Commentary

Despite all its glamour and opportunities to write columns like this one, primary care does not attract as many clinicians as it needs to provide for the aging population. Some have proposed that this is because when learners rotate with us, they witness frustration with preauthorizations and physician-patient relationships poisoned by opioid addiction – not the intangible spiritual fulfillment of long-term relationships with people who share their lives with us.

In addition, many primary care providers have other competing interests that take them away from practice. This trend will likely increase as practitioners work beyond the age of 65 years but at reduced hours. These demands naturally decrease patient access and can theoretically lead to dissatisfaction, which is potentially devastating if we are reimbursed based upon satisfaction scores.

So, do reduced hours frustrate patients?

Laura Panattoni, Ph.D., and her colleagues at the Palo Alto Medical Foundation Research Institute, Mountain View, Calif., evaluated the relationship between physicians’ clinical time, continuity of care, access to care, and patient satisfaction with the physician (J. Gen. Intern. Med. 2015;30:327-33). The study was a cross-section survey of physicians in family and internal medicine and their patients.

The investigators found that greater office time was directly associated with increased continuity and access but with lower patient satisfaction scores. Restated, reduced clinical hours were associated with improved patient satisfaction.

These findings are interesting and important at many levels. First, they suggest that clinicians who choose less than a full-time clinical obligation can keep their patients happy. Second, we can hypothesize that what is lost in continuity and access is made up for in effective communication delivered by clinicians who are happy themselves. Third, practice redesign should not require full-time commitment to deliver on the satisfaction side of the equation. The world is clamoring for alternative care models where electronic “touches” alleviate the pressure for “patients in rooms.” Studies have shown that up to 93% of patients would select a physician who allows them to communicate with them electronically. About 450,000 patients will see a doctor through the Internet this year. UnitedHealth Group started covering telemedicine and plans to expand this to 20 million customers next year.

I personally spend one-third of my time seeing patients in rooms, but I am electronically and telephonically accessible to them every day at all times. Maybe this helps keep my patients happy, despite me not being in the office every day.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified, practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article. Follow Dr. Ebbert on Twitter @jonebbert.

Despite all its glamour and opportunities to write columns like this one, primary care does not attract as many clinicians as it needs to provide for the aging population. Some have proposed that this is because when learners rotate with us, they witness frustration with preauthorizations and physician-patient relationships poisoned by opioid addiction – not the intangible spiritual fulfillment of long-term relationships with people who share their lives with us.

In addition, many primary care providers have other competing interests that take them away from practice. This trend will likely increase as practitioners work beyond the age of 65 years but at reduced hours. These demands naturally decrease patient access and can theoretically lead to dissatisfaction, which is potentially devastating if we are reimbursed based upon satisfaction scores.

So, do reduced hours frustrate patients?

Laura Panattoni, Ph.D., and her colleagues at the Palo Alto Medical Foundation Research Institute, Mountain View, Calif., evaluated the relationship between physicians’ clinical time, continuity of care, access to care, and patient satisfaction with the physician (J. Gen. Intern. Med. 2015;30:327-33). The study was a cross-section survey of physicians in family and internal medicine and their patients.

The investigators found that greater office time was directly associated with increased continuity and access but with lower patient satisfaction scores. Restated, reduced clinical hours were associated with improved patient satisfaction.

These findings are interesting and important at many levels. First, they suggest that clinicians who choose less than a full-time clinical obligation can keep their patients happy. Second, we can hypothesize that what is lost in continuity and access is made up for in effective communication delivered by clinicians who are happy themselves. Third, practice redesign should not require full-time commitment to deliver on the satisfaction side of the equation. The world is clamoring for alternative care models where electronic “touches” alleviate the pressure for “patients in rooms.” Studies have shown that up to 93% of patients would select a physician who allows them to communicate with them electronically. About 450,000 patients will see a doctor through the Internet this year. UnitedHealth Group started covering telemedicine and plans to expand this to 20 million customers next year.

I personally spend one-third of my time seeing patients in rooms, but I am electronically and telephonically accessible to them every day at all times. Maybe this helps keep my patients happy, despite me not being in the office every day.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified, practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article. Follow Dr. Ebbert on Twitter @jonebbert.

Despite all its glamour and opportunities to write columns like this one, primary care does not attract as many clinicians as it needs to provide for the aging population. Some have proposed that this is because when learners rotate with us, they witness frustration with preauthorizations and physician-patient relationships poisoned by opioid addiction – not the intangible spiritual fulfillment of long-term relationships with people who share their lives with us.

In addition, many primary care providers have other competing interests that take them away from practice. This trend will likely increase as practitioners work beyond the age of 65 years but at reduced hours. These demands naturally decrease patient access and can theoretically lead to dissatisfaction, which is potentially devastating if we are reimbursed based upon satisfaction scores.

So, do reduced hours frustrate patients?

Laura Panattoni, Ph.D., and her colleagues at the Palo Alto Medical Foundation Research Institute, Mountain View, Calif., evaluated the relationship between physicians’ clinical time, continuity of care, access to care, and patient satisfaction with the physician (J. Gen. Intern. Med. 2015;30:327-33). The study was a cross-section survey of physicians in family and internal medicine and their patients.

The investigators found that greater office time was directly associated with increased continuity and access but with lower patient satisfaction scores. Restated, reduced clinical hours were associated with improved patient satisfaction.

These findings are interesting and important at many levels. First, they suggest that clinicians who choose less than a full-time clinical obligation can keep their patients happy. Second, we can hypothesize that what is lost in continuity and access is made up for in effective communication delivered by clinicians who are happy themselves. Third, practice redesign should not require full-time commitment to deliver on the satisfaction side of the equation. The world is clamoring for alternative care models where electronic “touches” alleviate the pressure for “patients in rooms.” Studies have shown that up to 93% of patients would select a physician who allows them to communicate with them electronically. About 450,000 patients will see a doctor through the Internet this year. UnitedHealth Group started covering telemedicine and plans to expand this to 20 million customers next year.

I personally spend one-third of my time seeing patients in rooms, but I am electronically and telephonically accessible to them every day at all times. Maybe this helps keep my patients happy, despite me not being in the office every day.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified, practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article. Follow Dr. Ebbert on Twitter @jonebbert.

For those of us who appreciate the value of science and accept its limitations, it is sometimes difficult to understand how parents can choose to not immunize their children against serious and life-threatening diseases. To some extent, the explanation may be that immunizations simply have become victims of their own success.

How many adults have a relative, friend, or neighbor whose child has died as the result of bacterial meningitis or epiglottitis? They might have had a friend whose month-long cough was eventually diagnosed as whooping cough, but how many parents know of an infant who succumbed to pertussis? If you were trained in the last decade, you may not have had first-hand experience with most of the diseases for which we now have immunizations.

Reading a recent review of a new biography of Jonas Salk triggered a stream of memories of what it was like when polio descended on the landscape of North America – unchecked by an effective immunization. Moving through communities, choosing victims seemingly at random, it was every parent’s nightmare.

I grew up in a small town in New York State, so small that its inhabitants refer to it as a “village.” Everyone in Pleasantville knew at least one family that had been touched by polio. I don’t recall being aware of anyone in my family’s extended network of acquaintances who had died of the disease, but I suspect there may have been some fatalities that my parents avoided discussing in my presence. But I knew it was a disease with a significant mortality rate, and I knew of children and adults who had luckily survived several weeks or months in an iron lung. One of my parents’ closest friends walked with a limp as a result of polio.

There was rumor in town that all five members in one family had contracted polio and incredibly survived. Their cat had allegedly died of the disease. Our community was said to be particularly vulnerable because we had a public pool. This gift from the federal government’s Works Progress Administration provided a multi-lane superhighway for the virus to spread from child to child.

Even as a young child, I could sense that a blanket of fear hung over our little village during the summer when the disease was at its most prevalent. Now, as a parent, I am surprised how well my own parents disguised the fears that they and their peers must have harbored. My sister and I were still allowed to go swimming at the pool on the hottest days, but we knew that there were other families who stayed away.

When a vaccine trial began at our school, there was no question that we would participate. In fact, I don’t recall bringing home any permission slips to be signed. Nor do I remember hearing of any families who had opted out. We always wondered whether we had received the real vaccine or the placebo. But when the trials were over and the real vaccine was available, what parent in his or her right mind would even consider depriving his or her child from protection against this scourge that had taken up residence among us? I’m sure that Dr. Blum, my pediatrician, never needed to spend more than 30 seconds trying to convince my parents or any other parents, for that matter, of the need to vaccinate against polio.

My childhood ended before the development of the vaccines against the other common viral illnesses, and as a result I contracted and survived measles, mumps, rubella, and varicella. Of course, there must have been a few children who died of the diseases that had left me unscathed, but the number of fatalities was so small that I’m sure my parents would have wondered why we would need vaccines for these “usual diseases of childhood.”

But polio was different, and while it pales in comparison to Ebola, polio and its successful eradication created a generation of parents with a respect for science and the value of immunization. However, that generation has passed, and with it the stories they could have told the parents of today. Unfortunately, vaccine refusers seem to be immune to education and deaf to the lessons history can teach. I suspect that they would have foolishly ignored my parents’ stories about polio as just so much when-I-was-your-age mumbling.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.” E-mail him at pdnews@frontlinemedcom.com.

For those of us who appreciate the value of science and accept its limitations, it is sometimes difficult to understand how parents can choose to not immunize their children against serious and life-threatening diseases. To some extent, the explanation may be that immunizations simply have become victims of their own success.

How many adults have a relative, friend, or neighbor whose child has died as the result of bacterial meningitis or epiglottitis? They might have had a friend whose month-long cough was eventually diagnosed as whooping cough, but how many parents know of an infant who succumbed to pertussis? If you were trained in the last decade, you may not have had first-hand experience with most of the diseases for which we now have immunizations.

Reading a recent review of a new biography of Jonas Salk triggered a stream of memories of what it was like when polio descended on the landscape of North America – unchecked by an effective immunization. Moving through communities, choosing victims seemingly at random, it was every parent’s nightmare.

I grew up in a small town in New York State, so small that its inhabitants refer to it as a “village.” Everyone in Pleasantville knew at least one family that had been touched by polio. I don’t recall being aware of anyone in my family’s extended network of acquaintances who had died of the disease, but I suspect there may have been some fatalities that my parents avoided discussing in my presence. But I knew it was a disease with a significant mortality rate, and I knew of children and adults who had luckily survived several weeks or months in an iron lung. One of my parents’ closest friends walked with a limp as a result of polio.

There was rumor in town that all five members in one family had contracted polio and incredibly survived. Their cat had allegedly died of the disease. Our community was said to be particularly vulnerable because we had a public pool. This gift from the federal government’s Works Progress Administration provided a multi-lane superhighway for the virus to spread from child to child.

Even as a young child, I could sense that a blanket of fear hung over our little village during the summer when the disease was at its most prevalent. Now, as a parent, I am surprised how well my own parents disguised the fears that they and their peers must have harbored. My sister and I were still allowed to go swimming at the pool on the hottest days, but we knew that there were other families who stayed away.

When a vaccine trial began at our school, there was no question that we would participate. In fact, I don’t recall bringing home any permission slips to be signed. Nor do I remember hearing of any families who had opted out. We always wondered whether we had received the real vaccine or the placebo. But when the trials were over and the real vaccine was available, what parent in his or her right mind would even consider depriving his or her child from protection against this scourge that had taken up residence among us? I’m sure that Dr. Blum, my pediatrician, never needed to spend more than 30 seconds trying to convince my parents or any other parents, for that matter, of the need to vaccinate against polio.

My childhood ended before the development of the vaccines against the other common viral illnesses, and as a result I contracted and survived measles, mumps, rubella, and varicella. Of course, there must have been a few children who died of the diseases that had left me unscathed, but the number of fatalities was so small that I’m sure my parents would have wondered why we would need vaccines for these “usual diseases of childhood.”

But polio was different, and while it pales in comparison to Ebola, polio and its successful eradication created a generation of parents with a respect for science and the value of immunization. However, that generation has passed, and with it the stories they could have told the parents of today. Unfortunately, vaccine refusers seem to be immune to education and deaf to the lessons history can teach. I suspect that they would have foolishly ignored my parents’ stories about polio as just so much when-I-was-your-age mumbling.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.” E-mail him at pdnews@frontlinemedcom.com.

For those of us who appreciate the value of science and accept its limitations, it is sometimes difficult to understand how parents can choose to not immunize their children against serious and life-threatening diseases. To some extent, the explanation may be that immunizations simply have become victims of their own success.

How many adults have a relative, friend, or neighbor whose child has died as the result of bacterial meningitis or epiglottitis? They might have had a friend whose month-long cough was eventually diagnosed as whooping cough, but how many parents know of an infant who succumbed to pertussis? If you were trained in the last decade, you may not have had first-hand experience with most of the diseases for which we now have immunizations.

Reading a recent review of a new biography of Jonas Salk triggered a stream of memories of what it was like when polio descended on the landscape of North America – unchecked by an effective immunization. Moving through communities, choosing victims seemingly at random, it was every parent’s nightmare.

I grew up in a small town in New York State, so small that its inhabitants refer to it as a “village.” Everyone in Pleasantville knew at least one family that had been touched by polio. I don’t recall being aware of anyone in my family’s extended network of acquaintances who had died of the disease, but I suspect there may have been some fatalities that my parents avoided discussing in my presence. But I knew it was a disease with a significant mortality rate, and I knew of children and adults who had luckily survived several weeks or months in an iron lung. One of my parents’ closest friends walked with a limp as a result of polio.

There was rumor in town that all five members in one family had contracted polio and incredibly survived. Their cat had allegedly died of the disease. Our community was said to be particularly vulnerable because we had a public pool. This gift from the federal government’s Works Progress Administration provided a multi-lane superhighway for the virus to spread from child to child.

Even as a young child, I could sense that a blanket of fear hung over our little village during the summer when the disease was at its most prevalent. Now, as a parent, I am surprised how well my own parents disguised the fears that they and their peers must have harbored. My sister and I were still allowed to go swimming at the pool on the hottest days, but we knew that there were other families who stayed away.

When a vaccine trial began at our school, there was no question that we would participate. In fact, I don’t recall bringing home any permission slips to be signed. Nor do I remember hearing of any families who had opted out. We always wondered whether we had received the real vaccine or the placebo. But when the trials were over and the real vaccine was available, what parent in his or her right mind would even consider depriving his or her child from protection against this scourge that had taken up residence among us? I’m sure that Dr. Blum, my pediatrician, never needed to spend more than 30 seconds trying to convince my parents or any other parents, for that matter, of the need to vaccinate against polio.

My childhood ended before the development of the vaccines against the other common viral illnesses, and as a result I contracted and survived measles, mumps, rubella, and varicella. Of course, there must have been a few children who died of the diseases that had left me unscathed, but the number of fatalities was so small that I’m sure my parents would have wondered why we would need vaccines for these “usual diseases of childhood.”

But polio was different, and while it pales in comparison to Ebola, polio and its successful eradication created a generation of parents with a respect for science and the value of immunization. However, that generation has passed, and with it the stories they could have told the parents of today. Unfortunately, vaccine refusers seem to be immune to education and deaf to the lessons history can teach. I suspect that they would have foolishly ignored my parents’ stories about polio as just so much when-I-was-your-age mumbling.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.” E-mail him at pdnews@frontlinemedcom.com.

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

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

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

Research findings

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

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

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

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

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

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

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

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

In practice

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

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

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

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

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

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

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

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

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

Research findings

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

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

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

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

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

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

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

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

In practice

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

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

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

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

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

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

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

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

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

Research findings

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

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

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

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

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

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

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

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

In practice

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Dr. Powell said he had no relevant financial disclosures or conflicts of interest. E-mail him at pdnews@frontlinemedcom.com.

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

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

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

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

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

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

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

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

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

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

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

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Dr. Powell said he had no relevant financial disclosures or conflicts of interest. E-mail him at pdnews@frontlinemedcom.com.

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

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

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

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

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

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

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

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

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

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

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

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Dr. Powell said he had no relevant financial disclosures or conflicts of interest. E-mail him at pdnews@frontlinemedcom.com.

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

Case summary

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

Discussion

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

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

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

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

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

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

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

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

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

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

Case follow-up

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

Dr. Rettew is an associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. Follow him on Twitter @pedipsych. E-mail him at pdnews@frontlinemedcom.com.

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

Case summary

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

Discussion

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

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

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

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

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

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

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

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

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

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

Case follow-up

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

Dr. Rettew is an associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. Follow him on Twitter @pedipsych. E-mail him at pdnews@frontlinemedcom.com.

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

Case summary

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

Discussion

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

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

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

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

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

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

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

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

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

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

Case follow-up

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

Dr. Rettew is an associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. Follow him on Twitter @pedipsych. E-mail him at pdnews@frontlinemedcom.com.