Pediatrics

Levetiracetam may be a superior initial treatment for infants with nonsyndromic epilepsy, according to a multicenter, prospective, observational study published online ahead of print February 12 in JAMA Pediatrics.

“Our findings suggest that levetiracetam has superior effectiveness, compared with phenobarbital, as initial monotherapy for nonsyndromic epilepsy in infants,” said Zachary Grinspan, MD, Director of the Pediatric Epilepsy Program at Cornell University, New York, and colleagues. “We estimate that for every 100 infants with epilepsy treated with levetiracetam instead of phenobarbital, 44 infants would be free from monotherapy failure instead of 16.”

—Ian Lacy

Suggested Reading

Grinspan ZM, Shellhaas RA, Coryell J, et al. Comparative effectiveness of levetiracetam vs phenobarbital for infantile epilepsy. JAMA Pediatr. 2018 Feb 12 [Epub ahead of print].

Levetiracetam may be a superior initial treatment for infants with nonsyndromic epilepsy, according to a multicenter, prospective, observational study published online ahead of print February 12 in JAMA Pediatrics.

“Our findings suggest that levetiracetam has superior effectiveness, compared with phenobarbital, as initial monotherapy for nonsyndromic epilepsy in infants,” said Zachary Grinspan, MD, Director of the Pediatric Epilepsy Program at Cornell University, New York, and colleagues. “We estimate that for every 100 infants with epilepsy treated with levetiracetam instead of phenobarbital, 44 infants would be free from monotherapy failure instead of 16.”

—Ian Lacy

Suggested Reading

Grinspan ZM, Shellhaas RA, Coryell J, et al. Comparative effectiveness of levetiracetam vs phenobarbital for infantile epilepsy. JAMA Pediatr. 2018 Feb 12 [Epub ahead of print].

Levetiracetam may be a superior initial treatment for infants with nonsyndromic epilepsy, according to a multicenter, prospective, observational study published online ahead of print February 12 in JAMA Pediatrics.

“Our findings suggest that levetiracetam has superior effectiveness, compared with phenobarbital, as initial monotherapy for nonsyndromic epilepsy in infants,” said Zachary Grinspan, MD, Director of the Pediatric Epilepsy Program at Cornell University, New York, and colleagues. “We estimate that for every 100 infants with epilepsy treated with levetiracetam instead of phenobarbital, 44 infants would be free from monotherapy failure instead of 16.”

—Ian Lacy

Suggested Reading

Grinspan ZM, Shellhaas RA, Coryell J, et al. Comparative effectiveness of levetiracetam vs phenobarbital for infantile epilepsy. JAMA Pediatr. 2018 Feb 12 [Epub ahead of print].

SAN DIEGO—Newer oral and IV disease-modifying therapies (DMTs) for multiple sclerosis (MS) increasingly are used in children, according to data presented at the ACTRIMS 2018 Forum. These DMTs often are second-line therapies, but some patients receive them as first-line treatment.

“Newer DMTs … are being started more often over time at clinics participating in the US Network of Pediatric MS Centers,” said Kristen M. Krysko, MD, Clinical Fellow at the University of California, San Francisco School of Medicine, and colleagues.

Treatment Challenges

About 5% of patients with MS develop symptoms before age 18. “Treatment of pediatric MS is challenging, given high relapse rates and the lack of safety and efficacy data for DMTs in children,” Dr. Krysko and colleagues said. “Conventionally, first-line treatments for pediatric MS include interferon beta and glatiramer acetate, but these agents may be poorly tolerated, since they are given by injection, and may not adequately control the disease. Those with breakthrough events require escalation to more potent agents, which are increasingly used off-label in pediatric MS despite limited data about safety or efficacy in children.”

To characterize the use and safety of newer DMTs in children with MS and clinically isolated syndrome (CIS), Dr. Krysko and colleagues conducted a retrospective cohort study of prospectively collected data at 12 clinics participating in the US Network of Pediatric MS Centers as of August 2017.

The researchers examined patterns of newer DMT use and newer DMT side effects. They classified DMTs as injectable (ie, glatiramer acetate and beta-interferons), oral (ie, dimethyl fumarate, fingolimod, and teriflunomide), or IV (ie, natalizumab, rituximab, alemtuzumab, and ocrelizumab). The researchers considered dimethyl fumarate, fingolimod, teriflunomide, natalizumab, rituximab, ocrelizumab, alemtuzumab, and daclizumab to be newer therapies.

The cohort included more than 1,000 patients with MS or CIS. In all, 618 patients had received a DMT before age 18 (587 patients with a diagnosis of MS at last follow-up and 31 patients with a diagnosis of CIS at last follow-up). About 66% were female, and patients’ mean age at MS onset was approximately 13.

The Use of Oral and IV DMTs

From 2008 to 2017, use of newer oral and IV DMTs increased overall and as first-line therapy in patients younger than 12 and in patients 12 or older. Of the 618 patients who received a DMT before age 18, 259 (42%) received a newer DMT, and 104 (17%) received a newer DMT as a first-line therapy.

Newer DMTs used in patients before age 18 included natalizumab in 101 patients, dimethyl fumarate in 100 patients, rituximab in 57 patients, fingolimod in 37 patients, daclizumab in five patients, and teriflunomide in three patients. Newer DMTs used as first-line therapy in patients before age 18 included dimethyl fumarate in 36 patients, natalizumab in 30 patients, rituximab in 22 patients, fingolimod in 14 patients, and teriflunomide in two patients.

Patients were exposed to dimethyl fumarate for 149 person-years, natalizumab for 140 person-years, rituximab for 75 person-years, fingolimod for 55 person-years, daclizumab for 10 person-years, and teriflunomide for one person-year.

Randomized controlled trials of the efficacy of DMTs in children with MS are ongoing. Future studies may explore predictors of newer DMT use in children with MS, the researchers said.

—Jake Remaly

SAN DIEGO—Newer oral and IV disease-modifying therapies (DMTs) for multiple sclerosis (MS) increasingly are used in children, according to data presented at the ACTRIMS 2018 Forum. These DMTs often are second-line therapies, but some patients receive them as first-line treatment.

“Newer DMTs … are being started more often over time at clinics participating in the US Network of Pediatric MS Centers,” said Kristen M. Krysko, MD, Clinical Fellow at the University of California, San Francisco School of Medicine, and colleagues.

Treatment Challenges

About 5% of patients with MS develop symptoms before age 18. “Treatment of pediatric MS is challenging, given high relapse rates and the lack of safety and efficacy data for DMTs in children,” Dr. Krysko and colleagues said. “Conventionally, first-line treatments for pediatric MS include interferon beta and glatiramer acetate, but these agents may be poorly tolerated, since they are given by injection, and may not adequately control the disease. Those with breakthrough events require escalation to more potent agents, which are increasingly used off-label in pediatric MS despite limited data about safety or efficacy in children.”

To characterize the use and safety of newer DMTs in children with MS and clinically isolated syndrome (CIS), Dr. Krysko and colleagues conducted a retrospective cohort study of prospectively collected data at 12 clinics participating in the US Network of Pediatric MS Centers as of August 2017.

The researchers examined patterns of newer DMT use and newer DMT side effects. They classified DMTs as injectable (ie, glatiramer acetate and beta-interferons), oral (ie, dimethyl fumarate, fingolimod, and teriflunomide), or IV (ie, natalizumab, rituximab, alemtuzumab, and ocrelizumab). The researchers considered dimethyl fumarate, fingolimod, teriflunomide, natalizumab, rituximab, ocrelizumab, alemtuzumab, and daclizumab to be newer therapies.

The cohort included more than 1,000 patients with MS or CIS. In all, 618 patients had received a DMT before age 18 (587 patients with a diagnosis of MS at last follow-up and 31 patients with a diagnosis of CIS at last follow-up). About 66% were female, and patients’ mean age at MS onset was approximately 13.

The Use of Oral and IV DMTs

From 2008 to 2017, use of newer oral and IV DMTs increased overall and as first-line therapy in patients younger than 12 and in patients 12 or older. Of the 618 patients who received a DMT before age 18, 259 (42%) received a newer DMT, and 104 (17%) received a newer DMT as a first-line therapy.

Newer DMTs used in patients before age 18 included natalizumab in 101 patients, dimethyl fumarate in 100 patients, rituximab in 57 patients, fingolimod in 37 patients, daclizumab in five patients, and teriflunomide in three patients. Newer DMTs used as first-line therapy in patients before age 18 included dimethyl fumarate in 36 patients, natalizumab in 30 patients, rituximab in 22 patients, fingolimod in 14 patients, and teriflunomide in two patients.

Patients were exposed to dimethyl fumarate for 149 person-years, natalizumab for 140 person-years, rituximab for 75 person-years, fingolimod for 55 person-years, daclizumab for 10 person-years, and teriflunomide for one person-year.

Randomized controlled trials of the efficacy of DMTs in children with MS are ongoing. Future studies may explore predictors of newer DMT use in children with MS, the researchers said.

—Jake Remaly

SAN DIEGO—Newer oral and IV disease-modifying therapies (DMTs) for multiple sclerosis (MS) increasingly are used in children, according to data presented at the ACTRIMS 2018 Forum. These DMTs often are second-line therapies, but some patients receive them as first-line treatment.

“Newer DMTs … are being started more often over time at clinics participating in the US Network of Pediatric MS Centers,” said Kristen M. Krysko, MD, Clinical Fellow at the University of California, San Francisco School of Medicine, and colleagues.

Treatment Challenges

About 5% of patients with MS develop symptoms before age 18. “Treatment of pediatric MS is challenging, given high relapse rates and the lack of safety and efficacy data for DMTs in children,” Dr. Krysko and colleagues said. “Conventionally, first-line treatments for pediatric MS include interferon beta and glatiramer acetate, but these agents may be poorly tolerated, since they are given by injection, and may not adequately control the disease. Those with breakthrough events require escalation to more potent agents, which are increasingly used off-label in pediatric MS despite limited data about safety or efficacy in children.”

To characterize the use and safety of newer DMTs in children with MS and clinically isolated syndrome (CIS), Dr. Krysko and colleagues conducted a retrospective cohort study of prospectively collected data at 12 clinics participating in the US Network of Pediatric MS Centers as of August 2017.

The researchers examined patterns of newer DMT use and newer DMT side effects. They classified DMTs as injectable (ie, glatiramer acetate and beta-interferons), oral (ie, dimethyl fumarate, fingolimod, and teriflunomide), or IV (ie, natalizumab, rituximab, alemtuzumab, and ocrelizumab). The researchers considered dimethyl fumarate, fingolimod, teriflunomide, natalizumab, rituximab, ocrelizumab, alemtuzumab, and daclizumab to be newer therapies.

The cohort included more than 1,000 patients with MS or CIS. In all, 618 patients had received a DMT before age 18 (587 patients with a diagnosis of MS at last follow-up and 31 patients with a diagnosis of CIS at last follow-up). About 66% were female, and patients’ mean age at MS onset was approximately 13.

The Use of Oral and IV DMTs

From 2008 to 2017, use of newer oral and IV DMTs increased overall and as first-line therapy in patients younger than 12 and in patients 12 or older. Of the 618 patients who received a DMT before age 18, 259 (42%) received a newer DMT, and 104 (17%) received a newer DMT as a first-line therapy.

Newer DMTs used in patients before age 18 included natalizumab in 101 patients, dimethyl fumarate in 100 patients, rituximab in 57 patients, fingolimod in 37 patients, daclizumab in five patients, and teriflunomide in three patients. Newer DMTs used as first-line therapy in patients before age 18 included dimethyl fumarate in 36 patients, natalizumab in 30 patients, rituximab in 22 patients, fingolimod in 14 patients, and teriflunomide in two patients.

Patients were exposed to dimethyl fumarate for 149 person-years, natalizumab for 140 person-years, rituximab for 75 person-years, fingolimod for 55 person-years, daclizumab for 10 person-years, and teriflunomide for one person-year.

Randomized controlled trials of the efficacy of DMTs in children with MS are ongoing. Future studies may explore predictors of newer DMT use in children with MS, the researchers said.

—Jake Remaly

2018 BMT Tandem Meetings

SALT LAKE CITY—Researchers say they have identified prognostic biomarkers for chronic graft-vs-host disease (cGVHD) in children.

The group found that recent thymic emigrants (RTEs) and regulatory T cells expressing CD31 and CD45RA (Treg RTEs) were significantly lower at day 100 after transplant in patients who developed cGVHD.

Because prior research indicated that RTEs are higher in adults with cGVHD, the researchers concluded that thymic function may play a bigger role in cGVHD development for children than for adults.

Geoff D.E. Cuvelier, MD, of CancerCare Manitoba in Winnipeg, Canada, presented these findings at the 2018 BMT Tandem Meetings (abstract 104).

“Our group became interested in these populations of recent thymic emigrants when 2 adult studies^1,2 . . . showed that higher proportions of recent thymic emigrants at day 100 were prognostic for the development of chronic graft-vs-host disease,” Dr Cuvelier said.

This led his group to evaluate whether RTEs (CD4⁺CD45RA⁺CD31⁺ T cells), as well as Treg RTEs—Tregs (CD4⁺CD25⁺CD127^Low) that co-express naïve and recently emigrated markers (CD45RA⁺CD31⁺)—are prognostic for pediatric cGVHD at day 100 after allogeneic hematopoietic stem cell transplant (allo-HSCT).

The researchers’ study enrolled patients younger than 18 years of age who underwent allo-HSCT to treat malignant and non-malignant diseases. There were 144 patients who had 1 year of follow-up after allo-HSCT.

Thirty-seven of the patients (25.7%) had cGVHD, and 34 (23.6%) had late acute GVHD (post-day 100). The remaining 73 patients (50.7%) had neither cGVHD nor late acute GVHD, so they served as controls.

Twenty cases of cGVHD were severe, 12 were moderate, and 5 were mild. cGVHD was initially diagnosed at a mean of 192 days post-transplant. The median number of organ systems involved was 3 (range, 1-6). Seventeen patients (46%) had overlap syndrome.

The researchers found that RTEs as a percentage of CD4 T cells were significantly lower at day 100 in patients with cGVHD than in controls—7.8% and 13.5%, respectively (P=0.007). The difference between controls and patients with late acute GVHD was not significant—13.5% and 9.4%, respectively (P=0.08).

Treg RTEs as a percentage of all Tregs were also significantly lower at day 100 in patients with cGVHD than in controls—6.4% and 13.2%, respectively (P=0.002). Again, the difference between controls and patients with late acute GVHD was not significant—13.2% and 9.1%, respectively (P=0.06).

However, further analysis revealed that percentages of RTEs and Treg RTEs were significantly lower at day 100 in patients who developed any type of GVHD after day 100.

The percentage of RTEs was 13.5% in controls and 8.5% in patients with any GVHD after day 100 (P=0.009). The percentage of Treg RTEs was 13.2% and 7.6%, respectively (P=0.004).

“Both recent thymic emigrants and Treg RTEs at day 100 are prognostic biomarkers for chronic graft-vs-host disease in children in this large, multi-institutional, prospective trial,” Dr Cuvelier said in closing.

“Unlike adults, in children, RTEs are proportionally lower, not higher, in patients that later develop chronic GVHD compared to no chronic GVHD. This may suggest that thymic dysfunction and thymic output may play a greater role in chronic GVHD development in children compared to adults.”

To expand upon this research, Dr Cuvelier and his colleagues are planning to begin model building using prognostic cellular and plasma biomarkers at day 100 to determine high-risk profiles for cGVHD.

1. Greinix HT et al; CD19+CD21low B Cells and CD4+CD45RA+CD31+ T Cells Correlate with First Diagnosis of Chronic Graft-versus-Host Disease. BBMT 2015; 21(2):250-258.

2. Li AM et al. An Early Naïve T Cell Population Lacking PD1 Expression at Day 100 As A Prognostic Biomarker of Chronic GVHD. TSS 2017; 210.6.

2018 BMT Tandem Meetings

SALT LAKE CITY—Researchers say they have identified prognostic biomarkers for chronic graft-vs-host disease (cGVHD) in children.

The group found that recent thymic emigrants (RTEs) and regulatory T cells expressing CD31 and CD45RA (Treg RTEs) were significantly lower at day 100 after transplant in patients who developed cGVHD.

Because prior research indicated that RTEs are higher in adults with cGVHD, the researchers concluded that thymic function may play a bigger role in cGVHD development for children than for adults.

Geoff D.E. Cuvelier, MD, of CancerCare Manitoba in Winnipeg, Canada, presented these findings at the 2018 BMT Tandem Meetings (abstract 104).

“Our group became interested in these populations of recent thymic emigrants when 2 adult studies^1,2 . . . showed that higher proportions of recent thymic emigrants at day 100 were prognostic for the development of chronic graft-vs-host disease,” Dr Cuvelier said.

This led his group to evaluate whether RTEs (CD4⁺CD45RA⁺CD31⁺ T cells), as well as Treg RTEs—Tregs (CD4⁺CD25⁺CD127^Low) that co-express naïve and recently emigrated markers (CD45RA⁺CD31⁺)—are prognostic for pediatric cGVHD at day 100 after allogeneic hematopoietic stem cell transplant (allo-HSCT).

The researchers’ study enrolled patients younger than 18 years of age who underwent allo-HSCT to treat malignant and non-malignant diseases. There were 144 patients who had 1 year of follow-up after allo-HSCT.

Thirty-seven of the patients (25.7%) had cGVHD, and 34 (23.6%) had late acute GVHD (post-day 100). The remaining 73 patients (50.7%) had neither cGVHD nor late acute GVHD, so they served as controls.

Twenty cases of cGVHD were severe, 12 were moderate, and 5 were mild. cGVHD was initially diagnosed at a mean of 192 days post-transplant. The median number of organ systems involved was 3 (range, 1-6). Seventeen patients (46%) had overlap syndrome.

The researchers found that RTEs as a percentage of CD4 T cells were significantly lower at day 100 in patients with cGVHD than in controls—7.8% and 13.5%, respectively (P=0.007). The difference between controls and patients with late acute GVHD was not significant—13.5% and 9.4%, respectively (P=0.08).

Treg RTEs as a percentage of all Tregs were also significantly lower at day 100 in patients with cGVHD than in controls—6.4% and 13.2%, respectively (P=0.002). Again, the difference between controls and patients with late acute GVHD was not significant—13.2% and 9.1%, respectively (P=0.06).

However, further analysis revealed that percentages of RTEs and Treg RTEs were significantly lower at day 100 in patients who developed any type of GVHD after day 100.

The percentage of RTEs was 13.5% in controls and 8.5% in patients with any GVHD after day 100 (P=0.009). The percentage of Treg RTEs was 13.2% and 7.6%, respectively (P=0.004).

“Both recent thymic emigrants and Treg RTEs at day 100 are prognostic biomarkers for chronic graft-vs-host disease in children in this large, multi-institutional, prospective trial,” Dr Cuvelier said in closing.

“Unlike adults, in children, RTEs are proportionally lower, not higher, in patients that later develop chronic GVHD compared to no chronic GVHD. This may suggest that thymic dysfunction and thymic output may play a greater role in chronic GVHD development in children compared to adults.”

To expand upon this research, Dr Cuvelier and his colleagues are planning to begin model building using prognostic cellular and plasma biomarkers at day 100 to determine high-risk profiles for cGVHD.

1. Greinix HT et al; CD19+CD21low B Cells and CD4+CD45RA+CD31+ T Cells Correlate with First Diagnosis of Chronic Graft-versus-Host Disease. BBMT 2015; 21(2):250-258.

2. Li AM et al. An Early Naïve T Cell Population Lacking PD1 Expression at Day 100 As A Prognostic Biomarker of Chronic GVHD. TSS 2017; 210.6.

2018 BMT Tandem Meetings

SALT LAKE CITY—Researchers say they have identified prognostic biomarkers for chronic graft-vs-host disease (cGVHD) in children.

The group found that recent thymic emigrants (RTEs) and regulatory T cells expressing CD31 and CD45RA (Treg RTEs) were significantly lower at day 100 after transplant in patients who developed cGVHD.

Because prior research indicated that RTEs are higher in adults with cGVHD, the researchers concluded that thymic function may play a bigger role in cGVHD development for children than for adults.

Geoff D.E. Cuvelier, MD, of CancerCare Manitoba in Winnipeg, Canada, presented these findings at the 2018 BMT Tandem Meetings (abstract 104).

“Our group became interested in these populations of recent thymic emigrants when 2 adult studies^1,2 . . . showed that higher proportions of recent thymic emigrants at day 100 were prognostic for the development of chronic graft-vs-host disease,” Dr Cuvelier said.

This led his group to evaluate whether RTEs (CD4⁺CD45RA⁺CD31⁺ T cells), as well as Treg RTEs—Tregs (CD4⁺CD25⁺CD127^Low) that co-express naïve and recently emigrated markers (CD45RA⁺CD31⁺)—are prognostic for pediatric cGVHD at day 100 after allogeneic hematopoietic stem cell transplant (allo-HSCT).

The researchers’ study enrolled patients younger than 18 years of age who underwent allo-HSCT to treat malignant and non-malignant diseases. There were 144 patients who had 1 year of follow-up after allo-HSCT.

Thirty-seven of the patients (25.7%) had cGVHD, and 34 (23.6%) had late acute GVHD (post-day 100). The remaining 73 patients (50.7%) had neither cGVHD nor late acute GVHD, so they served as controls.

Twenty cases of cGVHD were severe, 12 were moderate, and 5 were mild. cGVHD was initially diagnosed at a mean of 192 days post-transplant. The median number of organ systems involved was 3 (range, 1-6). Seventeen patients (46%) had overlap syndrome.

The researchers found that RTEs as a percentage of CD4 T cells were significantly lower at day 100 in patients with cGVHD than in controls—7.8% and 13.5%, respectively (P=0.007). The difference between controls and patients with late acute GVHD was not significant—13.5% and 9.4%, respectively (P=0.08).

Treg RTEs as a percentage of all Tregs were also significantly lower at day 100 in patients with cGVHD than in controls—6.4% and 13.2%, respectively (P=0.002). Again, the difference between controls and patients with late acute GVHD was not significant—13.2% and 9.1%, respectively (P=0.06).

However, further analysis revealed that percentages of RTEs and Treg RTEs were significantly lower at day 100 in patients who developed any type of GVHD after day 100.

The percentage of RTEs was 13.5% in controls and 8.5% in patients with any GVHD after day 100 (P=0.009). The percentage of Treg RTEs was 13.2% and 7.6%, respectively (P=0.004).

“Both recent thymic emigrants and Treg RTEs at day 100 are prognostic biomarkers for chronic graft-vs-host disease in children in this large, multi-institutional, prospective trial,” Dr Cuvelier said in closing.

“Unlike adults, in children, RTEs are proportionally lower, not higher, in patients that later develop chronic GVHD compared to no chronic GVHD. This may suggest that thymic dysfunction and thymic output may play a greater role in chronic GVHD development in children compared to adults.”

To expand upon this research, Dr Cuvelier and his colleagues are planning to begin model building using prognostic cellular and plasma biomarkers at day 100 to determine high-risk profiles for cGVHD.

1. Greinix HT et al; CD19+CD21low B Cells and CD4+CD45RA+CD31+ T Cells Correlate with First Diagnosis of Chronic Graft-versus-Host Disease. BBMT 2015; 21(2):250-258.

2. Li AM et al. An Early Naïve T Cell Population Lacking PD1 Expression at Day 100 As A Prognostic Biomarker of Chronic GVHD. TSS 2017; 210.6.

How to deal with aggression delivered by a child’s peers is a common concern and social dilemma for both parents and children. How does a child ward off aggressive peers without getting hurt or in trouble while also not looking weak or whiny? What can parents do to stop their child from being hurt or frightened but also not humiliate them or interfere with their learning important life skills by being over protective?

Markus Wegmann/Thinkstock

Children do not want to fight, but they do want to be treated fairly. Frustration, with its associated feelings of anger, is the most common reason for aggression. Being a child is certainly full of its frustrations because, while autonomy and desires are increasing, opportunities expand at a slower rate, particularly for children with developmental weaknesses or economic disadvantage. Fear and a lack of coping skills are other major reasons for resorting to aggressive responses.

Physical bullying affects 21% of students in grades 3-12 and is a risk factor for aggression at all ages. A full one-third of 9th-12th graders report having been in a physical fight in the last year. In grade school age and adolescence, factors known to be associated with peer aggression include the humiliation of school failure, substance use, and anger from experiencing parental or sibling aggression.

One would think a universal goal of parents would be to raise their children to get along with others without fighting. Unfortunately, some parents actually espouse childrearing methods that directly or indirectly make fighting more likely.


Essentially all toddlers and preschoolers can be aggressive at times to get things they want (instrumental) or when angry in the beginning of their second year of life; this peaks in the third year and typically declines after age 3 years. But for some 10% of children, aggression remains high. What parent and child factors set children up for such persistent aggression?

Parents have many reasons for how they raise their children, but some myths about parenting that persist promote aggression.
 

“My child will love me more if I am more permissive.”

Infants and toddlers develop self-regulation skills better when it is gradually expected of them with encouragement and support from their parents. Parents may feel that they are showing love to their toddler by having a “relaxed” home with few limits and no specific bedtime or rules. These parents also may “rescue” their child from frustrating situations by giving in to their demands or removing them from even mildly stressful situations.

These strategies can interfere with the progressive development of frustration tolerance, a key life skill. A lack of routines, inadequate sleep or food, overstimulation by noise, frightening experiences (including fighting in the home or neighborhood), or violent media exposure sets toddlers up to be out of control and thereby increases dysregulation. In addition, the dysregulated child may then act up, which can invoke punishment from that same parent.

Frustrating toddlers with inconsistent expectations and arbitrary punishment, a common result of low structure, makes the child feel insecure and leads to aggression. Instead, children need small doses of frustration appropriate to their age and encouragement from a supportive adult to problem solve. You can praise (or model), cheering on a child with words such as “Are you stuck? You can do it! Try again,” instead of instantly solving problems for them.

“Spare the rod and spoil the child.”

Parents may feel that they are promoting obedience when they use corporal punishment, thinking this will keep the child out of trouble in society. Instead, corporal punishment is associated with increased aggression toward peers, as well as defiance toward parents. These effects are especially strong when mothers are distant emotionally. As pediatricians, we can educate people on the importance of warm parenting, redirection instead of punishment for younger children, and using small, logical consequences or time out when needed for aggression.

“Just ignore bullies.”

It is a rare child who can follow the command to “ignore” a bully without turning red or getting tears in his or her eyes – making them appealing targets. We can coach parents and kids how to disarm bullies by standing tall, putting hands on hips, making eye contact, and asking the peer a question such as “I do not understand what you’re trying to accomplish.” Learning martial arts also teaches children that they are powerful (but not to fight outside the class) so they can present themselves in this way. Programs that encourage children to get together to confront bullies supported by a school administration that uses comprehensive assessment and habilitation strategies for aggressive students are most effective in reducing aggression in schools. Anonymous reporting (for example, by using a cell phone app, such as STOPit) empowers students to report bullying or fights to school staff without risking later retribution from the peer.

“Tough teachers help kids fall in line.”

While peer fights generally increase from 2nd to 4th grade before declining, student fighting progressively increases when teachers use reprimands, rather than praise, to manage their classes. Children look to teachers to learn more than what is in books – how to be respectful and in control without putting others down. The most effective classroom management includes clear, fair rules; any correction should be done privately to avoid shaming students. Students dealt with this way are less likely to be angry and take it out on others. Of course, appropriate services helping every child experience success in learning is the foundation of positive behavior in school.

“Children with ADHD won’t learn self-regulation if they are treated with medicine.”

Children who show “low effortful control” or higher “dysregulation” are both more aggressive and also less likely to decline in aggression in early childhood. ADHD is a neurological condition characterized by such dysregulation and low effortful control. Children with ADHD often have higher and more persistent aggression. These tendencies also result in impulsive behaviors that can irritate peers and adults and can result in correction and criticism, further increasing aggression. Children with ADHD who are better controlled, often with the help of medication, have more positive interactions at school and at home, receive more praise and less correction, and develop more reasoned interaction patterns.

“I am the parent, and my child should do what I say.”

When adults step in to stop a fight, they are rarely in a position to know what actually happened between the kids. Children may quickly learn how to entrap a sibling or peer to look like the perpetrator in order to get them in trouble and/or avoid consequences for themselves, especially if large or harsh punishments are being used.

While it can seem tricky to treat children who are very different in age or development equally, having parents elicit or at least verbalize each child’s point of view is part of how children learn respect and mediation skills. Parents who refrain from taking sides or dictating how disputes should be resolved leave the chance for the children to acquire these component skills of negotiation. This does not mean there are no consequences, just that a brief discussion comes first.

When aggression persists, mindfulness training, cognitive-behavioral techniques, social-emotional approaches, or peer mentoring programs delivered through individual counseling or school programs are all ways of teaching kids important interaction skills to reduce peer aggression. Remember, 40% of severe adult aggression begins before age 8 years, so preventive education or early referral to mental health services is key.
 

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. E-mail her at pdnews@frontlinemedcom.com.

How to deal with aggression delivered by a child’s peers is a common concern and social dilemma for both parents and children. How does a child ward off aggressive peers without getting hurt or in trouble while also not looking weak or whiny? What can parents do to stop their child from being hurt or frightened but also not humiliate them or interfere with their learning important life skills by being over protective?

Markus Wegmann/Thinkstock

Children do not want to fight, but they do want to be treated fairly. Frustration, with its associated feelings of anger, is the most common reason for aggression. Being a child is certainly full of its frustrations because, while autonomy and desires are increasing, opportunities expand at a slower rate, particularly for children with developmental weaknesses or economic disadvantage. Fear and a lack of coping skills are other major reasons for resorting to aggressive responses.

Physical bullying affects 21% of students in grades 3-12 and is a risk factor for aggression at all ages. A full one-third of 9th-12th graders report having been in a physical fight in the last year. In grade school age and adolescence, factors known to be associated with peer aggression include the humiliation of school failure, substance use, and anger from experiencing parental or sibling aggression.

One would think a universal goal of parents would be to raise their children to get along with others without fighting. Unfortunately, some parents actually espouse childrearing methods that directly or indirectly make fighting more likely.


Essentially all toddlers and preschoolers can be aggressive at times to get things they want (instrumental) or when angry in the beginning of their second year of life; this peaks in the third year and typically declines after age 3 years. But for some 10% of children, aggression remains high. What parent and child factors set children up for such persistent aggression?

Parents have many reasons for how they raise their children, but some myths about parenting that persist promote aggression.
 

“My child will love me more if I am more permissive.”

Infants and toddlers develop self-regulation skills better when it is gradually expected of them with encouragement and support from their parents. Parents may feel that they are showing love to their toddler by having a “relaxed” home with few limits and no specific bedtime or rules. These parents also may “rescue” their child from frustrating situations by giving in to their demands or removing them from even mildly stressful situations.

These strategies can interfere with the progressive development of frustration tolerance, a key life skill. A lack of routines, inadequate sleep or food, overstimulation by noise, frightening experiences (including fighting in the home or neighborhood), or violent media exposure sets toddlers up to be out of control and thereby increases dysregulation. In addition, the dysregulated child may then act up, which can invoke punishment from that same parent.

Frustrating toddlers with inconsistent expectations and arbitrary punishment, a common result of low structure, makes the child feel insecure and leads to aggression. Instead, children need small doses of frustration appropriate to their age and encouragement from a supportive adult to problem solve. You can praise (or model), cheering on a child with words such as “Are you stuck? You can do it! Try again,” instead of instantly solving problems for them.

“Spare the rod and spoil the child.”

Parents may feel that they are promoting obedience when they use corporal punishment, thinking this will keep the child out of trouble in society. Instead, corporal punishment is associated with increased aggression toward peers, as well as defiance toward parents. These effects are especially strong when mothers are distant emotionally. As pediatricians, we can educate people on the importance of warm parenting, redirection instead of punishment for younger children, and using small, logical consequences or time out when needed for aggression.

“Just ignore bullies.”

It is a rare child who can follow the command to “ignore” a bully without turning red or getting tears in his or her eyes – making them appealing targets. We can coach parents and kids how to disarm bullies by standing tall, putting hands on hips, making eye contact, and asking the peer a question such as “I do not understand what you’re trying to accomplish.” Learning martial arts also teaches children that they are powerful (but not to fight outside the class) so they can present themselves in this way. Programs that encourage children to get together to confront bullies supported by a school administration that uses comprehensive assessment and habilitation strategies for aggressive students are most effective in reducing aggression in schools. Anonymous reporting (for example, by using a cell phone app, such as STOPit) empowers students to report bullying or fights to school staff without risking later retribution from the peer.

“Tough teachers help kids fall in line.”

While peer fights generally increase from 2nd to 4th grade before declining, student fighting progressively increases when teachers use reprimands, rather than praise, to manage their classes. Children look to teachers to learn more than what is in books – how to be respectful and in control without putting others down. The most effective classroom management includes clear, fair rules; any correction should be done privately to avoid shaming students. Students dealt with this way are less likely to be angry and take it out on others. Of course, appropriate services helping every child experience success in learning is the foundation of positive behavior in school.

“Children with ADHD won’t learn self-regulation if they are treated with medicine.”

Children who show “low effortful control” or higher “dysregulation” are both more aggressive and also less likely to decline in aggression in early childhood. ADHD is a neurological condition characterized by such dysregulation and low effortful control. Children with ADHD often have higher and more persistent aggression. These tendencies also result in impulsive behaviors that can irritate peers and adults and can result in correction and criticism, further increasing aggression. Children with ADHD who are better controlled, often with the help of medication, have more positive interactions at school and at home, receive more praise and less correction, and develop more reasoned interaction patterns.

“I am the parent, and my child should do what I say.”

When adults step in to stop a fight, they are rarely in a position to know what actually happened between the kids. Children may quickly learn how to entrap a sibling or peer to look like the perpetrator in order to get them in trouble and/or avoid consequences for themselves, especially if large or harsh punishments are being used.

While it can seem tricky to treat children who are very different in age or development equally, having parents elicit or at least verbalize each child’s point of view is part of how children learn respect and mediation skills. Parents who refrain from taking sides or dictating how disputes should be resolved leave the chance for the children to acquire these component skills of negotiation. This does not mean there are no consequences, just that a brief discussion comes first.

When aggression persists, mindfulness training, cognitive-behavioral techniques, social-emotional approaches, or peer mentoring programs delivered through individual counseling or school programs are all ways of teaching kids important interaction skills to reduce peer aggression. Remember, 40% of severe adult aggression begins before age 8 years, so preventive education or early referral to mental health services is key.
 

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. E-mail her at pdnews@frontlinemedcom.com.

How to deal with aggression delivered by a child’s peers is a common concern and social dilemma for both parents and children. How does a child ward off aggressive peers without getting hurt or in trouble while also not looking weak or whiny? What can parents do to stop their child from being hurt or frightened but also not humiliate them or interfere with their learning important life skills by being over protective?

Markus Wegmann/Thinkstock

Children do not want to fight, but they do want to be treated fairly. Frustration, with its associated feelings of anger, is the most common reason for aggression. Being a child is certainly full of its frustrations because, while autonomy and desires are increasing, opportunities expand at a slower rate, particularly for children with developmental weaknesses or economic disadvantage. Fear and a lack of coping skills are other major reasons for resorting to aggressive responses.

Physical bullying affects 21% of students in grades 3-12 and is a risk factor for aggression at all ages. A full one-third of 9th-12th graders report having been in a physical fight in the last year. In grade school age and adolescence, factors known to be associated with peer aggression include the humiliation of school failure, substance use, and anger from experiencing parental or sibling aggression.

One would think a universal goal of parents would be to raise their children to get along with others without fighting. Unfortunately, some parents actually espouse childrearing methods that directly or indirectly make fighting more likely.


Essentially all toddlers and preschoolers can be aggressive at times to get things they want (instrumental) or when angry in the beginning of their second year of life; this peaks in the third year and typically declines after age 3 years. But for some 10% of children, aggression remains high. What parent and child factors set children up for such persistent aggression?

Parents have many reasons for how they raise their children, but some myths about parenting that persist promote aggression.
 

“My child will love me more if I am more permissive.”

Infants and toddlers develop self-regulation skills better when it is gradually expected of them with encouragement and support from their parents. Parents may feel that they are showing love to their toddler by having a “relaxed” home with few limits and no specific bedtime or rules. These parents also may “rescue” their child from frustrating situations by giving in to their demands or removing them from even mildly stressful situations.

These strategies can interfere with the progressive development of frustration tolerance, a key life skill. A lack of routines, inadequate sleep or food, overstimulation by noise, frightening experiences (including fighting in the home or neighborhood), or violent media exposure sets toddlers up to be out of control and thereby increases dysregulation. In addition, the dysregulated child may then act up, which can invoke punishment from that same parent.

Frustrating toddlers with inconsistent expectations and arbitrary punishment, a common result of low structure, makes the child feel insecure and leads to aggression. Instead, children need small doses of frustration appropriate to their age and encouragement from a supportive adult to problem solve. You can praise (or model), cheering on a child with words such as “Are you stuck? You can do it! Try again,” instead of instantly solving problems for them.

“Spare the rod and spoil the child.”

Parents may feel that they are promoting obedience when they use corporal punishment, thinking this will keep the child out of trouble in society. Instead, corporal punishment is associated with increased aggression toward peers, as well as defiance toward parents. These effects are especially strong when mothers are distant emotionally. As pediatricians, we can educate people on the importance of warm parenting, redirection instead of punishment for younger children, and using small, logical consequences or time out when needed for aggression.

“Just ignore bullies.”

It is a rare child who can follow the command to “ignore” a bully without turning red or getting tears in his or her eyes – making them appealing targets. We can coach parents and kids how to disarm bullies by standing tall, putting hands on hips, making eye contact, and asking the peer a question such as “I do not understand what you’re trying to accomplish.” Learning martial arts also teaches children that they are powerful (but not to fight outside the class) so they can present themselves in this way. Programs that encourage children to get together to confront bullies supported by a school administration that uses comprehensive assessment and habilitation strategies for aggressive students are most effective in reducing aggression in schools. Anonymous reporting (for example, by using a cell phone app, such as STOPit) empowers students to report bullying or fights to school staff without risking later retribution from the peer.

“Tough teachers help kids fall in line.”

While peer fights generally increase from 2nd to 4th grade before declining, student fighting progressively increases when teachers use reprimands, rather than praise, to manage their classes. Children look to teachers to learn more than what is in books – how to be respectful and in control without putting others down. The most effective classroom management includes clear, fair rules; any correction should be done privately to avoid shaming students. Students dealt with this way are less likely to be angry and take it out on others. Of course, appropriate services helping every child experience success in learning is the foundation of positive behavior in school.

“Children with ADHD won’t learn self-regulation if they are treated with medicine.”

Children who show “low effortful control” or higher “dysregulation” are both more aggressive and also less likely to decline in aggression in early childhood. ADHD is a neurological condition characterized by such dysregulation and low effortful control. Children with ADHD often have higher and more persistent aggression. These tendencies also result in impulsive behaviors that can irritate peers and adults and can result in correction and criticism, further increasing aggression. Children with ADHD who are better controlled, often with the help of medication, have more positive interactions at school and at home, receive more praise and less correction, and develop more reasoned interaction patterns.

“I am the parent, and my child should do what I say.”

When adults step in to stop a fight, they are rarely in a position to know what actually happened between the kids. Children may quickly learn how to entrap a sibling or peer to look like the perpetrator in order to get them in trouble and/or avoid consequences for themselves, especially if large or harsh punishments are being used.

While it can seem tricky to treat children who are very different in age or development equally, having parents elicit or at least verbalize each child’s point of view is part of how children learn respect and mediation skills. Parents who refrain from taking sides or dictating how disputes should be resolved leave the chance for the children to acquire these component skills of negotiation. This does not mean there are no consequences, just that a brief discussion comes first.

When aggression persists, mindfulness training, cognitive-behavioral techniques, social-emotional approaches, or peer mentoring programs delivered through individual counseling or school programs are all ways of teaching kids important interaction skills to reduce peer aggression. Remember, 40% of severe adult aggression begins before age 8 years, so preventive education or early referral to mental health services is key.
 

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. E-mail her at pdnews@frontlinemedcom.com.

As we providers begin to gain a better understanding of the complexities of gender identity and expression, studies examining the health of transgender and gender-nonconforming (TGNC) youth are emerging. Multiple studies have demonstrated the mental health disparities that TGNC youth face, but more studies examining other health risks and disparities are needed.

Prevalence of TGNC students higher than expected

The 2.7% prevalence of TGNC youth in this sample is higher than previously reported. Previous studies looking at prevalence rates of TGNC youth often dichotomized gender identities into binary (masculine or feminine) groups and were not inclusive of nonbinary and questioning identities. This may have led to underestimation of the size of this population.^2,3 This study assessed for TGNC identities by asking, “Do you consider yourself transgender, genderqueer, gender fluid, or unsure about your gender identity?” Given the prevalence of TGNC identities in this sample, it is likely that TGNC youth will be encountered in general pediatric practice. As such, it is important that we as providers continue to build our competency in working with this population.
 

Statistically significant differences in health status were identified

Almost two-thirds (62%) of TGNC youth identified their health as poor, fair, or good as opposed to very good or excellent, compared with one-third (33.1%) of cisgender youth. Over half (52%) of TGNC youth reported staying home from school because of illness at least once in the past month, compared with 43% of cisgender youth. About 60% of TGNC youth reported a preventive medical check-up in the past year, compared with 65% of cisgender youth. In terms of long-term health problems, TGNC youth reported higher rates of long-term physical (25% vs. 15%) and mental health (59% vs. 17%) problems than did their cisgender peers.

Role of perceived gender expression

A unique aspect of this study was that it sought to examine the effect of perceived gender expression (the way others interpret a person’s gender presentation; their appearance, style, dress, or the way they walk or talk) on health status and care utilization. Categories of perceived gender expression included very or mostly feminine, somewhat feminine, equally feminine and masculine, somewhat masculine, or very or mostly masculine. The prevalence of TGNC adolescents with an equally feminine and masculine gender expression was highest for both those assigned male (29%) and assigned female (41%) at birth, compared with other perceived gender presentations.

TGNC youth who were perceived to have a gender expression that was incongruent with the sex assigned at birth were at higher risk of reporting poor health status. For example, in TGNC participants who were assigned male at birth, those perceived as equally feminine and masculine (49%) or somewhat masculine (58%) were significantly more likely to report having poorer general health than those with a very masculine perceived gender expression (32%).
 

Suggestions for providers

The authors of the study and the accompanying commentary by Daniel Shumer, MD, MPH, suggest that there are things we as health care providers can do to address these barriers.

• Recognize that health disparities exist in this population. Individuals perceived as gender nonconforming may be vulnerable to discrimination and have difficulty accessing and receiving heath care, compared with their cisgender peers.
• Screen for health risks and identify barriers to care for TGNC youth while promoting and bolstering wellness within this community.
• Continue to promote access to gender affirming care. Data suggest that children who receive gender affirming care achieve mental health status similar to that of their cisgender peers.^3,4,5
• Continue to develop an understanding of how youth understand and express gender.
• Nonbinary youth face unique barriers when accessing health affirming services because of fears that their gender identity may be misunderstood. These barriers lead to delays in seeking health care services, which may lead to poorer outcomes. As providers, educating ourselves about these diverse identities and being respectful of all patients’ identities can help reduce these barriers.

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at Ohio State University, both in Columbus. She said she had no relevant financial disclosures. Email her at pdnews@frontlinemedcom.com.

References

1. Pediatrics. 2018 Feb 5. doi: 10.1542/peds.2017-1683.

2. J Adolesc Health. 2017 Oct;61(4):521-6.

3. Pediatrics. 2018. doi: 10.1542/peds.2017-4079.

4. Pediatrics. 2014 Oct;134(4):696-704.

5. Pediatrics. 2016 Mar;137(3):e20153223.

As we providers begin to gain a better understanding of the complexities of gender identity and expression, studies examining the health of transgender and gender-nonconforming (TGNC) youth are emerging. Multiple studies have demonstrated the mental health disparities that TGNC youth face, but more studies examining other health risks and disparities are needed.

Prevalence of TGNC students higher than expected

The 2.7% prevalence of TGNC youth in this sample is higher than previously reported. Previous studies looking at prevalence rates of TGNC youth often dichotomized gender identities into binary (masculine or feminine) groups and were not inclusive of nonbinary and questioning identities. This may have led to underestimation of the size of this population.^2,3 This study assessed for TGNC identities by asking, “Do you consider yourself transgender, genderqueer, gender fluid, or unsure about your gender identity?” Given the prevalence of TGNC identities in this sample, it is likely that TGNC youth will be encountered in general pediatric practice. As such, it is important that we as providers continue to build our competency in working with this population.
 

Statistically significant differences in health status were identified

Almost two-thirds (62%) of TGNC youth identified their health as poor, fair, or good as opposed to very good or excellent, compared with one-third (33.1%) of cisgender youth. Over half (52%) of TGNC youth reported staying home from school because of illness at least once in the past month, compared with 43% of cisgender youth. About 60% of TGNC youth reported a preventive medical check-up in the past year, compared with 65% of cisgender youth. In terms of long-term health problems, TGNC youth reported higher rates of long-term physical (25% vs. 15%) and mental health (59% vs. 17%) problems than did their cisgender peers.

Role of perceived gender expression

A unique aspect of this study was that it sought to examine the effect of perceived gender expression (the way others interpret a person’s gender presentation; their appearance, style, dress, or the way they walk or talk) on health status and care utilization. Categories of perceived gender expression included very or mostly feminine, somewhat feminine, equally feminine and masculine, somewhat masculine, or very or mostly masculine. The prevalence of TGNC adolescents with an equally feminine and masculine gender expression was highest for both those assigned male (29%) and assigned female (41%) at birth, compared with other perceived gender presentations.

TGNC youth who were perceived to have a gender expression that was incongruent with the sex assigned at birth were at higher risk of reporting poor health status. For example, in TGNC participants who were assigned male at birth, those perceived as equally feminine and masculine (49%) or somewhat masculine (58%) were significantly more likely to report having poorer general health than those with a very masculine perceived gender expression (32%).
 

Suggestions for providers

The authors of the study and the accompanying commentary by Daniel Shumer, MD, MPH, suggest that there are things we as health care providers can do to address these barriers.

• Recognize that health disparities exist in this population. Individuals perceived as gender nonconforming may be vulnerable to discrimination and have difficulty accessing and receiving heath care, compared with their cisgender peers.
• Screen for health risks and identify barriers to care for TGNC youth while promoting and bolstering wellness within this community.
• Continue to promote access to gender affirming care. Data suggest that children who receive gender affirming care achieve mental health status similar to that of their cisgender peers.^3,4,5
• Continue to develop an understanding of how youth understand and express gender.
• Nonbinary youth face unique barriers when accessing health affirming services because of fears that their gender identity may be misunderstood. These barriers lead to delays in seeking health care services, which may lead to poorer outcomes. As providers, educating ourselves about these diverse identities and being respectful of all patients’ identities can help reduce these barriers.

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at Ohio State University, both in Columbus. She said she had no relevant financial disclosures. Email her at pdnews@frontlinemedcom.com.

References

1. Pediatrics. 2018 Feb 5. doi: 10.1542/peds.2017-1683.

2. J Adolesc Health. 2017 Oct;61(4):521-6.

3. Pediatrics. 2018. doi: 10.1542/peds.2017-4079.

4. Pediatrics. 2014 Oct;134(4):696-704.

5. Pediatrics. 2016 Mar;137(3):e20153223.

As we providers begin to gain a better understanding of the complexities of gender identity and expression, studies examining the health of transgender and gender-nonconforming (TGNC) youth are emerging. Multiple studies have demonstrated the mental health disparities that TGNC youth face, but more studies examining other health risks and disparities are needed.

Prevalence of TGNC students higher than expected

The 2.7% prevalence of TGNC youth in this sample is higher than previously reported. Previous studies looking at prevalence rates of TGNC youth often dichotomized gender identities into binary (masculine or feminine) groups and were not inclusive of nonbinary and questioning identities. This may have led to underestimation of the size of this population.^2,3 This study assessed for TGNC identities by asking, “Do you consider yourself transgender, genderqueer, gender fluid, or unsure about your gender identity?” Given the prevalence of TGNC identities in this sample, it is likely that TGNC youth will be encountered in general pediatric practice. As such, it is important that we as providers continue to build our competency in working with this population.
 

Statistically significant differences in health status were identified

Almost two-thirds (62%) of TGNC youth identified their health as poor, fair, or good as opposed to very good or excellent, compared with one-third (33.1%) of cisgender youth. Over half (52%) of TGNC youth reported staying home from school because of illness at least once in the past month, compared with 43% of cisgender youth. About 60% of TGNC youth reported a preventive medical check-up in the past year, compared with 65% of cisgender youth. In terms of long-term health problems, TGNC youth reported higher rates of long-term physical (25% vs. 15%) and mental health (59% vs. 17%) problems than did their cisgender peers.

Role of perceived gender expression

A unique aspect of this study was that it sought to examine the effect of perceived gender expression (the way others interpret a person’s gender presentation; their appearance, style, dress, or the way they walk or talk) on health status and care utilization. Categories of perceived gender expression included very or mostly feminine, somewhat feminine, equally feminine and masculine, somewhat masculine, or very or mostly masculine. The prevalence of TGNC adolescents with an equally feminine and masculine gender expression was highest for both those assigned male (29%) and assigned female (41%) at birth, compared with other perceived gender presentations.

TGNC youth who were perceived to have a gender expression that was incongruent with the sex assigned at birth were at higher risk of reporting poor health status. For example, in TGNC participants who were assigned male at birth, those perceived as equally feminine and masculine (49%) or somewhat masculine (58%) were significantly more likely to report having poorer general health than those with a very masculine perceived gender expression (32%).
 

Suggestions for providers

The authors of the study and the accompanying commentary by Daniel Shumer, MD, MPH, suggest that there are things we as health care providers can do to address these barriers.

• Recognize that health disparities exist in this population. Individuals perceived as gender nonconforming may be vulnerable to discrimination and have difficulty accessing and receiving heath care, compared with their cisgender peers.
• Screen for health risks and identify barriers to care for TGNC youth while promoting and bolstering wellness within this community.
• Continue to promote access to gender affirming care. Data suggest that children who receive gender affirming care achieve mental health status similar to that of their cisgender peers.^3,4,5
• Continue to develop an understanding of how youth understand and express gender.
• Nonbinary youth face unique barriers when accessing health affirming services because of fears that their gender identity may be misunderstood. These barriers lead to delays in seeking health care services, which may lead to poorer outcomes. As providers, educating ourselves about these diverse identities and being respectful of all patients’ identities can help reduce these barriers.

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at Ohio State University, both in Columbus. She said she had no relevant financial disclosures. Email her at pdnews@frontlinemedcom.com.

References

1. Pediatrics. 2018 Feb 5. doi: 10.1542/peds.2017-1683.

2. J Adolesc Health. 2017 Oct;61(4):521-6.

3. Pediatrics. 2018. doi: 10.1542/peds.2017-4079.

4. Pediatrics. 2014 Oct;134(4):696-704.

5. Pediatrics. 2016 Mar;137(3):e20153223.

Nutrition during a child’s first 1,000 days—from conception to age 2—is pivotal for a child’s neurodevelopment and lifelong health, according to an American Academy of Pediatrics (AAP) policy statement.

“Healthy, normal neurodevelopment is a complex process involving cellular and structural changes in the brain that proceed in a specified sequence,” said Sara Jane Schwarzenberg, MD, and Michael K. Georgieff, MD, both of the University of Minnesota Masonic Children’s Hospital, Minneapolis, and the AAP Committee on Nutrition, in the statement. “Changes that are too rapid or too slow in one part of the brain may result in the failure of crucial pathway connections to other parts of the brain. Timing is crucial; once a particular developmental sequence fails, it may not be possible to retrieve all the lost function.”

The policy statement was published in the February issue of Pediatrics.

A Crucial Period

Research shows that the most active period of neural development is in the first 1,000 days. During this time, structures and processes develop that influence behavior and provide a basis for later-developing structures, including auditory and visual systems, myelination, and brain circuits involved in social development.

The importance of macronutrients for development was highlighted in a study of rural Guatemalan children between 1969 and 1989. Children in some villages received a high-calorie, high-protein supplement, and some children received a low-calorie supplement without protein. Both supplements contained vitamins and minerals. Children who received the high-calorie, high-protein supplements before age 2 had higher test scores, better reading and vocabulary skills, and faster information processing, compared with children who received the low-calorie supplements.

Many populations lack access to high-quality macronutrient sources, however. In the United States in 2015, 16.6% of households (6.4 million) were food insecure (ie, their access to adequate food was limited by a lack of money or other resources). In households with incomes below 185% of the poverty line, 36.8% were food insecure, according to the Department of Agriculture.

Food insecurity extends to micronutrients such as vitamins and minerals like zinc; iron; choline; folate; iodine; vitamins A, D, B6, and B12; and long-chain polyunsaturated fatty acids. A lack of any of these micronutrients in early childhood can lead to neurodevelopmental issues later in life, the authors said. An important source of micronutrients is human milk, provided by breastfeeding. Studies have shown that infants who are fed human milk have improved cognitive performance, compared with infants who consume formula.

Government-sponsored programs exist that provide nutritional support to women, infants, and young children. The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is one of the most important programs, helping 53% of children under age 1, the authors said. The Supplemental Nutrition Assistance Program (SNAP) provides economic aid to buy food; it kept approximately 4.9 million children out of poverty in 2012, the authors said. SNAP Nutrition Education is intended to help people make healthy food choices with limited money.

10 Recommendations

The AAP policy statement includes the following 10 recommendations:

• Be knowledgeable about breastfeeding, and help breastfeeding mothers. The AAP recommends exclusive breastfeeding for the first six months and continued breastfeeding with the addition of food for at least the first year.
• Advocate at the local, state, and federal levels to preserve and strengthen programs focused on maternal, fetal, and neonatal nutrition.
• Be familiar with food sources that supply nutrients necessary for brain development, and make appropriate dietary recommendations. Know which nutrients are at risk in the breastfed infant after six months, such as zinc, iron, and vitamin D.
• Nutritional advice should convey that eating healthy is a positive choice, not just an avoidance of unhealthy foods.
• Existing assistance programs should aim to improve micro- and macronutrient offerings. For example, food pantries and soup kitchens can create food packages and meals that target the needs of pregnant women, breastfeeding women, and children up to age 2.
• Encourage parents to use programs that provide early childhood nutrition (eg, WIC), and advocate for the removal of barriers to enrolling or staying enrolled in these programs.
• Oppose changes in eligibility or financing structures that would adversely affect programs providing early childhood nutrition.
• Anticipate neurodevelopmental issues in children with early nutrient deficiency.
• Work with obstetricians and family physicians to encourage improvements in maternal diet and identify clinical situations that may limit the availability of crucial micronutrients to the fetus.
• Advocate to reduce hunger at the local, national, and global levels. The statement lists organizations focused on hunger, such as Feeding America, 1,000 Days, and Share Our Strength.

—Ian Lacy

Suggested Reading

Schwarzenberg SJ, Georgieff MK; Committee on Nutrition. Advocacy for improving nutrition in the first 1000 days to support childhood development and adult health. Pediatrics. 2018;141(2). pii: e20173716.

Nutrition during a child’s first 1,000 days—from conception to age 2—is pivotal for a child’s neurodevelopment and lifelong health, according to an American Academy of Pediatrics (AAP) policy statement.

“Healthy, normal neurodevelopment is a complex process involving cellular and structural changes in the brain that proceed in a specified sequence,” said Sara Jane Schwarzenberg, MD, and Michael K. Georgieff, MD, both of the University of Minnesota Masonic Children’s Hospital, Minneapolis, and the AAP Committee on Nutrition, in the statement. “Changes that are too rapid or too slow in one part of the brain may result in the failure of crucial pathway connections to other parts of the brain. Timing is crucial; once a particular developmental sequence fails, it may not be possible to retrieve all the lost function.”

The policy statement was published in the February issue of Pediatrics.

A Crucial Period

Research shows that the most active period of neural development is in the first 1,000 days. During this time, structures and processes develop that influence behavior and provide a basis for later-developing structures, including auditory and visual systems, myelination, and brain circuits involved in social development.

The importance of macronutrients for development was highlighted in a study of rural Guatemalan children between 1969 and 1989. Children in some villages received a high-calorie, high-protein supplement, and some children received a low-calorie supplement without protein. Both supplements contained vitamins and minerals. Children who received the high-calorie, high-protein supplements before age 2 had higher test scores, better reading and vocabulary skills, and faster information processing, compared with children who received the low-calorie supplements.

Many populations lack access to high-quality macronutrient sources, however. In the United States in 2015, 16.6% of households (6.4 million) were food insecure (ie, their access to adequate food was limited by a lack of money or other resources). In households with incomes below 185% of the poverty line, 36.8% were food insecure, according to the Department of Agriculture.

Food insecurity extends to micronutrients such as vitamins and minerals like zinc; iron; choline; folate; iodine; vitamins A, D, B6, and B12; and long-chain polyunsaturated fatty acids. A lack of any of these micronutrients in early childhood can lead to neurodevelopmental issues later in life, the authors said. An important source of micronutrients is human milk, provided by breastfeeding. Studies have shown that infants who are fed human milk have improved cognitive performance, compared with infants who consume formula.

Government-sponsored programs exist that provide nutritional support to women, infants, and young children. The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is one of the most important programs, helping 53% of children under age 1, the authors said. The Supplemental Nutrition Assistance Program (SNAP) provides economic aid to buy food; it kept approximately 4.9 million children out of poverty in 2012, the authors said. SNAP Nutrition Education is intended to help people make healthy food choices with limited money.

10 Recommendations

The AAP policy statement includes the following 10 recommendations:

• Be knowledgeable about breastfeeding, and help breastfeeding mothers. The AAP recommends exclusive breastfeeding for the first six months and continued breastfeeding with the addition of food for at least the first year.
• Advocate at the local, state, and federal levels to preserve and strengthen programs focused on maternal, fetal, and neonatal nutrition.
• Be familiar with food sources that supply nutrients necessary for brain development, and make appropriate dietary recommendations. Know which nutrients are at risk in the breastfed infant after six months, such as zinc, iron, and vitamin D.
• Nutritional advice should convey that eating healthy is a positive choice, not just an avoidance of unhealthy foods.
• Existing assistance programs should aim to improve micro- and macronutrient offerings. For example, food pantries and soup kitchens can create food packages and meals that target the needs of pregnant women, breastfeeding women, and children up to age 2.
• Encourage parents to use programs that provide early childhood nutrition (eg, WIC), and advocate for the removal of barriers to enrolling or staying enrolled in these programs.
• Oppose changes in eligibility or financing structures that would adversely affect programs providing early childhood nutrition.
• Anticipate neurodevelopmental issues in children with early nutrient deficiency.
• Work with obstetricians and family physicians to encourage improvements in maternal diet and identify clinical situations that may limit the availability of crucial micronutrients to the fetus.
• Advocate to reduce hunger at the local, national, and global levels. The statement lists organizations focused on hunger, such as Feeding America, 1,000 Days, and Share Our Strength.

—Ian Lacy

Suggested Reading

Schwarzenberg SJ, Georgieff MK; Committee on Nutrition. Advocacy for improving nutrition in the first 1000 days to support childhood development and adult health. Pediatrics. 2018;141(2). pii: e20173716.

Nutrition during a child’s first 1,000 days—from conception to age 2—is pivotal for a child’s neurodevelopment and lifelong health, according to an American Academy of Pediatrics (AAP) policy statement.

“Healthy, normal neurodevelopment is a complex process involving cellular and structural changes in the brain that proceed in a specified sequence,” said Sara Jane Schwarzenberg, MD, and Michael K. Georgieff, MD, both of the University of Minnesota Masonic Children’s Hospital, Minneapolis, and the AAP Committee on Nutrition, in the statement. “Changes that are too rapid or too slow in one part of the brain may result in the failure of crucial pathway connections to other parts of the brain. Timing is crucial; once a particular developmental sequence fails, it may not be possible to retrieve all the lost function.”

The policy statement was published in the February issue of Pediatrics.

A Crucial Period

Research shows that the most active period of neural development is in the first 1,000 days. During this time, structures and processes develop that influence behavior and provide a basis for later-developing structures, including auditory and visual systems, myelination, and brain circuits involved in social development.

The importance of macronutrients for development was highlighted in a study of rural Guatemalan children between 1969 and 1989. Children in some villages received a high-calorie, high-protein supplement, and some children received a low-calorie supplement without protein. Both supplements contained vitamins and minerals. Children who received the high-calorie, high-protein supplements before age 2 had higher test scores, better reading and vocabulary skills, and faster information processing, compared with children who received the low-calorie supplements.

Many populations lack access to high-quality macronutrient sources, however. In the United States in 2015, 16.6% of households (6.4 million) were food insecure (ie, their access to adequate food was limited by a lack of money or other resources). In households with incomes below 185% of the poverty line, 36.8% were food insecure, according to the Department of Agriculture.

Food insecurity extends to micronutrients such as vitamins and minerals like zinc; iron; choline; folate; iodine; vitamins A, D, B6, and B12; and long-chain polyunsaturated fatty acids. A lack of any of these micronutrients in early childhood can lead to neurodevelopmental issues later in life, the authors said. An important source of micronutrients is human milk, provided by breastfeeding. Studies have shown that infants who are fed human milk have improved cognitive performance, compared with infants who consume formula.

Government-sponsored programs exist that provide nutritional support to women, infants, and young children. The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is one of the most important programs, helping 53% of children under age 1, the authors said. The Supplemental Nutrition Assistance Program (SNAP) provides economic aid to buy food; it kept approximately 4.9 million children out of poverty in 2012, the authors said. SNAP Nutrition Education is intended to help people make healthy food choices with limited money.

10 Recommendations

The AAP policy statement includes the following 10 recommendations:

• Be knowledgeable about breastfeeding, and help breastfeeding mothers. The AAP recommends exclusive breastfeeding for the first six months and continued breastfeeding with the addition of food for at least the first year.
• Advocate at the local, state, and federal levels to preserve and strengthen programs focused on maternal, fetal, and neonatal nutrition.
• Be familiar with food sources that supply nutrients necessary for brain development, and make appropriate dietary recommendations. Know which nutrients are at risk in the breastfed infant after six months, such as zinc, iron, and vitamin D.
• Nutritional advice should convey that eating healthy is a positive choice, not just an avoidance of unhealthy foods.
• Existing assistance programs should aim to improve micro- and macronutrient offerings. For example, food pantries and soup kitchens can create food packages and meals that target the needs of pregnant women, breastfeeding women, and children up to age 2.
• Encourage parents to use programs that provide early childhood nutrition (eg, WIC), and advocate for the removal of barriers to enrolling or staying enrolled in these programs.
• Oppose changes in eligibility or financing structures that would adversely affect programs providing early childhood nutrition.
• Anticipate neurodevelopmental issues in children with early nutrient deficiency.
• Work with obstetricians and family physicians to encourage improvements in maternal diet and identify clinical situations that may limit the availability of crucial micronutrients to the fetus.
• Advocate to reduce hunger at the local, national, and global levels. The statement lists organizations focused on hunger, such as Feeding America, 1,000 Days, and Share Our Strength.

—Ian Lacy

Suggested Reading

Schwarzenberg SJ, Georgieff MK; Committee on Nutrition. Advocacy for improving nutrition in the first 1000 days to support childhood development and adult health. Pediatrics. 2018;141(2). pii: e20173716.

During my training as a child and adolescent psychiatry fellow, I “lived” down the hall from 10 other people just like me who had similar offices and training. Our pace was tailored to pediatric psychiatry. Appointments were 30 minutes or more. Our goal was to provide the most comprehensive mental health care for the families whom we grew to know and love.

Comstock Images/Thinkstock

Dr. Pawlowski is an adult, adolescent, and child psychiatrist at the University of Vermont Medical Center and an assistant professor of psychiatry at UVM, both in Burlington. Email her at pdnews@frontlinemedcom.com.

Resources

The AACAP website has materials to help clinicians develop a collaborative mental health care model in the primary care setting: Search for “collaboration with primary care.”

The journal Pediatrics also has a useful resource: Improving mental health services in primary care: Reducing administrative and financial barriers to access and collaboration. (2009;123;1248-51).

During my training as a child and adolescent psychiatry fellow, I “lived” down the hall from 10 other people just like me who had similar offices and training. Our pace was tailored to pediatric psychiatry. Appointments were 30 minutes or more. Our goal was to provide the most comprehensive mental health care for the families whom we grew to know and love.

Comstock Images/Thinkstock

Dr. Pawlowski is an adult, adolescent, and child psychiatrist at the University of Vermont Medical Center and an assistant professor of psychiatry at UVM, both in Burlington. Email her at pdnews@frontlinemedcom.com.

Resources

The AACAP website has materials to help clinicians develop a collaborative mental health care model in the primary care setting: Search for “collaboration with primary care.”

The journal Pediatrics also has a useful resource: Improving mental health services in primary care: Reducing administrative and financial barriers to access and collaboration. (2009;123;1248-51).

During my training as a child and adolescent psychiatry fellow, I “lived” down the hall from 10 other people just like me who had similar offices and training. Our pace was tailored to pediatric psychiatry. Appointments were 30 minutes or more. Our goal was to provide the most comprehensive mental health care for the families whom we grew to know and love.

Comstock Images/Thinkstock

Dr. Pawlowski is an adult, adolescent, and child psychiatrist at the University of Vermont Medical Center and an assistant professor of psychiatry at UVM, both in Burlington. Email her at pdnews@frontlinemedcom.com.

Resources

The AACAP website has materials to help clinicians develop a collaborative mental health care model in the primary care setting: Search for “collaboration with primary care.”

The journal Pediatrics also has a useful resource: Improving mental health services in primary care: Reducing administrative and financial barriers to access and collaboration. (2009;123;1248-51).

More teenagers are sending and receiving sexts than in previous years, based on data from a meta-analysis of 39 studies including 110,380 individuals younger than 18 years.

Published rates of sexting in teens range from 1% to 60%, wrote Sheri Madigan, PhD, of the University of Calgary, Alberta, Canada, and her colleagues. “However, the true public health importance of youth sexting is unclear at present because the field is handicapped by inconsistent information regarding its prevalence.”

Denise Fulton/Frontline Medical News

SOURCE: Madigan S et al. JAMA Pediatr. 2018 Feb 26. doi: 10.1001/jamapediatrics.2017.5314.

More teenagers are sending and receiving sexts than in previous years, based on data from a meta-analysis of 39 studies including 110,380 individuals younger than 18 years.

Published rates of sexting in teens range from 1% to 60%, wrote Sheri Madigan, PhD, of the University of Calgary, Alberta, Canada, and her colleagues. “However, the true public health importance of youth sexting is unclear at present because the field is handicapped by inconsistent information regarding its prevalence.”

Denise Fulton/Frontline Medical News

SOURCE: Madigan S et al. JAMA Pediatr. 2018 Feb 26. doi: 10.1001/jamapediatrics.2017.5314.

More teenagers are sending and receiving sexts than in previous years, based on data from a meta-analysis of 39 studies including 110,380 individuals younger than 18 years.

Published rates of sexting in teens range from 1% to 60%, wrote Sheri Madigan, PhD, of the University of Calgary, Alberta, Canada, and her colleagues. “However, the true public health importance of youth sexting is unclear at present because the field is handicapped by inconsistent information regarding its prevalence.”

Denise Fulton/Frontline Medical News

SOURCE: Madigan S et al. JAMA Pediatr. 2018 Feb 26. doi: 10.1001/jamapediatrics.2017.5314.

Fluarix Quadrivalent is highly effective against moderate and severe flu strains in children aged 6-35 months, and has the potential to simplify influenza vaccinations for all ages, according the results of a phase 3 clinical trial presented at a meeting of the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices.

“Fluarix Quadrivalent, at the 0.5-mL dose in young children 6 to 35 months of age, demonstrated efficacy of 63.2% against moderate to severe influenza and 49.8% against any severity influenza disease” stated Leonard Friedland, MD, director of scientific affairs and public health, Vaccines North America, GlaxoSmithKline. Dr. Friedland, a pediatrician in Pennsylvania, said that a standard 0.5-mL dose of Fluarix Quadrivalent has practice-changing implications for physicians. “The use of a 0.5-mL dose (15 mcg per strain) for all persons aged 6 months and older potentially simplifies influenza vaccination by allowing the same vaccine dose to be used for all eligible individuals.”

Cynthia Goldsmith/CDC photo #10073

The high efficacy of Fluarix against almost half of all influenza strains, regardless of severity, and in preventing moderate to severe influenza, correlated with a reduction in health care utilization by pediatric influenza patients, he said. Visits to general practitioners and emergency departments decreased by 47% and 79%, respectively, in children aged 6-35 months. Influenza-associated antibiotic use in these pediatric influenza patients also decreased by 50%.

These findings were the result of D-QIV-004, a phase 3, observer-blinded, randomized trial of 12,018 children aged 6-35 months. These children were split into five cohorts, each in a different influenza season. The study spanned 13 countries and ran from October 2011 to December 2014. To determine the safety of Fluarix, the study utilized noninfluenza vaccine comparator vaccines that were age appropriate, including Prevnar 13, Havrix, and Varivax.

A majority of the children in the study (98%) were vaccine unprimed (had never received two doses of seasonal influenza vaccine) and received two doses of Fluarix. The remaining children received one dose.

On Jan. 11, 2018, the Food and Drug Administration expanded the indication of Fluarix Quadrivalent to include use in persons 6 months and older. Previously, it was approved only for persons 3 years and older.

SOURCE: D-QIV-004.

Fluarix Quadrivalent is highly effective against moderate and severe flu strains in children aged 6-35 months, and has the potential to simplify influenza vaccinations for all ages, according the results of a phase 3 clinical trial presented at a meeting of the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices.

“Fluarix Quadrivalent, at the 0.5-mL dose in young children 6 to 35 months of age, demonstrated efficacy of 63.2% against moderate to severe influenza and 49.8% against any severity influenza disease” stated Leonard Friedland, MD, director of scientific affairs and public health, Vaccines North America, GlaxoSmithKline. Dr. Friedland, a pediatrician in Pennsylvania, said that a standard 0.5-mL dose of Fluarix Quadrivalent has practice-changing implications for physicians. “The use of a 0.5-mL dose (15 mcg per strain) for all persons aged 6 months and older potentially simplifies influenza vaccination by allowing the same vaccine dose to be used for all eligible individuals.”

Cynthia Goldsmith/CDC photo #10073

The high efficacy of Fluarix against almost half of all influenza strains, regardless of severity, and in preventing moderate to severe influenza, correlated with a reduction in health care utilization by pediatric influenza patients, he said. Visits to general practitioners and emergency departments decreased by 47% and 79%, respectively, in children aged 6-35 months. Influenza-associated antibiotic use in these pediatric influenza patients also decreased by 50%.

These findings were the result of D-QIV-004, a phase 3, observer-blinded, randomized trial of 12,018 children aged 6-35 months. These children were split into five cohorts, each in a different influenza season. The study spanned 13 countries and ran from October 2011 to December 2014. To determine the safety of Fluarix, the study utilized noninfluenza vaccine comparator vaccines that were age appropriate, including Prevnar 13, Havrix, and Varivax.

A majority of the children in the study (98%) were vaccine unprimed (had never received two doses of seasonal influenza vaccine) and received two doses of Fluarix. The remaining children received one dose.

On Jan. 11, 2018, the Food and Drug Administration expanded the indication of Fluarix Quadrivalent to include use in persons 6 months and older. Previously, it was approved only for persons 3 years and older.

SOURCE: D-QIV-004.

Fluarix Quadrivalent is highly effective against moderate and severe flu strains in children aged 6-35 months, and has the potential to simplify influenza vaccinations for all ages, according the results of a phase 3 clinical trial presented at a meeting of the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices.

“Fluarix Quadrivalent, at the 0.5-mL dose in young children 6 to 35 months of age, demonstrated efficacy of 63.2% against moderate to severe influenza and 49.8% against any severity influenza disease” stated Leonard Friedland, MD, director of scientific affairs and public health, Vaccines North America, GlaxoSmithKline. Dr. Friedland, a pediatrician in Pennsylvania, said that a standard 0.5-mL dose of Fluarix Quadrivalent has practice-changing implications for physicians. “The use of a 0.5-mL dose (15 mcg per strain) for all persons aged 6 months and older potentially simplifies influenza vaccination by allowing the same vaccine dose to be used for all eligible individuals.”

Cynthia Goldsmith/CDC photo #10073

The high efficacy of Fluarix against almost half of all influenza strains, regardless of severity, and in preventing moderate to severe influenza, correlated with a reduction in health care utilization by pediatric influenza patients, he said. Visits to general practitioners and emergency departments decreased by 47% and 79%, respectively, in children aged 6-35 months. Influenza-associated antibiotic use in these pediatric influenza patients also decreased by 50%.

These findings were the result of D-QIV-004, a phase 3, observer-blinded, randomized trial of 12,018 children aged 6-35 months. These children were split into five cohorts, each in a different influenza season. The study spanned 13 countries and ran from October 2011 to December 2014. To determine the safety of Fluarix, the study utilized noninfluenza vaccine comparator vaccines that were age appropriate, including Prevnar 13, Havrix, and Varivax.

A majority of the children in the study (98%) were vaccine unprimed (had never received two doses of seasonal influenza vaccine) and received two doses of Fluarix. The remaining children received one dose.

On Jan. 11, 2018, the Food and Drug Administration expanded the indication of Fluarix Quadrivalent to include use in persons 6 months and older. Previously, it was approved only for persons 3 years and older.

SOURCE: D-QIV-004.

While you might not typically put chopped or blended, unsalted, boiled canned oysters on your usual list of recommended infant and toddler foods, maybe you should.

The American Academy of Pediatrics just published a new policy statement on advocacy to improve child nutrition in the first 1,000 days (from conception to age 2). The statement emphasizes the importance of nutrition to optimal brain development. Pediatricians are encouraged to be familiar with community services to support optimal nutrition such as the Special Supplemental Nutrition Program for Women, Infants, and Children, the Supplemental Nutrition Assistance Program, the Child and Adult Care Food Program, and food pantries and soup kitchens, but also to get beyond recommending a “good diet” to something more specific that is high in key nutrients important for brain development such as protein; zinc; iron; choline; folate; iodine; vitamins A, D, B6, and B12; and polyunsaturated fatty acids. That’s where the boiled oysters, a decent source of the listed nutrients and especially loaded with zinc, iron, and vitamin B12, come in. While not everyone is going to rush out to buy their babies such an unexpected (and for many, unfamiliar) food, the statement reminds pediatricians to recommend foods that are good sources of the nutrients that babies and toddlers need most. Other foods that fit the bill include oatmeal, meat and poultry, fish like salmon and tuna, eggs, tofu and soybeans, and other legumes and beans like chickpeas and lentils.

—Natalie D. Muth, MD
Pediatrician
Children's Primary Care Medical Group
Carlsbad, California

While you might not typically put chopped or blended, unsalted, boiled canned oysters on your usual list of recommended infant and toddler foods, maybe you should.

The American Academy of Pediatrics just published a new policy statement on advocacy to improve child nutrition in the first 1,000 days (from conception to age 2). The statement emphasizes the importance of nutrition to optimal brain development. Pediatricians are encouraged to be familiar with community services to support optimal nutrition such as the Special Supplemental Nutrition Program for Women, Infants, and Children, the Supplemental Nutrition Assistance Program, the Child and Adult Care Food Program, and food pantries and soup kitchens, but also to get beyond recommending a “good diet” to something more specific that is high in key nutrients important for brain development such as protein; zinc; iron; choline; folate; iodine; vitamins A, D, B6, and B12; and polyunsaturated fatty acids. That’s where the boiled oysters, a decent source of the listed nutrients and especially loaded with zinc, iron, and vitamin B12, come in. While not everyone is going to rush out to buy their babies such an unexpected (and for many, unfamiliar) food, the statement reminds pediatricians to recommend foods that are good sources of the nutrients that babies and toddlers need most. Other foods that fit the bill include oatmeal, meat and poultry, fish like salmon and tuna, eggs, tofu and soybeans, and other legumes and beans like chickpeas and lentils.

—Natalie D. Muth, MD
Pediatrician
Children's Primary Care Medical Group
Carlsbad, California

While you might not typically put chopped or blended, unsalted, boiled canned oysters on your usual list of recommended infant and toddler foods, maybe you should.

The American Academy of Pediatrics just published a new policy statement on advocacy to improve child nutrition in the first 1,000 days (from conception to age 2). The statement emphasizes the importance of nutrition to optimal brain development. Pediatricians are encouraged to be familiar with community services to support optimal nutrition such as the Special Supplemental Nutrition Program for Women, Infants, and Children, the Supplemental Nutrition Assistance Program, the Child and Adult Care Food Program, and food pantries and soup kitchens, but also to get beyond recommending a “good diet” to something more specific that is high in key nutrients important for brain development such as protein; zinc; iron; choline; folate; iodine; vitamins A, D, B6, and B12; and polyunsaturated fatty acids. That’s where the boiled oysters, a decent source of the listed nutrients and especially loaded with zinc, iron, and vitamin B12, come in. While not everyone is going to rush out to buy their babies such an unexpected (and for many, unfamiliar) food, the statement reminds pediatricians to recommend foods that are good sources of the nutrients that babies and toddlers need most. Other foods that fit the bill include oatmeal, meat and poultry, fish like salmon and tuna, eggs, tofu and soybeans, and other legumes and beans like chickpeas and lentils.

—Natalie D. Muth, MD
Pediatrician
Children's Primary Care Medical Group
Carlsbad, California