch behind the ear of 46 patients. By 24 hours after surgery, patients in the nicotine group had used a mean of 33 mg of morphine, significantly less than the mean 45 mg used by the placebo group, Dr. Habib said.

There were no significant differences between groups at any time points in pain scores on coughing or at rest, or in incidence of nausea and vomiting.

There were significant negative correlations between serum nicotine levels at 4 hours and cumulative morphine consumption at 24 hours, and between serum nicotine levels at 24 hours and morphine consumption at all time points (in the PACU and at 6, 12, and 24 hours after surgery).

Dr. Habib has no association with the companies that make the lidocaine or nicotine patches.

The nicotine group used 33 mg of morphine, significantly less than the 45 mg used by the placebo group. DR. HABIB

SAN FRANCISCO — A longer preoperative period without fluids led to a higher incidence of postoperative delirium in the recovery room, Dr. Finn M. Radtke reported in a poster presentation at the annual meeting of the American Society of Anesthesiologists.

In his study of 516 patients, 45 (9%) who later developed delirium went without fluids for a median of 12 hours before surgery, compared with 10 hours for the 471 patients without delirium, a statistically significant difference. Delirium after surgical procedures is associated with increased morbidity and mortality, said Dr. Radtke of Charité School of Medicine-Berlin and his associates.

“There's no reason that a patient shouldn't get clear fluids until 2 hours before an operation,” Dr. Radtke said.

The study included adult patients who were moved to a recovery room after general anesthesia and surgery. It excluded patients who were undergoing neurosurgery or who had a history of psychiatric or immunologic illness. Nurses assessed patients in the recovery room using the Nursing Delirium Screening Scale, an observational five-item scale that can be completed within about a minute.

In addition to preoperative fluid fasting, the duration of anesthesia was associated with delirium in the recovery room. Patients with delirium had a significantly longer duration of anesthesia (a median of 150 minutes), compared with nondelirious patients (120 minutes), he reported. Similarly, patients with delirium stayed a median of 5 minutes longer in the recovery room than did their counterparts, a statistically significant difference.

A physician in the audience at the poster presentation commented, “I expected to see an older population in the delirium group, but there wasn't [a significant age difference].” The median age in the delirium group was 58 years, compared with 53 years in those without delirium.

The study did not assess the depth of anesthesia experienced by patients, which could have played some role in the risk for postoperative delirium, Dr. Radtke said. He said his hospital performs approximately 90,000 operations each year.

'There's no reason that a patient shouldn't get clear fluids until 2 hours before an operation.' DR. RADTKE

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO — A longer preoperative period without fluids led to a higher incidence of postoperative delirium in the recovery room, Dr. Finn M. Radtke reported in a poster presentation at the annual meeting of the American Society of Anesthesiologists.

In his study of 516 patients, 45 (9%) who later developed delirium went without fluids for a median of 12 hours before surgery, compared with 10 hours for the 471 patients without delirium, a statistically significant difference. Delirium after surgical procedures is associated with increased morbidity and mortality, said Dr. Radtke of Charité School of Medicine-Berlin and his associates.

“There's no reason that a patient shouldn't get clear fluids until 2 hours before an operation,” Dr. Radtke said.

The study included adult patients who were moved to a recovery room after general anesthesia and surgery. It excluded patients who were undergoing neurosurgery or who had a history of psychiatric or immunologic illness. Nurses assessed patients in the recovery room using the Nursing Delirium Screening Scale, an observational five-item scale that can be completed within about a minute.

In addition to preoperative fluid fasting, the duration of anesthesia was associated with delirium in the recovery room. Patients with delirium had a significantly longer duration of anesthesia (a median of 150 minutes), compared with nondelirious patients (120 minutes), he reported. Similarly, patients with delirium stayed a median of 5 minutes longer in the recovery room than did their counterparts, a statistically significant difference.

A physician in the audience at the poster presentation commented, “I expected to see an older population in the delirium group, but there wasn't [a significant age difference].” The median age in the delirium group was 58 years, compared with 53 years in those without delirium.

The study did not assess the depth of anesthesia experienced by patients, which could have played some role in the risk for postoperative delirium, Dr. Radtke said. He said his hospital performs approximately 90,000 operations each year.

'There's no reason that a patient shouldn't get clear fluids until 2 hours before an operation.' DR. RADTKE

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO — A longer preoperative period without fluids led to a higher incidence of postoperative delirium in the recovery room, Dr. Finn M. Radtke reported in a poster presentation at the annual meeting of the American Society of Anesthesiologists.

In his study of 516 patients, 45 (9%) who later developed delirium went without fluids for a median of 12 hours before surgery, compared with 10 hours for the 471 patients without delirium, a statistically significant difference. Delirium after surgical procedures is associated with increased morbidity and mortality, said Dr. Radtke of Charité School of Medicine-Berlin and his associates.

“There's no reason that a patient shouldn't get clear fluids until 2 hours before an operation,” Dr. Radtke said.

The study included adult patients who were moved to a recovery room after general anesthesia and surgery. It excluded patients who were undergoing neurosurgery or who had a history of psychiatric or immunologic illness. Nurses assessed patients in the recovery room using the Nursing Delirium Screening Scale, an observational five-item scale that can be completed within about a minute.

In addition to preoperative fluid fasting, the duration of anesthesia was associated with delirium in the recovery room. Patients with delirium had a significantly longer duration of anesthesia (a median of 150 minutes), compared with nondelirious patients (120 minutes), he reported. Similarly, patients with delirium stayed a median of 5 minutes longer in the recovery room than did their counterparts, a statistically significant difference.

A physician in the audience at the poster presentation commented, “I expected to see an older population in the delirium group, but there wasn't [a significant age difference].” The median age in the delirium group was 58 years, compared with 53 years in those without delirium.

The study did not assess the depth of anesthesia experienced by patients, which could have played some role in the risk for postoperative delirium, Dr. Radtke said. He said his hospital performs approximately 90,000 operations each year.

'There's no reason that a patient shouldn't get clear fluids until 2 hours before an operation.' DR. RADTKE

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO — Nearly half of congenital dermoid cysts on infant heads may have risky intracranial connections that link the outside world to the brain, said Dr. Brandie J. Metz.

Tracts that expose the brain put a child "at higher risk for meningitis and abscess formation," Dr. Metz said at a meeting sponsored by Skin Disease Education Foundation. Fortunately, dermoid cysts in the most common location—the lateral third of an eyebrow—have never been reported to contain intracranial connections.

Dermoid cysts also can occur on the midline nasal bridge, the scalp, the anterior lateral neck, or postauricular areas, and may need imaging to check for intracranial connections, said Dr. Metz, chief of pediatric dermatology at the University of California, Irvine.

Congenital dermoid cysts are epithelial-lined cysts containing epidermal appendages such as hair, sebum, and sebaceous and apocrine glands. They are formed as the embryonic fusion lines of the skull close and structures get sequestered into the skin.

In some reports, almost half of the cysts are associated with intracranial connections.

Dermoid cysts in the nasal or midline scalp regions are more likely to have intracranial extensions.

Dr. Metz recommended getting MRI exams of all congenital dermoid cysts on the scalp, especially if there's an overlying hair collar sign (longer, courser, darker hair surround the scalp nodule) or capillary stain, or if the cyst is in an atypical location.

All midline dermoid cysts deserve imaging as well, especially if there are sinus pits or hairs projecting from the cyst, she said.

Most dermoid cysts appear at birth, and 70% are visible by age 5 years. They present as soft, rubbery, mobile subcutaneous tumors.

Dermoid cysts on the nose can appear anywhere from the glabella down to the tip of the nose, and may present with a subtle appearance–"just a kind of yellow broadening of the tip of the nose or the nasal bridge," Dr. Metz said.

An MRI will show the extent and nature of the lesion and can rule out intracranial connection.

The one scenario in which a CT scan may be preferable to an MRI is in an older child with a very long, thin lesion in a classic location. Dermoid cysts that have been present for a long time can cause bony erosions.

"If it's a teenager with a dermoid cyst in a very classic location, and you're not looking for an intracranial connection but rather to determine if there's any bony defect, CT might be useful," she explained.

If it is found that there is intracranial connection to the cyst, the patient should be referred to a neurosurgeon for surgical removal of the connection, Dr. Metz said.

In a 1988 study, 70 children had a solitary nontraumatic lump on the scalp, of which 26 had intracranial extensions.

Forty-one (59%) of these lumps were determined to be dermoid cysts. Other causes of the lumps included cephalhematoma deformans, eosinophilic granuloma, or occult meningoceles or encephaloceles.

The lumps that were determined to be dermoid cysts were the most likely to have intracranial extensions, in 15 of the 41 cases (37%).

Most of the dermoid cysts with extensions were on the posterior fontanelle or occipital scalp, "where we would have done preoperative imaging" to look for intracranial connections, Dr. Metz said.

A different infant scalp lesion that often gets confused with dermoid cysts also can have a rudimentary stalk that opens intracranial communication—heterotopic neural nodules of the scalp.

"The ones that are heterotopic neural nodules are more likely to have some other signs than do dermoids," noted Dr. Metz.

In a 2005 study of 12 heterotopic neural nodules of the scalp, 10 had a hair collar sign, 9 had capillary stain overlying the nodule, and 5 had calvarial defects in the bone that were identified with preoperative imaging.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

Dr. Brandie J. Metz: Dermoid cysts located on the lateral third of the eyebrow do not require radiologic imaging.

This MRI of a midline nasal dermoid cyst on a child confirms an intracranial connection to the cyst. Photos courtesy Dr. Brandie J. Metz

SAN FRANCISCO — Nearly half of congenital dermoid cysts on infant heads may have risky intracranial connections that link the outside world to the brain, said Dr. Brandie J. Metz.

Tracts that expose the brain put a child "at higher risk for meningitis and abscess formation," Dr. Metz said at a meeting sponsored by Skin Disease Education Foundation. Fortunately, dermoid cysts in the most common location—the lateral third of an eyebrow—have never been reported to contain intracranial connections.

Dermoid cysts also can occur on the midline nasal bridge, the scalp, the anterior lateral neck, or postauricular areas, and may need imaging to check for intracranial connections, said Dr. Metz, chief of pediatric dermatology at the University of California, Irvine.

Congenital dermoid cysts are epithelial-lined cysts containing epidermal appendages such as hair, sebum, and sebaceous and apocrine glands. They are formed as the embryonic fusion lines of the skull close and structures get sequestered into the skin.

In some reports, almost half of the cysts are associated with intracranial connections.

Dermoid cysts in the nasal or midline scalp regions are more likely to have intracranial extensions.

Dr. Metz recommended getting MRI exams of all congenital dermoid cysts on the scalp, especially if there's an overlying hair collar sign (longer, courser, darker hair surround the scalp nodule) or capillary stain, or if the cyst is in an atypical location.

All midline dermoid cysts deserve imaging as well, especially if there are sinus pits or hairs projecting from the cyst, she said.

Most dermoid cysts appear at birth, and 70% are visible by age 5 years. They present as soft, rubbery, mobile subcutaneous tumors.

Dermoid cysts on the nose can appear anywhere from the glabella down to the tip of the nose, and may present with a subtle appearance–"just a kind of yellow broadening of the tip of the nose or the nasal bridge," Dr. Metz said.

An MRI will show the extent and nature of the lesion and can rule out intracranial connection.

The one scenario in which a CT scan may be preferable to an MRI is in an older child with a very long, thin lesion in a classic location. Dermoid cysts that have been present for a long time can cause bony erosions.

"If it's a teenager with a dermoid cyst in a very classic location, and you're not looking for an intracranial connection but rather to determine if there's any bony defect, CT might be useful," she explained.

If it is found that there is intracranial connection to the cyst, the patient should be referred to a neurosurgeon for surgical removal of the connection, Dr. Metz said.

In a 1988 study, 70 children had a solitary nontraumatic lump on the scalp, of which 26 had intracranial extensions.

Forty-one (59%) of these lumps were determined to be dermoid cysts. Other causes of the lumps included cephalhematoma deformans, eosinophilic granuloma, or occult meningoceles or encephaloceles.

The lumps that were determined to be dermoid cysts were the most likely to have intracranial extensions, in 15 of the 41 cases (37%).

Most of the dermoid cysts with extensions were on the posterior fontanelle or occipital scalp, "where we would have done preoperative imaging" to look for intracranial connections, Dr. Metz said.

A different infant scalp lesion that often gets confused with dermoid cysts also can have a rudimentary stalk that opens intracranial communication—heterotopic neural nodules of the scalp.

"The ones that are heterotopic neural nodules are more likely to have some other signs than do dermoids," noted Dr. Metz.

In a 2005 study of 12 heterotopic neural nodules of the scalp, 10 had a hair collar sign, 9 had capillary stain overlying the nodule, and 5 had calvarial defects in the bone that were identified with preoperative imaging.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

Dr. Brandie J. Metz: Dermoid cysts located on the lateral third of the eyebrow do not require radiologic imaging.

This MRI of a midline nasal dermoid cyst on a child confirms an intracranial connection to the cyst. Photos courtesy Dr. Brandie J. Metz

SAN FRANCISCO — Nearly half of congenital dermoid cysts on infant heads may have risky intracranial connections that link the outside world to the brain, said Dr. Brandie J. Metz.

Tracts that expose the brain put a child "at higher risk for meningitis and abscess formation," Dr. Metz said at a meeting sponsored by Skin Disease Education Foundation. Fortunately, dermoid cysts in the most common location—the lateral third of an eyebrow—have never been reported to contain intracranial connections.

Dermoid cysts also can occur on the midline nasal bridge, the scalp, the anterior lateral neck, or postauricular areas, and may need imaging to check for intracranial connections, said Dr. Metz, chief of pediatric dermatology at the University of California, Irvine.

Congenital dermoid cysts are epithelial-lined cysts containing epidermal appendages such as hair, sebum, and sebaceous and apocrine glands. They are formed as the embryonic fusion lines of the skull close and structures get sequestered into the skin.

In some reports, almost half of the cysts are associated with intracranial connections.

Dermoid cysts in the nasal or midline scalp regions are more likely to have intracranial extensions.

Dr. Metz recommended getting MRI exams of all congenital dermoid cysts on the scalp, especially if there's an overlying hair collar sign (longer, courser, darker hair surround the scalp nodule) or capillary stain, or if the cyst is in an atypical location.

All midline dermoid cysts deserve imaging as well, especially if there are sinus pits or hairs projecting from the cyst, she said.

Most dermoid cysts appear at birth, and 70% are visible by age 5 years. They present as soft, rubbery, mobile subcutaneous tumors.

Dermoid cysts on the nose can appear anywhere from the glabella down to the tip of the nose, and may present with a subtle appearance–"just a kind of yellow broadening of the tip of the nose or the nasal bridge," Dr. Metz said.

An MRI will show the extent and nature of the lesion and can rule out intracranial connection.

The one scenario in which a CT scan may be preferable to an MRI is in an older child with a very long, thin lesion in a classic location. Dermoid cysts that have been present for a long time can cause bony erosions.

"If it's a teenager with a dermoid cyst in a very classic location, and you're not looking for an intracranial connection but rather to determine if there's any bony defect, CT might be useful," she explained.

If it is found that there is intracranial connection to the cyst, the patient should be referred to a neurosurgeon for surgical removal of the connection, Dr. Metz said.

In a 1988 study, 70 children had a solitary nontraumatic lump on the scalp, of which 26 had intracranial extensions.

Forty-one (59%) of these lumps were determined to be dermoid cysts. Other causes of the lumps included cephalhematoma deformans, eosinophilic granuloma, or occult meningoceles or encephaloceles.

The lumps that were determined to be dermoid cysts were the most likely to have intracranial extensions, in 15 of the 41 cases (37%).

Most of the dermoid cysts with extensions were on the posterior fontanelle or occipital scalp, "where we would have done preoperative imaging" to look for intracranial connections, Dr. Metz said.

A different infant scalp lesion that often gets confused with dermoid cysts also can have a rudimentary stalk that opens intracranial communication—heterotopic neural nodules of the scalp.

"The ones that are heterotopic neural nodules are more likely to have some other signs than do dermoids," noted Dr. Metz.

In a 2005 study of 12 heterotopic neural nodules of the scalp, 10 had a hair collar sign, 9 had capillary stain overlying the nodule, and 5 had calvarial defects in the bone that were identified with preoperative imaging.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

Dr. Brandie J. Metz: Dermoid cysts located on the lateral third of the eyebrow do not require radiologic imaging.

This MRI of a midline nasal dermoid cyst on a child confirms an intracranial connection to the cyst. Photos courtesy Dr. Brandie J. Metz

SAN FRANCISCO — Children can get acne at any age, but what parents think is acne actually may be something else, Dr. Rebecca L. Smith said at a meeting sponsored by Skin Disease Education Foundation.

A good example is "neonatal acne." That's what this imposter used to be called, until it was recognized as a pustulosis process, not acne, she said. Now called neonatal cephalic pustulosis, it is a common, transient eruption in the first weeks of life that is localized to cheeks, chin, forehead, and eyelids. Lesions may develop on the chest, neck, and scalp as well.

"This takes some hand holding" to get parents through these weeks until the lesions resolve, said Dr. Smith, a dermatologist in Fort Mill, S.C. If a parent demands treatment, a bit of topical 2% ketoconazole cream usually clears the skin quickly.

The term neonatal acne may be a thing of the past, but "infants can get acne, and it can be very bad," she acknowledged. It's most common on the cheeks, and more likely in boys than in girls. "You can treat these children just like virtually any other acne patients, with topical and oral antibiotics and even topical tretinoin at times. Extreme cases can be treated with isotretinoin," she added.

The situation changes after the first year, however. Dr. Smith refers any child between 1 year of age and puberty who has bad acne to an endocrinologist. Neonatal adrenal glands produce only minimal androgen after 1 year of life, so acne in early childhood raises concern about underlying disease and hyperandrogenism. "I don't keep them. I send them off to my colleagues" in endocrinology, she said.

"We're seeing children younger and younger these days" with typically midfacial acne that's often the first sign of pubertal maturation, she said. These acne-prone children secrete sebum in the midfacial area earlier than do children without acne.

When it comes to management, Dr. Smith said she tries to translate the treatment strategy into terms children can understand, targeting as many age-appropriate factors as possible.

"We're going to treat your oil, treat your plugs, treat your bugs, and then treat your redness," she tells them. "A teenager can get that." That corresponds with treating sebum, faulty follicular keratinization, bacteria, and inflammation.

To avoid inducing drug resistance in Propionibacterium acnes, use the least aggressive treatment regimen that provides a sustained response, she advised. "I'm not worried about P. acnes resistance. [I'm] worried about P. acnes sharing that" resistance with other bacteria.

She said she always adds benzoyl peroxide to antibiotic therapy for acne because it increases antibiotic penetration and creates a tough environment for P. acnes. Some combination products are on the market. Patients should be told that these products can bleach clothing, pillowcases, carpet, and hair, but not skin, she said.

Retinoids are the foundation of maintenance therapy for acne. "I want everyone on retinoids eventually," she said. Many retinoid options are available. Get to know them, and choose the one that's right for each patient, she suggested.

Don't instruct children to use a pea-sized amount for the entire face, because that may not mean much to vegetable-averse children. "Tell them to use a chocolate chip-sized amount," and show them how to dot the face and rub the retinoid in, she said.

To increase children's ability to tolerate retinoid therapy, have them wash their faces with a gentle cleanser and apply an oil-free moisturizer before applying the retinoid. This may slightly decrease the effect of the retinoid, but increased adherence to therapy can provide better results than applying the retinoid alone, she said. Another strategy is to titrate dosing by starting applications every second or third night for the first week, and increasing frequency as tolerated.

Dr. Smith has been a speaker or adviser for, or has received funding from, companies that make retinoids, antibiotics, or tretinoin products for the treatment of acne. These companies include Allergan, CollaGenex, Dermik, Galderma, Medicis, SkinMedica, Stiefel, and Warner Chilcott.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

SAN FRANCISCO — Children can get acne at any age, but what parents think is acne actually may be something else, Dr. Rebecca L. Smith said at a meeting sponsored by Skin Disease Education Foundation.

A good example is "neonatal acne." That's what this imposter used to be called, until it was recognized as a pustulosis process, not acne, she said. Now called neonatal cephalic pustulosis, it is a common, transient eruption in the first weeks of life that is localized to cheeks, chin, forehead, and eyelids. Lesions may develop on the chest, neck, and scalp as well.

"This takes some hand holding" to get parents through these weeks until the lesions resolve, said Dr. Smith, a dermatologist in Fort Mill, S.C. If a parent demands treatment, a bit of topical 2% ketoconazole cream usually clears the skin quickly.

The term neonatal acne may be a thing of the past, but "infants can get acne, and it can be very bad," she acknowledged. It's most common on the cheeks, and more likely in boys than in girls. "You can treat these children just like virtually any other acne patients, with topical and oral antibiotics and even topical tretinoin at times. Extreme cases can be treated with isotretinoin," she added.

The situation changes after the first year, however. Dr. Smith refers any child between 1 year of age and puberty who has bad acne to an endocrinologist. Neonatal adrenal glands produce only minimal androgen after 1 year of life, so acne in early childhood raises concern about underlying disease and hyperandrogenism. "I don't keep them. I send them off to my colleagues" in endocrinology, she said.

"We're seeing children younger and younger these days" with typically midfacial acne that's often the first sign of pubertal maturation, she said. These acne-prone children secrete sebum in the midfacial area earlier than do children without acne.

When it comes to management, Dr. Smith said she tries to translate the treatment strategy into terms children can understand, targeting as many age-appropriate factors as possible.

"We're going to treat your oil, treat your plugs, treat your bugs, and then treat your redness," she tells them. "A teenager can get that." That corresponds with treating sebum, faulty follicular keratinization, bacteria, and inflammation.

To avoid inducing drug resistance in Propionibacterium acnes, use the least aggressive treatment regimen that provides a sustained response, she advised. "I'm not worried about P. acnes resistance. [I'm] worried about P. acnes sharing that" resistance with other bacteria.

She said she always adds benzoyl peroxide to antibiotic therapy for acne because it increases antibiotic penetration and creates a tough environment for P. acnes. Some combination products are on the market. Patients should be told that these products can bleach clothing, pillowcases, carpet, and hair, but not skin, she said.

Retinoids are the foundation of maintenance therapy for acne. "I want everyone on retinoids eventually," she said. Many retinoid options are available. Get to know them, and choose the one that's right for each patient, she suggested.

Don't instruct children to use a pea-sized amount for the entire face, because that may not mean much to vegetable-averse children. "Tell them to use a chocolate chip-sized amount," and show them how to dot the face and rub the retinoid in, she said.

To increase children's ability to tolerate retinoid therapy, have them wash their faces with a gentle cleanser and apply an oil-free moisturizer before applying the retinoid. This may slightly decrease the effect of the retinoid, but increased adherence to therapy can provide better results than applying the retinoid alone, she said. Another strategy is to titrate dosing by starting applications every second or third night for the first week, and increasing frequency as tolerated.

Dr. Smith has been a speaker or adviser for, or has received funding from, companies that make retinoids, antibiotics, or tretinoin products for the treatment of acne. These companies include Allergan, CollaGenex, Dermik, Galderma, Medicis, SkinMedica, Stiefel, and Warner Chilcott.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

SAN FRANCISCO — Children can get acne at any age, but what parents think is acne actually may be something else, Dr. Rebecca L. Smith said at a meeting sponsored by Skin Disease Education Foundation.

A good example is "neonatal acne." That's what this imposter used to be called, until it was recognized as a pustulosis process, not acne, she said. Now called neonatal cephalic pustulosis, it is a common, transient eruption in the first weeks of life that is localized to cheeks, chin, forehead, and eyelids. Lesions may develop on the chest, neck, and scalp as well.

"This takes some hand holding" to get parents through these weeks until the lesions resolve, said Dr. Smith, a dermatologist in Fort Mill, S.C. If a parent demands treatment, a bit of topical 2% ketoconazole cream usually clears the skin quickly.

The term neonatal acne may be a thing of the past, but "infants can get acne, and it can be very bad," she acknowledged. It's most common on the cheeks, and more likely in boys than in girls. "You can treat these children just like virtually any other acne patients, with topical and oral antibiotics and even topical tretinoin at times. Extreme cases can be treated with isotretinoin," she added.

The situation changes after the first year, however. Dr. Smith refers any child between 1 year of age and puberty who has bad acne to an endocrinologist. Neonatal adrenal glands produce only minimal androgen after 1 year of life, so acne in early childhood raises concern about underlying disease and hyperandrogenism. "I don't keep them. I send them off to my colleagues" in endocrinology, she said.

"We're seeing children younger and younger these days" with typically midfacial acne that's often the first sign of pubertal maturation, she said. These acne-prone children secrete sebum in the midfacial area earlier than do children without acne.

When it comes to management, Dr. Smith said she tries to translate the treatment strategy into terms children can understand, targeting as many age-appropriate factors as possible.

"We're going to treat your oil, treat your plugs, treat your bugs, and then treat your redness," she tells them. "A teenager can get that." That corresponds with treating sebum, faulty follicular keratinization, bacteria, and inflammation.

To avoid inducing drug resistance in Propionibacterium acnes, use the least aggressive treatment regimen that provides a sustained response, she advised. "I'm not worried about P. acnes resistance. [I'm] worried about P. acnes sharing that" resistance with other bacteria.

She said she always adds benzoyl peroxide to antibiotic therapy for acne because it increases antibiotic penetration and creates a tough environment for P. acnes. Some combination products are on the market. Patients should be told that these products can bleach clothing, pillowcases, carpet, and hair, but not skin, she said.

Retinoids are the foundation of maintenance therapy for acne. "I want everyone on retinoids eventually," she said. Many retinoid options are available. Get to know them, and choose the one that's right for each patient, she suggested.

Don't instruct children to use a pea-sized amount for the entire face, because that may not mean much to vegetable-averse children. "Tell them to use a chocolate chip-sized amount," and show them how to dot the face and rub the retinoid in, she said.

To increase children's ability to tolerate retinoid therapy, have them wash their faces with a gentle cleanser and apply an oil-free moisturizer before applying the retinoid. This may slightly decrease the effect of the retinoid, but increased adherence to therapy can provide better results than applying the retinoid alone, she said. Another strategy is to titrate dosing by starting applications every second or third night for the first week, and increasing frequency as tolerated.

Dr. Smith has been a speaker or adviser for, or has received funding from, companies that make retinoids, antibiotics, or tretinoin products for the treatment of acne. These companies include Allergan, CollaGenex, Dermik, Galderma, Medicis, SkinMedica, Stiefel, and Warner Chilcott.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

SAN FRANCISCO — Iatrogenic injuries to a baby's skin from a stay in the neonatal intensive care unit often get overlooked until parents notice them at home and think they are seeing new injuries, Dr. Ilona J. Frieden said.

"These are very 'busy' babies, covered with monitors, and they're very tiny" babies, she said at a meeting sponsored by Skin Disease Education Foundation. Many things that are used on preterm babies can cause skin injury or scarring, such as tape, electrodes, transcutaneous monitoring devices, adhesives, and cleansers. Phototherapy can sunburn their fragile skin, and infusions and blood draws cause punctures and possible scars.

"A majority of infants who come out of the premature NICU will have some degree of minor skin scarring. You can almost expect it. The more preterm they are, the more likely this is," said Dr. Frieden, professor of dermatology and pediatrics at the University of California, San Francisco.

Later in infancy, after discharge from the hospital, parents may notice what they think is a new lesion. "People get worried this may be a new rash, when in fact, it's a so-called anetoderma of prematurity," she said. These atrophic lesions, usually on the ventral skin, initially can be progressive, and then stabilize.

Another iatrogenic injury seen in preterm infants is halo scalp injury—a temporary or permanent alopecia, usually in the occipital area, from pressure on the affected area.

"You would think it would be more common in big, term babies," but halo scalp injury is more common in preterm infants, Dr. Frieden said. "They may just be more susceptible to the pressure."

Providing a dermatologic consult in the NICU has its advantages and disadvantages, she noted.

The young patient has a short history, and you can do a complete exam relatively quickly. Biopsies are easy to do (if needed) because the infants are easy to hold down.

On the other hand, you go to the babies instead of patients coming to you, which involves commute time. Extra hand washing is required. Premature infants can stop breathing when touched, which can be scary for dermatologists. Rashes can be hard to see on such tiny bodies, especially when viewed through plexiglass coverings. You may have no idea what's wrong and feel inadequate. And nurses may be annoyed at your mere presence, she said.

Listen to the nurses, Dr. Frieden advised. "It is their territory. You're only a visitor."

Get permission before you do anything. Don't panic. You probably know more than you think you do, and you can get help if needed. Think in terms of disease categories if you suspect something is more than a benign iatrogenic injury.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

SAN FRANCISCO — Iatrogenic injuries to a baby's skin from a stay in the neonatal intensive care unit often get overlooked until parents notice them at home and think they are seeing new injuries, Dr. Ilona J. Frieden said.

"These are very 'busy' babies, covered with monitors, and they're very tiny" babies, she said at a meeting sponsored by Skin Disease Education Foundation. Many things that are used on preterm babies can cause skin injury or scarring, such as tape, electrodes, transcutaneous monitoring devices, adhesives, and cleansers. Phototherapy can sunburn their fragile skin, and infusions and blood draws cause punctures and possible scars.

"A majority of infants who come out of the premature NICU will have some degree of minor skin scarring. You can almost expect it. The more preterm they are, the more likely this is," said Dr. Frieden, professor of dermatology and pediatrics at the University of California, San Francisco.

Later in infancy, after discharge from the hospital, parents may notice what they think is a new lesion. "People get worried this may be a new rash, when in fact, it's a so-called anetoderma of prematurity," she said. These atrophic lesions, usually on the ventral skin, initially can be progressive, and then stabilize.

Another iatrogenic injury seen in preterm infants is halo scalp injury—a temporary or permanent alopecia, usually in the occipital area, from pressure on the affected area.

"You would think it would be more common in big, term babies," but halo scalp injury is more common in preterm infants, Dr. Frieden said. "They may just be more susceptible to the pressure."

Providing a dermatologic consult in the NICU has its advantages and disadvantages, she noted.

The young patient has a short history, and you can do a complete exam relatively quickly. Biopsies are easy to do (if needed) because the infants are easy to hold down.

On the other hand, you go to the babies instead of patients coming to you, which involves commute time. Extra hand washing is required. Premature infants can stop breathing when touched, which can be scary for dermatologists. Rashes can be hard to see on such tiny bodies, especially when viewed through plexiglass coverings. You may have no idea what's wrong and feel inadequate. And nurses may be annoyed at your mere presence, she said.

Listen to the nurses, Dr. Frieden advised. "It is their territory. You're only a visitor."

Get permission before you do anything. Don't panic. You probably know more than you think you do, and you can get help if needed. Think in terms of disease categories if you suspect something is more than a benign iatrogenic injury.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

SAN FRANCISCO — Iatrogenic injuries to a baby's skin from a stay in the neonatal intensive care unit often get overlooked until parents notice them at home and think they are seeing new injuries, Dr. Ilona J. Frieden said.

"These are very 'busy' babies, covered with monitors, and they're very tiny" babies, she said at a meeting sponsored by Skin Disease Education Foundation. Many things that are used on preterm babies can cause skin injury or scarring, such as tape, electrodes, transcutaneous monitoring devices, adhesives, and cleansers. Phototherapy can sunburn their fragile skin, and infusions and blood draws cause punctures and possible scars.

"A majority of infants who come out of the premature NICU will have some degree of minor skin scarring. You can almost expect it. The more preterm they are, the more likely this is," said Dr. Frieden, professor of dermatology and pediatrics at the University of California, San Francisco.

Later in infancy, after discharge from the hospital, parents may notice what they think is a new lesion. "People get worried this may be a new rash, when in fact, it's a so-called anetoderma of prematurity," she said. These atrophic lesions, usually on the ventral skin, initially can be progressive, and then stabilize.

Another iatrogenic injury seen in preterm infants is halo scalp injury—a temporary or permanent alopecia, usually in the occipital area, from pressure on the affected area.

"You would think it would be more common in big, term babies," but halo scalp injury is more common in preterm infants, Dr. Frieden said. "They may just be more susceptible to the pressure."

Providing a dermatologic consult in the NICU has its advantages and disadvantages, she noted.

The young patient has a short history, and you can do a complete exam relatively quickly. Biopsies are easy to do (if needed) because the infants are easy to hold down.

On the other hand, you go to the babies instead of patients coming to you, which involves commute time. Extra hand washing is required. Premature infants can stop breathing when touched, which can be scary for dermatologists. Rashes can be hard to see on such tiny bodies, especially when viewed through plexiglass coverings. You may have no idea what's wrong and feel inadequate. And nurses may be annoyed at your mere presence, she said.

Listen to the nurses, Dr. Frieden advised. "It is their territory. You're only a visitor."

Get permission before you do anything. Don't panic. You probably know more than you think you do, and you can get help if needed. Think in terms of disease categories if you suspect something is more than a benign iatrogenic injury.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

SAN FRANCISCO — When pediatricians call in dermatologists to assess neonatal vesiculopustular eruptions, what they're really asking is, "Could it be herpes?" said Dr. Ilona J. Frieden.

Think of the neonate as an immunocompromised host, and consider the worst possible diagnosis, she advised at a meeting sponsored by Skin Disease Education Foundation.

Think of infection first, but don't stop there, because more than 25 other conditions can cause vesicles and pustules on the skin. "This is something that pediatricians call us about most often—children who have vesiculopustular eruptions," said Dr. Frieden, professor of dermatology and pediatrics at the University of California, San Francisco.

Herpes simplex virus infection in neonates is rare but devastating. The lesions can look like typical herpes lesions in older patients, or can have a more fragile-looking pustule because baby skin is thinner, "an almost impetigo-like look," she said. Commonly, neonatal herpes lesions are on the scalp, buried in hair and hard to see. Widespread erosions of the skin may be seen in infants born with intrauterine herpes infection.

The initial findings of neonatal herpes, however, tend to be nonspecific, such as temperature instability, lethargy, and a little regurgitation of breast milk or formula. These symptoms, plus metabolic acidosis and tachycardia or tachypnea, are signs and symptoms of neonatal sepsis. "Not so much high fevers—that would be quite unusual—but temperature instability," Dr. Frieden said.

More benign causes of pustular eruptions that can be confused with herpes include erythema toxicum or transient pustular melanosis. These occur only in term infants, not preterm. Transient pustular melanosis usually appears on the first day of life, while erythema toxicum tends to appear in the first 5 days, she said. Later lesions are more likely to be something else.

Erythema toxicum lesions tend to be migrating rather than fixed, Dr. Frieden noted. A noninflamed base is characteristic of transient pustular melanosis.

Pruritic papules and pustules in newborns also can be caused by eosinophilic pustular folliculitis, "which is a pretty uncommon condition," she added.

Langerhans cell histiocytosis can produce multiple crusted lesions, papules, and pustules. "The clue is these kinds of roundish pustular lesions," she said. This disease can become more indolent or aggressive later in life.

Other skin problems can also be cause for neonatal emergencies, Dr. Frieden added. Small purpuric lesions on a neonate—sometimes called a "blueberry muffin baby"–may be caused by dermal erythropoiesis (the presence of blood cells in the skin because they're not being produced in bone marrow). "These are very stingy blueberries, typically. You're not looking for big, plump blueberries. They are teeny blueberries, almost more like currants in the skin," she explained.

The lesions may be caused by congenital infection, hemolytic disease of the newborn, or neoplastic-infiltrative diseases such as congenital leukemia. Among infections, the most common cause of "blueberry muffin" babies is cytomegalovirus, but any infection can be the cause, including parvovirus, enteroviruses, rubella, and more. In this case, biopsies and a full evaluation are urgent, Dr. Frieden said.

Newborn skin that is extremely fragile or falling off also needs immediate care to dress the wound.

Apply a topical antibiotic sparingly and petrolatum thickly, add Vaseline gauze (not Xeroform, which doesn't stick to newborn skin), wrap it all in Kerlix for padding and top it off with a stockinette instead of tape to minimize trauma, she suggested.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

SAN FRANCISCO — When pediatricians call in dermatologists to assess neonatal vesiculopustular eruptions, what they're really asking is, "Could it be herpes?" said Dr. Ilona J. Frieden.

Think of the neonate as an immunocompromised host, and consider the worst possible diagnosis, she advised at a meeting sponsored by Skin Disease Education Foundation.

Think of infection first, but don't stop there, because more than 25 other conditions can cause vesicles and pustules on the skin. "This is something that pediatricians call us about most often—children who have vesiculopustular eruptions," said Dr. Frieden, professor of dermatology and pediatrics at the University of California, San Francisco.

Herpes simplex virus infection in neonates is rare but devastating. The lesions can look like typical herpes lesions in older patients, or can have a more fragile-looking pustule because baby skin is thinner, "an almost impetigo-like look," she said. Commonly, neonatal herpes lesions are on the scalp, buried in hair and hard to see. Widespread erosions of the skin may be seen in infants born with intrauterine herpes infection.

The initial findings of neonatal herpes, however, tend to be nonspecific, such as temperature instability, lethargy, and a little regurgitation of breast milk or formula. These symptoms, plus metabolic acidosis and tachycardia or tachypnea, are signs and symptoms of neonatal sepsis. "Not so much high fevers—that would be quite unusual—but temperature instability," Dr. Frieden said.

More benign causes of pustular eruptions that can be confused with herpes include erythema toxicum or transient pustular melanosis. These occur only in term infants, not preterm. Transient pustular melanosis usually appears on the first day of life, while erythema toxicum tends to appear in the first 5 days, she said. Later lesions are more likely to be something else.

Erythema toxicum lesions tend to be migrating rather than fixed, Dr. Frieden noted. A noninflamed base is characteristic of transient pustular melanosis.

Pruritic papules and pustules in newborns also can be caused by eosinophilic pustular folliculitis, "which is a pretty uncommon condition," she added.

Langerhans cell histiocytosis can produce multiple crusted lesions, papules, and pustules. "The clue is these kinds of roundish pustular lesions," she said. This disease can become more indolent or aggressive later in life.

Other skin problems can also be cause for neonatal emergencies, Dr. Frieden added. Small purpuric lesions on a neonate—sometimes called a "blueberry muffin baby"–may be caused by dermal erythropoiesis (the presence of blood cells in the skin because they're not being produced in bone marrow). "These are very stingy blueberries, typically. You're not looking for big, plump blueberries. They are teeny blueberries, almost more like currants in the skin," she explained.

The lesions may be caused by congenital infection, hemolytic disease of the newborn, or neoplastic-infiltrative diseases such as congenital leukemia. Among infections, the most common cause of "blueberry muffin" babies is cytomegalovirus, but any infection can be the cause, including parvovirus, enteroviruses, rubella, and more. In this case, biopsies and a full evaluation are urgent, Dr. Frieden said.

Newborn skin that is extremely fragile or falling off also needs immediate care to dress the wound.

Apply a topical antibiotic sparingly and petrolatum thickly, add Vaseline gauze (not Xeroform, which doesn't stick to newborn skin), wrap it all in Kerlix for padding and top it off with a stockinette instead of tape to minimize trauma, she suggested.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

SAN FRANCISCO — When pediatricians call in dermatologists to assess neonatal vesiculopustular eruptions, what they're really asking is, "Could it be herpes?" said Dr. Ilona J. Frieden.

Think of the neonate as an immunocompromised host, and consider the worst possible diagnosis, she advised at a meeting sponsored by Skin Disease Education Foundation.

Think of infection first, but don't stop there, because more than 25 other conditions can cause vesicles and pustules on the skin. "This is something that pediatricians call us about most often—children who have vesiculopustular eruptions," said Dr. Frieden, professor of dermatology and pediatrics at the University of California, San Francisco.

Herpes simplex virus infection in neonates is rare but devastating. The lesions can look like typical herpes lesions in older patients, or can have a more fragile-looking pustule because baby skin is thinner, "an almost impetigo-like look," she said. Commonly, neonatal herpes lesions are on the scalp, buried in hair and hard to see. Widespread erosions of the skin may be seen in infants born with intrauterine herpes infection.

The initial findings of neonatal herpes, however, tend to be nonspecific, such as temperature instability, lethargy, and a little regurgitation of breast milk or formula. These symptoms, plus metabolic acidosis and tachycardia or tachypnea, are signs and symptoms of neonatal sepsis. "Not so much high fevers—that would be quite unusual—but temperature instability," Dr. Frieden said.

More benign causes of pustular eruptions that can be confused with herpes include erythema toxicum or transient pustular melanosis. These occur only in term infants, not preterm. Transient pustular melanosis usually appears on the first day of life, while erythema toxicum tends to appear in the first 5 days, she said. Later lesions are more likely to be something else.

Erythema toxicum lesions tend to be migrating rather than fixed, Dr. Frieden noted. A noninflamed base is characteristic of transient pustular melanosis.

Pruritic papules and pustules in newborns also can be caused by eosinophilic pustular folliculitis, "which is a pretty uncommon condition," she added.

Langerhans cell histiocytosis can produce multiple crusted lesions, papules, and pustules. "The clue is these kinds of roundish pustular lesions," she said. This disease can become more indolent or aggressive later in life.

Other skin problems can also be cause for neonatal emergencies, Dr. Frieden added. Small purpuric lesions on a neonate—sometimes called a "blueberry muffin baby"–may be caused by dermal erythropoiesis (the presence of blood cells in the skin because they're not being produced in bone marrow). "These are very stingy blueberries, typically. You're not looking for big, plump blueberries. They are teeny blueberries, almost more like currants in the skin," she explained.

The lesions may be caused by congenital infection, hemolytic disease of the newborn, or neoplastic-infiltrative diseases such as congenital leukemia. Among infections, the most common cause of "blueberry muffin" babies is cytomegalovirus, but any infection can be the cause, including parvovirus, enteroviruses, rubella, and more. In this case, biopsies and a full evaluation are urgent, Dr. Frieden said.

Newborn skin that is extremely fragile or falling off also needs immediate care to dress the wound.

Apply a topical antibiotic sparingly and petrolatum thickly, add Vaseline gauze (not Xeroform, which doesn't stick to newborn skin), wrap it all in Kerlix for padding and top it off with a stockinette instead of tape to minimize trauma, she suggested.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

SAN FRANCISCO — Signs of fetal well-being returned more rapidly after external cephalic version in 47 women given combined spinal-epidural analgesia, compared with 48 women given systemic opioids in a randomized study.

Neuraxial analgesia has been shown in previous studies to reduce pain from external cephalic version and to improve maternal satisfaction, compared with systemic opioids, but the fetal heart rate effects of the two types of analgesia have not been compared before the current study, Dr. John T. Sullivan and associates reported in a poster presentation at the annual meeting of the American Society of Anesthesiologists.

As part of a larger study on the success of external cephalic version using different analgesia techniques, pregnant women with breech presentation were randomized to combined spinal-epidural analgesia using intrathecal bupivacaine 2.5 mg plus 15 mcg of fentanyl, or to intravenous systemic opioid analgesia using 50 mcg fentanyl. A perinatologist blinded to assignments evaluated fetal heart rate patterns for 30 minutes before and for 60 minutes after external cephalic version.

No significant differences were seen between groups in preprocedural and postprocedural baseline fetal heart rates, the degree of heart rate variability, the number of accelerations, or the number and type of decelerations, said Dr. Sullivan, associate professor of anesthesiology, Northwestern University, Chicago.

A reactive fetal heart rate after external cephalic version is a sign of fetal well-being, so investigators assessed the time to reactivity from initiation of analgesia to the development of two 15-beat accelerations (of 15 seconds duration) occurring within 20 minutes of each other.

The median time to reactivity in the combined spinal-epidural group was 13 minutes, significantly shorter than the median 39 minutes in the systemic opioid group.

One patient in each group underwent cesarean delivery immediately after external cephalic version for nonreassuring fetal heart rate patterns.

“Combined spinal-epidural analgesia for external cephalic version has no discernible deleterious impact on fetal heart rate pattern as compared with systemic opioid analgesia,” Dr. Sullivan and his associates concluded. “Furthermore, it results in a more rapid return of a reactive fetal heart rate tracing. Therefore, combined spinal epidural may provide more immediate reassurance of fetal well-being following external cephalic version.”

SAN FRANCISCO — Signs of fetal well-being returned more rapidly after external cephalic version in 47 women given combined spinal-epidural analgesia, compared with 48 women given systemic opioids in a randomized study.

Neuraxial analgesia has been shown in previous studies to reduce pain from external cephalic version and to improve maternal satisfaction, compared with systemic opioids, but the fetal heart rate effects of the two types of analgesia have not been compared before the current study, Dr. John T. Sullivan and associates reported in a poster presentation at the annual meeting of the American Society of Anesthesiologists.

As part of a larger study on the success of external cephalic version using different analgesia techniques, pregnant women with breech presentation were randomized to combined spinal-epidural analgesia using intrathecal bupivacaine 2.5 mg plus 15 mcg of fentanyl, or to intravenous systemic opioid analgesia using 50 mcg fentanyl. A perinatologist blinded to assignments evaluated fetal heart rate patterns for 30 minutes before and for 60 minutes after external cephalic version.

No significant differences were seen between groups in preprocedural and postprocedural baseline fetal heart rates, the degree of heart rate variability, the number of accelerations, or the number and type of decelerations, said Dr. Sullivan, associate professor of anesthesiology, Northwestern University, Chicago.

A reactive fetal heart rate after external cephalic version is a sign of fetal well-being, so investigators assessed the time to reactivity from initiation of analgesia to the development of two 15-beat accelerations (of 15 seconds duration) occurring within 20 minutes of each other.

The median time to reactivity in the combined spinal-epidural group was 13 minutes, significantly shorter than the median 39 minutes in the systemic opioid group.

One patient in each group underwent cesarean delivery immediately after external cephalic version for nonreassuring fetal heart rate patterns.

“Combined spinal-epidural analgesia for external cephalic version has no discernible deleterious impact on fetal heart rate pattern as compared with systemic opioid analgesia,” Dr. Sullivan and his associates concluded. “Furthermore, it results in a more rapid return of a reactive fetal heart rate tracing. Therefore, combined spinal epidural may provide more immediate reassurance of fetal well-being following external cephalic version.”

SAN FRANCISCO — Signs of fetal well-being returned more rapidly after external cephalic version in 47 women given combined spinal-epidural analgesia, compared with 48 women given systemic opioids in a randomized study.

Neuraxial analgesia has been shown in previous studies to reduce pain from external cephalic version and to improve maternal satisfaction, compared with systemic opioids, but the fetal heart rate effects of the two types of analgesia have not been compared before the current study, Dr. John T. Sullivan and associates reported in a poster presentation at the annual meeting of the American Society of Anesthesiologists.

As part of a larger study on the success of external cephalic version using different analgesia techniques, pregnant women with breech presentation were randomized to combined spinal-epidural analgesia using intrathecal bupivacaine 2.5 mg plus 15 mcg of fentanyl, or to intravenous systemic opioid analgesia using 50 mcg fentanyl. A perinatologist blinded to assignments evaluated fetal heart rate patterns for 30 minutes before and for 60 minutes after external cephalic version.

No significant differences were seen between groups in preprocedural and postprocedural baseline fetal heart rates, the degree of heart rate variability, the number of accelerations, or the number and type of decelerations, said Dr. Sullivan, associate professor of anesthesiology, Northwestern University, Chicago.

A reactive fetal heart rate after external cephalic version is a sign of fetal well-being, so investigators assessed the time to reactivity from initiation of analgesia to the development of two 15-beat accelerations (of 15 seconds duration) occurring within 20 minutes of each other.

The median time to reactivity in the combined spinal-epidural group was 13 minutes, significantly shorter than the median 39 minutes in the systemic opioid group.

One patient in each group underwent cesarean delivery immediately after external cephalic version for nonreassuring fetal heart rate patterns.

“Combined spinal-epidural analgesia for external cephalic version has no discernible deleterious impact on fetal heart rate pattern as compared with systemic opioid analgesia,” Dr. Sullivan and his associates concluded. “Furthermore, it results in a more rapid return of a reactive fetal heart rate tracing. Therefore, combined spinal epidural may provide more immediate reassurance of fetal well-being following external cephalic version.”

SAN FRANCISCO — Pregnant women were more likely to have risk factors for obstructive sleep apnea compared with nonpregnant women in a study of 4,564 women.

In addition, pregnant women identified to be at risk for sleep apnea were more likely to develop preeclampsia compared with pregnant women who didn't have sleep apnea risk factors, Dr. Nicole Higgins, an anesthesiologist at Northwestern University, Chicago, and her associates reported in a poster presentation at the annual meeting of the American Society of Anesthesiologists.

Among adult women in general, about 2% have obstructive sleep apnea, a condition characterized by obstruction of the upper airway and episodes of apnea and hypopnea during sleep. The incidence of obstructive sleep apnea in pregnancy has been unknown.

“Obstructive sleep apnea is a condition that we see with a rising incidence because the population, in all honesty, is getting larger,” Dr. Higgins said in an interview, referring to the increasing prevalence of obesity. “That's one of the risk factors for obstructive sleep apnea.” In the prospective study, 33% of 4,074 pregnant women presenting for delivery and 20% of 490 control women presenting for outpatient surgery screened positive on the Berlin Questionnaire, a validated means of identifying patients at increased risk for sleep apnea through questions about snoring and daytime sleepiness.

Statistical analysis found that pregnancy doubled the chance for screening positive on the Berlin Questionnaire, and pregnant women who screened positive on the questionnaire were four times more likely to develop preeclampsia, compared with pregnant women who screened negative. Those who screened positive were significantly shorter, heavier before pregnancy, and heavier during pregnancy than were those with a negative screen.

Previous studies have suggested that sleep-disordered breathing or obstructive sleep apnea may increase the risk for preeclampsia or preterm delivery.

In the current study, there was a significant correlation between a positive Berlin screen and heavier infant weight (3,475 g vs. 3,374 g if the mother screened negative). A positive Berlin screen also correlated significantly with risk for low 1-minute Apgar scores. About 7% of infants born to mothers who screened positive had 1-minute Apgar scores below 7, compared with 6% of infants if the mother screened negative for sleep apnea.

Dr. Higgins is working with colleagues in maternal-fetal medicine to use the Berlin Questionnaire to screen women in the first and third trimesters. Women who screen positive are referred for formal sleep studies, and those diagnosed with obstructive sleep apnea will be followed through pregnancy to assess outcomes, she said.

SAN FRANCISCO — Pregnant women were more likely to have risk factors for obstructive sleep apnea compared with nonpregnant women in a study of 4,564 women.

In addition, pregnant women identified to be at risk for sleep apnea were more likely to develop preeclampsia compared with pregnant women who didn't have sleep apnea risk factors, Dr. Nicole Higgins, an anesthesiologist at Northwestern University, Chicago, and her associates reported in a poster presentation at the annual meeting of the American Society of Anesthesiologists.

Among adult women in general, about 2% have obstructive sleep apnea, a condition characterized by obstruction of the upper airway and episodes of apnea and hypopnea during sleep. The incidence of obstructive sleep apnea in pregnancy has been unknown.

“Obstructive sleep apnea is a condition that we see with a rising incidence because the population, in all honesty, is getting larger,” Dr. Higgins said in an interview, referring to the increasing prevalence of obesity. “That's one of the risk factors for obstructive sleep apnea.” In the prospective study, 33% of 4,074 pregnant women presenting for delivery and 20% of 490 control women presenting for outpatient surgery screened positive on the Berlin Questionnaire, a validated means of identifying patients at increased risk for sleep apnea through questions about snoring and daytime sleepiness.

Statistical analysis found that pregnancy doubled the chance for screening positive on the Berlin Questionnaire, and pregnant women who screened positive on the questionnaire were four times more likely to develop preeclampsia, compared with pregnant women who screened negative. Those who screened positive were significantly shorter, heavier before pregnancy, and heavier during pregnancy than were those with a negative screen.

Previous studies have suggested that sleep-disordered breathing or obstructive sleep apnea may increase the risk for preeclampsia or preterm delivery.

In the current study, there was a significant correlation between a positive Berlin screen and heavier infant weight (3,475 g vs. 3,374 g if the mother screened negative). A positive Berlin screen also correlated significantly with risk for low 1-minute Apgar scores. About 7% of infants born to mothers who screened positive had 1-minute Apgar scores below 7, compared with 6% of infants if the mother screened negative for sleep apnea.

Dr. Higgins is working with colleagues in maternal-fetal medicine to use the Berlin Questionnaire to screen women in the first and third trimesters. Women who screen positive are referred for formal sleep studies, and those diagnosed with obstructive sleep apnea will be followed through pregnancy to assess outcomes, she said.

SAN FRANCISCO — Pregnant women were more likely to have risk factors for obstructive sleep apnea compared with nonpregnant women in a study of 4,564 women.

In addition, pregnant women identified to be at risk for sleep apnea were more likely to develop preeclampsia compared with pregnant women who didn't have sleep apnea risk factors, Dr. Nicole Higgins, an anesthesiologist at Northwestern University, Chicago, and her associates reported in a poster presentation at the annual meeting of the American Society of Anesthesiologists.

Among adult women in general, about 2% have obstructive sleep apnea, a condition characterized by obstruction of the upper airway and episodes of apnea and hypopnea during sleep. The incidence of obstructive sleep apnea in pregnancy has been unknown.

“Obstructive sleep apnea is a condition that we see with a rising incidence because the population, in all honesty, is getting larger,” Dr. Higgins said in an interview, referring to the increasing prevalence of obesity. “That's one of the risk factors for obstructive sleep apnea.” In the prospective study, 33% of 4,074 pregnant women presenting for delivery and 20% of 490 control women presenting for outpatient surgery screened positive on the Berlin Questionnaire, a validated means of identifying patients at increased risk for sleep apnea through questions about snoring and daytime sleepiness.

Statistical analysis found that pregnancy doubled the chance for screening positive on the Berlin Questionnaire, and pregnant women who screened positive on the questionnaire were four times more likely to develop preeclampsia, compared with pregnant women who screened negative. Those who screened positive were significantly shorter, heavier before pregnancy, and heavier during pregnancy than were those with a negative screen.

Previous studies have suggested that sleep-disordered breathing or obstructive sleep apnea may increase the risk for preeclampsia or preterm delivery.

In the current study, there was a significant correlation between a positive Berlin screen and heavier infant weight (3,475 g vs. 3,374 g if the mother screened negative). A positive Berlin screen also correlated significantly with risk for low 1-minute Apgar scores. About 7% of infants born to mothers who screened positive had 1-minute Apgar scores below 7, compared with 6% of infants if the mother screened negative for sleep apnea.

Dr. Higgins is working with colleagues in maternal-fetal medicine to use the Berlin Questionnaire to screen women in the first and third trimesters. Women who screen positive are referred for formal sleep studies, and those diagnosed with obstructive sleep apnea will be followed through pregnancy to assess outcomes, she said.

SAN FRANCISCO — Multiple clinical trials have shown that both ginger and vitamin B₆ can safely help reduce the nausea and vomiting of “morning sickness” in pregnancy.

Cathi Dennehy, Pharm.D., reviewed the evidence for the efficacy and safety of the two supplements at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

▸ Ginger. Six randomized, controlled trials found significant reductions in nausea and vomiting during pregnancy in women who took powdered ginger, ginger syrup, or ginger extract products for 4–21 days. Four trials found greater reductions in nausea and vomiting, compared with placebo, and two trials found effects that were equivalent to treatment with 30 mg or 75 mg/day of vitamin B₆ (with no placebo arm in those studies).

The most common dose was 1 g/day of powdered ginger, which comes in capsules containing 250–500 mg each. Patients took divided doses b.i.d. or q.i.d. depending on the capsule size.

The studies included 26–291 women each. Four trials that included a total of 265 women found no increased risk of negative birth outcomes in the ginger groups. Most of the women in these studies used ginger during the first trimester of pregnancy, but some studies included women up to the 20th week of gestation and after the critical developmental stages, which might have diluted the findings regarding safety. A separate observational study that focused strictly on ginger use during the first trimester also found no increase in adverse events.

Side effects are rare but may include GI upset, heartburn, flatulence, or bloating. Much higher doses of ginger (2.5 g/day or higher) can produce antiplatelet effects.

Two previous studies—one in rats and the other an in vitro study—had raised some concerns about possible mutagenic properties or some increase in early embryonic loss. However, “there is quite a bit of evidence in clinical trials” to support the safety of ginger in pregnancy, said Dr. Dennehy of the university's School of Pharmacy.

▸ Vitamin B₆. Two randomized, controlled trials (with 59 and 342 patients, respectively) found that vitamin B₆ supplements worked significantly better than placebo to decrease severe nausea and vomiting in pregnancy or to decrease overall nausea scores and vomiting in the first 3 days of use.

Bendectin, a product that combined vitamin B₆, an antihistamine, and an anticholinergic, was pulled off the U.S. market in the early 1980s after lawsuits alleged that it caused limb deformities in children. Plaintiff victories on those charges were overturned on appeal. Moreover, late last year, the FDA took the unusual step of publishing a notice in the Federal Register stating that Bendectin had not been withdrawn from the market for safety or health reasons. The move was widely seen as an invitation for a pharmaceutical manufacturer to begin selling the drug again.

Today, a similar product called Diclectin is sold in Canada and combines vitamin B₆ with doxylamine. A meta-analysis of 170,000 exposures to Diclectin found no adverse effects on fetuses. “Overall, it looks like vitamin B₆ is a safe product to use” in pregnancy, Dr. Dennehy said.

Dr. Dennehy also reviewed the prospect of peppermint tea as a morning-sickness palliative. There are no trials of peppermint tea either in general use or during pregnancy, she said, but a small randomized controlled study of peppermint oil for postoperative pain found it to be more effective than placebo. Peppermint oil relaxes GI smooth muscle, and commonly is used for irritable bowel syndrome.

Six trials found reductions in nausea in women who took ginger products. ©Tasha/

SAN FRANCISCO — Multiple clinical trials have shown that both ginger and vitamin B₆ can safely help reduce the nausea and vomiting of “morning sickness” in pregnancy.

Cathi Dennehy, Pharm.D., reviewed the evidence for the efficacy and safety of the two supplements at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

▸ Ginger. Six randomized, controlled trials found significant reductions in nausea and vomiting during pregnancy in women who took powdered ginger, ginger syrup, or ginger extract products for 4–21 days. Four trials found greater reductions in nausea and vomiting, compared with placebo, and two trials found effects that were equivalent to treatment with 30 mg or 75 mg/day of vitamin B₆ (with no placebo arm in those studies).

The most common dose was 1 g/day of powdered ginger, which comes in capsules containing 250–500 mg each. Patients took divided doses b.i.d. or q.i.d. depending on the capsule size.

The studies included 26–291 women each. Four trials that included a total of 265 women found no increased risk of negative birth outcomes in the ginger groups. Most of the women in these studies used ginger during the first trimester of pregnancy, but some studies included women up to the 20th week of gestation and after the critical developmental stages, which might have diluted the findings regarding safety. A separate observational study that focused strictly on ginger use during the first trimester also found no increase in adverse events.

Side effects are rare but may include GI upset, heartburn, flatulence, or bloating. Much higher doses of ginger (2.5 g/day or higher) can produce antiplatelet effects.

Two previous studies—one in rats and the other an in vitro study—had raised some concerns about possible mutagenic properties or some increase in early embryonic loss. However, “there is quite a bit of evidence in clinical trials” to support the safety of ginger in pregnancy, said Dr. Dennehy of the university's School of Pharmacy.

▸ Vitamin B₆. Two randomized, controlled trials (with 59 and 342 patients, respectively) found that vitamin B₆ supplements worked significantly better than placebo to decrease severe nausea and vomiting in pregnancy or to decrease overall nausea scores and vomiting in the first 3 days of use.

Bendectin, a product that combined vitamin B₆, an antihistamine, and an anticholinergic, was pulled off the U.S. market in the early 1980s after lawsuits alleged that it caused limb deformities in children. Plaintiff victories on those charges were overturned on appeal. Moreover, late last year, the FDA took the unusual step of publishing a notice in the Federal Register stating that Bendectin had not been withdrawn from the market for safety or health reasons. The move was widely seen as an invitation for a pharmaceutical manufacturer to begin selling the drug again.

Today, a similar product called Diclectin is sold in Canada and combines vitamin B₆ with doxylamine. A meta-analysis of 170,000 exposures to Diclectin found no adverse effects on fetuses. “Overall, it looks like vitamin B₆ is a safe product to use” in pregnancy, Dr. Dennehy said.

Dr. Dennehy also reviewed the prospect of peppermint tea as a morning-sickness palliative. There are no trials of peppermint tea either in general use or during pregnancy, she said, but a small randomized controlled study of peppermint oil for postoperative pain found it to be more effective than placebo. Peppermint oil relaxes GI smooth muscle, and commonly is used for irritable bowel syndrome.

Six trials found reductions in nausea in women who took ginger products. ©Tasha/

SAN FRANCISCO — Multiple clinical trials have shown that both ginger and vitamin B₆ can safely help reduce the nausea and vomiting of “morning sickness” in pregnancy.

Cathi Dennehy, Pharm.D., reviewed the evidence for the efficacy and safety of the two supplements at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

▸ Ginger. Six randomized, controlled trials found significant reductions in nausea and vomiting during pregnancy in women who took powdered ginger, ginger syrup, or ginger extract products for 4–21 days. Four trials found greater reductions in nausea and vomiting, compared with placebo, and two trials found effects that were equivalent to treatment with 30 mg or 75 mg/day of vitamin B₆ (with no placebo arm in those studies).

The most common dose was 1 g/day of powdered ginger, which comes in capsules containing 250–500 mg each. Patients took divided doses b.i.d. or q.i.d. depending on the capsule size.

The studies included 26–291 women each. Four trials that included a total of 265 women found no increased risk of negative birth outcomes in the ginger groups. Most of the women in these studies used ginger during the first trimester of pregnancy, but some studies included women up to the 20th week of gestation and after the critical developmental stages, which might have diluted the findings regarding safety. A separate observational study that focused strictly on ginger use during the first trimester also found no increase in adverse events.

Side effects are rare but may include GI upset, heartburn, flatulence, or bloating. Much higher doses of ginger (2.5 g/day or higher) can produce antiplatelet effects.

Two previous studies—one in rats and the other an in vitro study—had raised some concerns about possible mutagenic properties or some increase in early embryonic loss. However, “there is quite a bit of evidence in clinical trials” to support the safety of ginger in pregnancy, said Dr. Dennehy of the university's School of Pharmacy.

▸ Vitamin B₆. Two randomized, controlled trials (with 59 and 342 patients, respectively) found that vitamin B₆ supplements worked significantly better than placebo to decrease severe nausea and vomiting in pregnancy or to decrease overall nausea scores and vomiting in the first 3 days of use.

Bendectin, a product that combined vitamin B₆, an antihistamine, and an anticholinergic, was pulled off the U.S. market in the early 1980s after lawsuits alleged that it caused limb deformities in children. Plaintiff victories on those charges were overturned on appeal. Moreover, late last year, the FDA took the unusual step of publishing a notice in the Federal Register stating that Bendectin had not been withdrawn from the market for safety or health reasons. The move was widely seen as an invitation for a pharmaceutical manufacturer to begin selling the drug again.

Today, a similar product called Diclectin is sold in Canada and combines vitamin B₆ with doxylamine. A meta-analysis of 170,000 exposures to Diclectin found no adverse effects on fetuses. “Overall, it looks like vitamin B₆ is a safe product to use” in pregnancy, Dr. Dennehy said.

Dr. Dennehy also reviewed the prospect of peppermint tea as a morning-sickness palliative. There are no trials of peppermint tea either in general use or during pregnancy, she said, but a small randomized controlled study of peppermint oil for postoperative pain found it to be more effective than placebo. Peppermint oil relaxes GI smooth muscle, and commonly is used for irritable bowel syndrome.

Six trials found reductions in nausea in women who took ginger products. ©Tasha/

SAN FRANCISCO — There's no quick way around the barriers faced by children who need mental health care, so pediatricians are developing a string of strategies to improve delivery of mental health services, Dr. Jane M. Foy said.

These strategies offer primary care physicians tools to remove impediments in the health care system, build physician competence in providing mental health care, and incrementally change practices to improve delivery of services, she said at the annual meeting of the American Academy of Pediatrics.

While primary care physicians have the advantages of ongoing relationships with children and families, opportunities for early intervention, and expertise in preventive care (among other strengths), physicians have varying comfort levels with mental health care, said Dr. Foy, chair of the AAP's Task Force on Mental Health and professor of pediatrics at Wake Forest University, Winston-Salem, N.C.

Primary care physicians are constrained by time (pediatric well-child visits average 18 minutes in length), lack of reimbursement for mental health services, variable access to mental health specialists, administrative barriers, and a reluctance by children and families to seek care for mental health problems.

The AAP's Task Force on Mental Health is offering the following tools to address these, some of which are based on successful programs around the country, Dr. Foy said.

▸ Facilitate system changes. A report to be published in the winter of 2007 will help primary care providers create changes in community-level systems.

This could include building relationships with local mental health professionals, creating protocols for the care of children with psychiatric emergencies, and developing a process for collaborating with school personnel.

One of the more promising strategies is to incorporate a mental health professional in the primary care setting, she said. The task force is creating a “PediaLink” module to describe this and other ways to build relationships with mental health specialists.

In September 2007 the AAP sent a new booklet to chapter leaders—Strategies for System Change in Children's Mental Health: A Chapter Action Kit—that's also available on the AAP Web site.

This can guide physicians in pursuing local and state improvements in reimbursement, establishing relationships with mental health professional organizations, and working with family advocacy groups to reduce stigma around mental health care. The AAP offered five $15,000 stipends to projects focusing on one of these areas.

The AAP and the American Academy of Child and Adolescent Psychiatrists (AACAP) created a position paper explaining the rationale for paying primary care physicians for mental health services, and jointly are lobbying insurers on the national level.

▸ Build competence. Core competencies for primary care physicians providing mental health care will be published in the journal Pediatrics in the next few months, Dr. Foy said.

The competencies were created by consensus of several AAP committees and have been endorsed by the AACAP, the American Board of Pediatrics, and the National Association of Pediatric Nurse Practitioners.

Among the competencies, primary care physicians should learn evidence-based, generic techniques that are useful across a wide range of mental health problems, “expand our comfort zone beyond attention-deficit/hyperactivity disorder to anxiety, depression, and substance abuse,” and apply chronic-care principles to children with mental health problems, she said.

▸ Incrementally change practices. In the spring of 2008, the AAP will publish algorithms proposing a process for providing mental health services in a primary care setting.

“We recognize that the process cannot be fully implemented until payment issues” are resolved, relationships with mental health professionals are in place, and clinicians are comfortable with mental health skills, she said.

Tools for screening children and families for mental health problems and for assessing functioning will be offered.

SAN FRANCISCO — There's no quick way around the barriers faced by children who need mental health care, so pediatricians are developing a string of strategies to improve delivery of mental health services, Dr. Jane M. Foy said.

These strategies offer primary care physicians tools to remove impediments in the health care system, build physician competence in providing mental health care, and incrementally change practices to improve delivery of services, she said at the annual meeting of the American Academy of Pediatrics.

While primary care physicians have the advantages of ongoing relationships with children and families, opportunities for early intervention, and expertise in preventive care (among other strengths), physicians have varying comfort levels with mental health care, said Dr. Foy, chair of the AAP's Task Force on Mental Health and professor of pediatrics at Wake Forest University, Winston-Salem, N.C.

Primary care physicians are constrained by time (pediatric well-child visits average 18 minutes in length), lack of reimbursement for mental health services, variable access to mental health specialists, administrative barriers, and a reluctance by children and families to seek care for mental health problems.

The AAP's Task Force on Mental Health is offering the following tools to address these, some of which are based on successful programs around the country, Dr. Foy said.

▸ Facilitate system changes. A report to be published in the winter of 2007 will help primary care providers create changes in community-level systems.

This could include building relationships with local mental health professionals, creating protocols for the care of children with psychiatric emergencies, and developing a process for collaborating with school personnel.

One of the more promising strategies is to incorporate a mental health professional in the primary care setting, she said. The task force is creating a “PediaLink” module to describe this and other ways to build relationships with mental health specialists.

In September 2007 the AAP sent a new booklet to chapter leaders—Strategies for System Change in Children's Mental Health: A Chapter Action Kit—that's also available on the AAP Web site.

This can guide physicians in pursuing local and state improvements in reimbursement, establishing relationships with mental health professional organizations, and working with family advocacy groups to reduce stigma around mental health care. The AAP offered five $15,000 stipends to projects focusing on one of these areas.

The AAP and the American Academy of Child and Adolescent Psychiatrists (AACAP) created a position paper explaining the rationale for paying primary care physicians for mental health services, and jointly are lobbying insurers on the national level.

▸ Build competence. Core competencies for primary care physicians providing mental health care will be published in the journal Pediatrics in the next few months, Dr. Foy said.

The competencies were created by consensus of several AAP committees and have been endorsed by the AACAP, the American Board of Pediatrics, and the National Association of Pediatric Nurse Practitioners.

Among the competencies, primary care physicians should learn evidence-based, generic techniques that are useful across a wide range of mental health problems, “expand our comfort zone beyond attention-deficit/hyperactivity disorder to anxiety, depression, and substance abuse,” and apply chronic-care principles to children with mental health problems, she said.

▸ Incrementally change practices. In the spring of 2008, the AAP will publish algorithms proposing a process for providing mental health services in a primary care setting.

“We recognize that the process cannot be fully implemented until payment issues” are resolved, relationships with mental health professionals are in place, and clinicians are comfortable with mental health skills, she said.

Tools for screening children and families for mental health problems and for assessing functioning will be offered.

SAN FRANCISCO — There's no quick way around the barriers faced by children who need mental health care, so pediatricians are developing a string of strategies to improve delivery of mental health services, Dr. Jane M. Foy said.

These strategies offer primary care physicians tools to remove impediments in the health care system, build physician competence in providing mental health care, and incrementally change practices to improve delivery of services, she said at the annual meeting of the American Academy of Pediatrics.

While primary care physicians have the advantages of ongoing relationships with children and families, opportunities for early intervention, and expertise in preventive care (among other strengths), physicians have varying comfort levels with mental health care, said Dr. Foy, chair of the AAP's Task Force on Mental Health and professor of pediatrics at Wake Forest University, Winston-Salem, N.C.

Primary care physicians are constrained by time (pediatric well-child visits average 18 minutes in length), lack of reimbursement for mental health services, variable access to mental health specialists, administrative barriers, and a reluctance by children and families to seek care for mental health problems.

The AAP's Task Force on Mental Health is offering the following tools to address these, some of which are based on successful programs around the country, Dr. Foy said.

▸ Facilitate system changes. A report to be published in the winter of 2007 will help primary care providers create changes in community-level systems.

This could include building relationships with local mental health professionals, creating protocols for the care of children with psychiatric emergencies, and developing a process for collaborating with school personnel.

One of the more promising strategies is to incorporate a mental health professional in the primary care setting, she said. The task force is creating a “PediaLink” module to describe this and other ways to build relationships with mental health specialists.

In September 2007 the AAP sent a new booklet to chapter leaders—Strategies for System Change in Children's Mental Health: A Chapter Action Kit—that's also available on the AAP Web site.

This can guide physicians in pursuing local and state improvements in reimbursement, establishing relationships with mental health professional organizations, and working with family advocacy groups to reduce stigma around mental health care. The AAP offered five $15,000 stipends to projects focusing on one of these areas.

The AAP and the American Academy of Child and Adolescent Psychiatrists (AACAP) created a position paper explaining the rationale for paying primary care physicians for mental health services, and jointly are lobbying insurers on the national level.

▸ Build competence. Core competencies for primary care physicians providing mental health care will be published in the journal Pediatrics in the next few months, Dr. Foy said.

The competencies were created by consensus of several AAP committees and have been endorsed by the AACAP, the American Board of Pediatrics, and the National Association of Pediatric Nurse Practitioners.

Among the competencies, primary care physicians should learn evidence-based, generic techniques that are useful across a wide range of mental health problems, “expand our comfort zone beyond attention-deficit/hyperactivity disorder to anxiety, depression, and substance abuse,” and apply chronic-care principles to children with mental health problems, she said.

▸ Incrementally change practices. In the spring of 2008, the AAP will publish algorithms proposing a process for providing mental health services in a primary care setting.

“We recognize that the process cannot be fully implemented until payment issues” are resolved, relationships with mental health professionals are in place, and clinicians are comfortable with mental health skills, she said.

Tools for screening children and families for mental health problems and for assessing functioning will be offered.