Pediatrics

A while ago, I gave a talk on LGBT health to a group of primary care pediatricians. Although I was glad that they invited me to speak, I also sensed some discomfort in the audience. At the end of the lecture, many pediatricians told me that they were uncomfortable with bringing up the topic of sexuality and gender identity with their patients, and others wanted guidance on how to ask questions on sexuality and gender identity.

There are many barriers for primary pediatricians in addressing sexuality and gender identity concerns in their patients. First, pediatricians often will have up to 15 minutes for a visit, so they will have little time to address a complex issue. Second, primary care pediatricians may have known many of their patients since birth, and asking questions on sexuality and gender can feel awkward. Finally, many pediatricians may be working in more conservative areas in the country where asking questions on sexuality and gender identity may be controversial.

Tip No. 1: The environment counts

I cannot overstate how important it is to make your clinic a welcoming place for LGBT youth. Having various signs and stickers – like rainbow flags or the Human Rights Campaign sticker – will signal to LGBT youth that they are safe in your clinic. Creating a safe and welcoming environment is important because many people in the LGBT community have experienced rejection and discrimination from their primary care doctors.¹ Making your clinic a safe space will make it easier and efficient for patients to ask questions about sexuality and gender identity (see Dr. Gaya Chelvakumar’s column “Creating safe spaces for LGBTQ youth, families in health care settings” at pediatricnews.com).

Tip No. 2: Consider the context

Most likely, many presenting complaints – such as colds or sports injuries – of your adolescent patients will not involve sexual orientation or gender identity. There are exceptions. If you suspect an STD, then the risk for certain infections, such as HIV² or gonorrhea of the anus or of the pharynx³ are higher in gay young men. For the latter, your screening method would be different (that is, obtaining a pharyngeal swab or an anal swab instead of a urine sample). Also, because many LGBT youth have higher rates of mental health problems compared with heterosexual youth,⁴ you may want to ask questions about sexuality or gender identity to patients complaining of depressive or anxiety symptoms. This is especially important for transgender youth, because the implementation of pubertal blockers or cross-sex hormones can be therapeutic.⁵ To prevent or reduce many of these health problems, asking about sexuality and gender identity is a good idea during the well visit, when you may have more time.

Tip No. 3: Not all developmental stages are considered equal

Adolescence is a period of rapid and phasic growth. Formation of an identity is one of the major psychosocial tasks for adolescence,⁶ and sexuality and gender are important identities. In general, in early adolescence identity becomes an issue as the teenager gains autonomy from parents. I typically start asking questions about sexuality and gender when the patient is 11 or 12, because many children may not understand sexuality and gender identity at a younger age. At these ages, I ask these questions with the parents in the room, then I ask them confidentially on subsequent well visits. This approach serves two purposes: it will prepare the adolescent for these complex and thought-provoking questions in future encounters, and it gives the parents an idea of the type of questions you will ask the children when they are old enough for the confidential visit, helping parents feel more comfortable in stepping out of the room during this time.

Tip No. 4: Keep it confidential

Many adolescents are reluctant to see a doctor, even if they are sick. The primary reason adolescents do not seek care is the fear that the provider will tell their parents about their illness.⁷ Although this should be applicable to all of your adolescent patients, you should make an extra effort to explicitly state to LGBT patients that the clinic visit is confidential (with the exception of risk of suicide, homicide, or child abuse). This is important for LGBT youth who are not out to their parents and may be in danger if they do come out.⁸

Tip No. 5: Normalize, normalize, normalize

Because of the stigma and discrimination surrounding sexual orientation and gender identity, many LGBT youth will be reluctant to disclose their sexual orientation or gender identity to their health care providers. At the same time, heterosexual youth may think that you’re asking them questions about sexuality or gender identity because you suspect them to be a member of the LGBT community. To avoid this awkward situation, many pediatricians do not ask these questions at all. A good remedy for this is to preface your questions about sexual orientation or gender identity by saying that you ask these questions to all your patients – that way no one feels singled out.

Tip No. 6: Ask for permission

As previously mentioned, members of the LGBT community may experience discrimination from their health care providers after disclosing to them their sexual orientation or gender identity.¹ This rejection can be traumatizing for LGBT youth, making them reluctant to discuss any issues related to sexual orientation or gender identity with any medical provider. As part of the trauma-informed approach, asking for permission before delving into issues related to sexual orientation and gender identity will give LGBT patients a sense of control, especially in an environment where there is a significant power differential.

Tip No. 7: Treat this as a skill

Despite the pressures for primary care pediatricians to maintain an efficient and effective clinical practice, many strive to learn new skills to provide the best care for their patients. Asking questions about sexuality and gender identity should be one of those skills. As with any skill, it will feel unnatural at first, and it will require practice. Mastering this skill, however, will help you address the health needs of this vulnerable population.

Asking questions about sexuality and gender identity is difficult for the primary care pediatrician. Hopefully, these tips can help you develop this important skill. It will also help you reach out to a population that is wary of the health care system.

References

1. J Am Board Fam Med. 2016;29(1):156-60.

2. https://www.cdc.gov/hiv/group/msm/index.html.

3. https://www.cdc.gov/std/tg2015/default.htm.

4. J Adolesc Health. 2011;49(2):115-23.

5. Nat Rev Endocrinol. 2011;7(8):466-72.
6. Neinstein LS. Adolescent health care: a practical guide. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2008.

7. J Adolesc Health. 2007;40(3):218-26.

8. Am J Orthopsychiatry. 1998;68(3):361-71.

Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of the University of Pittsburgh Medical Center and a postdoctoral fellow in the department of pediatrics at the University of Pittsburgh. Email him at pdnews@frontlinemedcom.com.

A while ago, I gave a talk on LGBT health to a group of primary care pediatricians. Although I was glad that they invited me to speak, I also sensed some discomfort in the audience. At the end of the lecture, many pediatricians told me that they were uncomfortable with bringing up the topic of sexuality and gender identity with their patients, and others wanted guidance on how to ask questions on sexuality and gender identity.

There are many barriers for primary pediatricians in addressing sexuality and gender identity concerns in their patients. First, pediatricians often will have up to 15 minutes for a visit, so they will have little time to address a complex issue. Second, primary care pediatricians may have known many of their patients since birth, and asking questions on sexuality and gender can feel awkward. Finally, many pediatricians may be working in more conservative areas in the country where asking questions on sexuality and gender identity may be controversial.

Tip No. 1: The environment counts

I cannot overstate how important it is to make your clinic a welcoming place for LGBT youth. Having various signs and stickers – like rainbow flags or the Human Rights Campaign sticker – will signal to LGBT youth that they are safe in your clinic. Creating a safe and welcoming environment is important because many people in the LGBT community have experienced rejection and discrimination from their primary care doctors.¹ Making your clinic a safe space will make it easier and efficient for patients to ask questions about sexuality and gender identity (see Dr. Gaya Chelvakumar’s column “Creating safe spaces for LGBTQ youth, families in health care settings” at pediatricnews.com).

Tip No. 2: Consider the context

Most likely, many presenting complaints – such as colds or sports injuries – of your adolescent patients will not involve sexual orientation or gender identity. There are exceptions. If you suspect an STD, then the risk for certain infections, such as HIV² or gonorrhea of the anus or of the pharynx³ are higher in gay young men. For the latter, your screening method would be different (that is, obtaining a pharyngeal swab or an anal swab instead of a urine sample). Also, because many LGBT youth have higher rates of mental health problems compared with heterosexual youth,⁴ you may want to ask questions about sexuality or gender identity to patients complaining of depressive or anxiety symptoms. This is especially important for transgender youth, because the implementation of pubertal blockers or cross-sex hormones can be therapeutic.⁵ To prevent or reduce many of these health problems, asking about sexuality and gender identity is a good idea during the well visit, when you may have more time.

Tip No. 3: Not all developmental stages are considered equal

Adolescence is a period of rapid and phasic growth. Formation of an identity is one of the major psychosocial tasks for adolescence,⁶ and sexuality and gender are important identities. In general, in early adolescence identity becomes an issue as the teenager gains autonomy from parents. I typically start asking questions about sexuality and gender when the patient is 11 or 12, because many children may not understand sexuality and gender identity at a younger age. At these ages, I ask these questions with the parents in the room, then I ask them confidentially on subsequent well visits. This approach serves two purposes: it will prepare the adolescent for these complex and thought-provoking questions in future encounters, and it gives the parents an idea of the type of questions you will ask the children when they are old enough for the confidential visit, helping parents feel more comfortable in stepping out of the room during this time.

Tip No. 4: Keep it confidential

Many adolescents are reluctant to see a doctor, even if they are sick. The primary reason adolescents do not seek care is the fear that the provider will tell their parents about their illness.⁷ Although this should be applicable to all of your adolescent patients, you should make an extra effort to explicitly state to LGBT patients that the clinic visit is confidential (with the exception of risk of suicide, homicide, or child abuse). This is important for LGBT youth who are not out to their parents and may be in danger if they do come out.⁸

Tip No. 5: Normalize, normalize, normalize

Because of the stigma and discrimination surrounding sexual orientation and gender identity, many LGBT youth will be reluctant to disclose their sexual orientation or gender identity to their health care providers. At the same time, heterosexual youth may think that you’re asking them questions about sexuality or gender identity because you suspect them to be a member of the LGBT community. To avoid this awkward situation, many pediatricians do not ask these questions at all. A good remedy for this is to preface your questions about sexual orientation or gender identity by saying that you ask these questions to all your patients – that way no one feels singled out.

Tip No. 6: Ask for permission

As previously mentioned, members of the LGBT community may experience discrimination from their health care providers after disclosing to them their sexual orientation or gender identity.¹ This rejection can be traumatizing for LGBT youth, making them reluctant to discuss any issues related to sexual orientation or gender identity with any medical provider. As part of the trauma-informed approach, asking for permission before delving into issues related to sexual orientation and gender identity will give LGBT patients a sense of control, especially in an environment where there is a significant power differential.

Tip No. 7: Treat this as a skill

Despite the pressures for primary care pediatricians to maintain an efficient and effective clinical practice, many strive to learn new skills to provide the best care for their patients. Asking questions about sexuality and gender identity should be one of those skills. As with any skill, it will feel unnatural at first, and it will require practice. Mastering this skill, however, will help you address the health needs of this vulnerable population.

Asking questions about sexuality and gender identity is difficult for the primary care pediatrician. Hopefully, these tips can help you develop this important skill. It will also help you reach out to a population that is wary of the health care system.

References

1. J Am Board Fam Med. 2016;29(1):156-60.

2. https://www.cdc.gov/hiv/group/msm/index.html.

3. https://www.cdc.gov/std/tg2015/default.htm.

4. J Adolesc Health. 2011;49(2):115-23.

5. Nat Rev Endocrinol. 2011;7(8):466-72.
6. Neinstein LS. Adolescent health care: a practical guide. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2008.

7. J Adolesc Health. 2007;40(3):218-26.

8. Am J Orthopsychiatry. 1998;68(3):361-71.

Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of the University of Pittsburgh Medical Center and a postdoctoral fellow in the department of pediatrics at the University of Pittsburgh. Email him at pdnews@frontlinemedcom.com.

A while ago, I gave a talk on LGBT health to a group of primary care pediatricians. Although I was glad that they invited me to speak, I also sensed some discomfort in the audience. At the end of the lecture, many pediatricians told me that they were uncomfortable with bringing up the topic of sexuality and gender identity with their patients, and others wanted guidance on how to ask questions on sexuality and gender identity.

There are many barriers for primary pediatricians in addressing sexuality and gender identity concerns in their patients. First, pediatricians often will have up to 15 minutes for a visit, so they will have little time to address a complex issue. Second, primary care pediatricians may have known many of their patients since birth, and asking questions on sexuality and gender can feel awkward. Finally, many pediatricians may be working in more conservative areas in the country where asking questions on sexuality and gender identity may be controversial.

Tip No. 1: The environment counts

I cannot overstate how important it is to make your clinic a welcoming place for LGBT youth. Having various signs and stickers – like rainbow flags or the Human Rights Campaign sticker – will signal to LGBT youth that they are safe in your clinic. Creating a safe and welcoming environment is important because many people in the LGBT community have experienced rejection and discrimination from their primary care doctors.¹ Making your clinic a safe space will make it easier and efficient for patients to ask questions about sexuality and gender identity (see Dr. Gaya Chelvakumar’s column “Creating safe spaces for LGBTQ youth, families in health care settings” at pediatricnews.com).

Tip No. 2: Consider the context

Most likely, many presenting complaints – such as colds or sports injuries – of your adolescent patients will not involve sexual orientation or gender identity. There are exceptions. If you suspect an STD, then the risk for certain infections, such as HIV² or gonorrhea of the anus or of the pharynx³ are higher in gay young men. For the latter, your screening method would be different (that is, obtaining a pharyngeal swab or an anal swab instead of a urine sample). Also, because many LGBT youth have higher rates of mental health problems compared with heterosexual youth,⁴ you may want to ask questions about sexuality or gender identity to patients complaining of depressive or anxiety symptoms. This is especially important for transgender youth, because the implementation of pubertal blockers or cross-sex hormones can be therapeutic.⁵ To prevent or reduce many of these health problems, asking about sexuality and gender identity is a good idea during the well visit, when you may have more time.

Tip No. 3: Not all developmental stages are considered equal

Adolescence is a period of rapid and phasic growth. Formation of an identity is one of the major psychosocial tasks for adolescence,⁶ and sexuality and gender are important identities. In general, in early adolescence identity becomes an issue as the teenager gains autonomy from parents. I typically start asking questions about sexuality and gender when the patient is 11 or 12, because many children may not understand sexuality and gender identity at a younger age. At these ages, I ask these questions with the parents in the room, then I ask them confidentially on subsequent well visits. This approach serves two purposes: it will prepare the adolescent for these complex and thought-provoking questions in future encounters, and it gives the parents an idea of the type of questions you will ask the children when they are old enough for the confidential visit, helping parents feel more comfortable in stepping out of the room during this time.

Tip No. 4: Keep it confidential

Many adolescents are reluctant to see a doctor, even if they are sick. The primary reason adolescents do not seek care is the fear that the provider will tell their parents about their illness.⁷ Although this should be applicable to all of your adolescent patients, you should make an extra effort to explicitly state to LGBT patients that the clinic visit is confidential (with the exception of risk of suicide, homicide, or child abuse). This is important for LGBT youth who are not out to their parents and may be in danger if they do come out.⁸

Tip No. 5: Normalize, normalize, normalize

Because of the stigma and discrimination surrounding sexual orientation and gender identity, many LGBT youth will be reluctant to disclose their sexual orientation or gender identity to their health care providers. At the same time, heterosexual youth may think that you’re asking them questions about sexuality or gender identity because you suspect them to be a member of the LGBT community. To avoid this awkward situation, many pediatricians do not ask these questions at all. A good remedy for this is to preface your questions about sexual orientation or gender identity by saying that you ask these questions to all your patients – that way no one feels singled out.

Tip No. 6: Ask for permission

As previously mentioned, members of the LGBT community may experience discrimination from their health care providers after disclosing to them their sexual orientation or gender identity.¹ This rejection can be traumatizing for LGBT youth, making them reluctant to discuss any issues related to sexual orientation or gender identity with any medical provider. As part of the trauma-informed approach, asking for permission before delving into issues related to sexual orientation and gender identity will give LGBT patients a sense of control, especially in an environment where there is a significant power differential.

Tip No. 7: Treat this as a skill

Despite the pressures for primary care pediatricians to maintain an efficient and effective clinical practice, many strive to learn new skills to provide the best care for their patients. Asking questions about sexuality and gender identity should be one of those skills. As with any skill, it will feel unnatural at first, and it will require practice. Mastering this skill, however, will help you address the health needs of this vulnerable population.

Asking questions about sexuality and gender identity is difficult for the primary care pediatrician. Hopefully, these tips can help you develop this important skill. It will also help you reach out to a population that is wary of the health care system.

References

1. J Am Board Fam Med. 2016;29(1):156-60.

2. https://www.cdc.gov/hiv/group/msm/index.html.

3. https://www.cdc.gov/std/tg2015/default.htm.

4. J Adolesc Health. 2011;49(2):115-23.

5. Nat Rev Endocrinol. 2011;7(8):466-72.
6. Neinstein LS. Adolescent health care: a practical guide. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2008.

7. J Adolesc Health. 2007;40(3):218-26.

8. Am J Orthopsychiatry. 1998;68(3):361-71.

Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of the University of Pittsburgh Medical Center and a postdoctoral fellow in the department of pediatrics at the University of Pittsburgh. Email him at pdnews@frontlinemedcom.com.

The Food and Drug Administration has issued a warning that repeated or lengthy use of general anesthetic and sedation drugs during surgeries or procedures in children younger than 3 years or in pregnant women during their third trimester may affect the development of children’s brains.

“Recent human studies suggest that a single, relatively short exposure to general anesthetic and sedation drugs in infants or toddlers is unlikely to have negative effects on behavior or learning.” The studies suggesting a problem with longer or repeat exposures “had limitations, and it is unclear whether any negative effects seen in children’s learning or behavior were due to the drugs or to other factors, such as the underlying medical condition that led to the need for the surgery or procedure.” Further research is needed, the agency said.

aotto@frontlinemedcom.com

The Food and Drug Administration has issued a warning that repeated or lengthy use of general anesthetic and sedation drugs during surgeries or procedures in children younger than 3 years or in pregnant women during their third trimester may affect the development of children’s brains.

“Recent human studies suggest that a single, relatively short exposure to general anesthetic and sedation drugs in infants or toddlers is unlikely to have negative effects on behavior or learning.” The studies suggesting a problem with longer or repeat exposures “had limitations, and it is unclear whether any negative effects seen in children’s learning or behavior were due to the drugs or to other factors, such as the underlying medical condition that led to the need for the surgery or procedure.” Further research is needed, the agency said.

aotto@frontlinemedcom.com

The Food and Drug Administration has issued a warning that repeated or lengthy use of general anesthetic and sedation drugs during surgeries or procedures in children younger than 3 years or in pregnant women during their third trimester may affect the development of children’s brains.

“Recent human studies suggest that a single, relatively short exposure to general anesthetic and sedation drugs in infants or toddlers is unlikely to have negative effects on behavior or learning.” The studies suggesting a problem with longer or repeat exposures “had limitations, and it is unclear whether any negative effects seen in children’s learning or behavior were due to the drugs or to other factors, such as the underlying medical condition that led to the need for the surgery or procedure.” Further research is needed, the agency said.

aotto@frontlinemedcom.com

Sleeping newborn

Photo by Vera Kratochvil

Newborns with congenital cytomegalovirus (CMV) infection may have an increased risk of developing acute lymphoblastic leukemia (ALL), according to a study published in Blood.

The data also suggest the risk may be particularly high among Hispanic children.

Researchers said this is the first study to suggest that congenital CMV infection is a risk factor for childhood ALL and is more prominent in Hispanic children.

To conduct this study, the researchers first identified all known infections present in the bone marrow of 127 children diagnosed with ALL and 38 children diagnosed with acute myeloid leukemia (AML).

The team found CMV infection was prevalent in children with ALL but rare in those with AML.

Next, the researchers looked for CMV in newborn blood samples from 268 children who went on to develop ALL. The team compared the samples with samples from 270 healthy children.

“Our goal in tracking CMV back from the time of diagnosis to the womb was to establish that this infection occurred well before initiation of disease,” said lead study author Stephen Francis, PhD, of the University of Nevada and University of California, San Francisco.

He and his colleagues found that children who went on to develop ALL were nearly 4 times more likely than control subjects to be CMV-positive at birth. The odds ratio was 3.71 (P=0.0016).

The odds ratio was 5.9 in Hispanic children and 2.1 in non-Hispanic whites. The researchers said this finding is particularly interesting because of the high rate of ALL observed in Hispanics.

“If it’s true that in utero CMV is one of the initiating events in the development of childhood leukemia, then control of the virus has the potential to be a prevention target,” Dr Francis said. “That’s the real take-home message.”

While this research is in the early stages, the researchers hope these results will inspire more studies that will validate these findings and lead to the development of a CMV vaccine.

“This is the first step, but if we do end up finding a causal link to the most common childhood cancer, we hope that will light a fire in terms of stopping mother-to-child transmission of CMV,” Dr Francis said.

Sleeping newborn

Photo by Vera Kratochvil

Newborns with congenital cytomegalovirus (CMV) infection may have an increased risk of developing acute lymphoblastic leukemia (ALL), according to a study published in Blood.

The data also suggest the risk may be particularly high among Hispanic children.

Researchers said this is the first study to suggest that congenital CMV infection is a risk factor for childhood ALL and is more prominent in Hispanic children.

To conduct this study, the researchers first identified all known infections present in the bone marrow of 127 children diagnosed with ALL and 38 children diagnosed with acute myeloid leukemia (AML).

The team found CMV infection was prevalent in children with ALL but rare in those with AML.

Next, the researchers looked for CMV in newborn blood samples from 268 children who went on to develop ALL. The team compared the samples with samples from 270 healthy children.

“Our goal in tracking CMV back from the time of diagnosis to the womb was to establish that this infection occurred well before initiation of disease,” said lead study author Stephen Francis, PhD, of the University of Nevada and University of California, San Francisco.

He and his colleagues found that children who went on to develop ALL were nearly 4 times more likely than control subjects to be CMV-positive at birth. The odds ratio was 3.71 (P=0.0016).

The odds ratio was 5.9 in Hispanic children and 2.1 in non-Hispanic whites. The researchers said this finding is particularly interesting because of the high rate of ALL observed in Hispanics.

“If it’s true that in utero CMV is one of the initiating events in the development of childhood leukemia, then control of the virus has the potential to be a prevention target,” Dr Francis said. “That’s the real take-home message.”

While this research is in the early stages, the researchers hope these results will inspire more studies that will validate these findings and lead to the development of a CMV vaccine.

“This is the first step, but if we do end up finding a causal link to the most common childhood cancer, we hope that will light a fire in terms of stopping mother-to-child transmission of CMV,” Dr Francis said.

Sleeping newborn

Photo by Vera Kratochvil

Newborns with congenital cytomegalovirus (CMV) infection may have an increased risk of developing acute lymphoblastic leukemia (ALL), according to a study published in Blood.

The data also suggest the risk may be particularly high among Hispanic children.

Researchers said this is the first study to suggest that congenital CMV infection is a risk factor for childhood ALL and is more prominent in Hispanic children.

To conduct this study, the researchers first identified all known infections present in the bone marrow of 127 children diagnosed with ALL and 38 children diagnosed with acute myeloid leukemia (AML).

The team found CMV infection was prevalent in children with ALL but rare in those with AML.

Next, the researchers looked for CMV in newborn blood samples from 268 children who went on to develop ALL. The team compared the samples with samples from 270 healthy children.

“Our goal in tracking CMV back from the time of diagnosis to the womb was to establish that this infection occurred well before initiation of disease,” said lead study author Stephen Francis, PhD, of the University of Nevada and University of California, San Francisco.

He and his colleagues found that children who went on to develop ALL were nearly 4 times more likely than control subjects to be CMV-positive at birth. The odds ratio was 3.71 (P=0.0016).

The odds ratio was 5.9 in Hispanic children and 2.1 in non-Hispanic whites. The researchers said this finding is particularly interesting because of the high rate of ALL observed in Hispanics.

“If it’s true that in utero CMV is one of the initiating events in the development of childhood leukemia, then control of the virus has the potential to be a prevention target,” Dr Francis said. “That’s the real take-home message.”

While this research is in the early stages, the researchers hope these results will inspire more studies that will validate these findings and lead to the development of a CMV vaccine.

“This is the first step, but if we do end up finding a causal link to the most common childhood cancer, we hope that will light a fire in terms of stopping mother-to-child transmission of CMV,” Dr Francis said.

NEW YORK – Emergency departments are seeing more pediatric and adolescent patients with autism spectrum disorder, and are struggling to meet their needs, experts say.

At the annual meeting of the American Academy of Child and Adolescent Psychiatry, researchers presented results from studies attempting to quantify and better understand the uptick in ED visits, while clinicians shared strategies aimed at improving care in a setting that, nearly all agreed, presents unique obstacles for treating children with ASD.

Bright lights, excess noise, frequently changing care staff, and a lack of training in nonverbal communication strategies were among the problems the clinicians highlighted.

“There’s been a huge increase in recent years in the number of children with ASD that are coming into the ED because of either behavioral crises or general pediatric medical concerns that require us to intervene,” said Eron Y. Friedlaender, MD, MPH, of Children’s Hospital of Philadelphia (CHOP). “Yet, we struggle to offer kids with challenging behaviors or communication vulnerabilities the same standard of care that we’re used to offering.”

John J. McGonigle, PhD, head of the autism center at the University of Pittsburgh, noted that incidents tied to safety issues, such as disruptive behavior, aggression, and self-injury, were occurring among young ASD patients in the ED. In 2015, he said, Pennsylvania’s statewide patient safety data reporting system reviewed hospital records from 2004 to 2014 and recorded 138 events in the ED involving patients with ASD, 86 of them involving children and adolescents.

Finding barriers to care

Dr. Friedlaender described a pilot study she and her colleagues conducted in her institution’s sedation unit that was designed to help them understand the barriers to optimal care for ASD patients, and to find ways around them. Many of the studies the investigators consulted “came from the dental literature, where there is a significant number of special-needs kids who need support during procedural care. [Dentists] were among the first to publish on how to make this a reasonable experience.”

One key insight gleaned from this literature, Dr. Friedlaender said, was that a simple screening question – whether the child could sit still for a haircut – proved sensitive in indicating a need for accommodation.

The CHOP researchers created a three-question universal screening tool that schedulers asked of all caregivers when a child presented to the ED. In addition to asking whether the child could sit still, schedulers asked whether he or she had a behavioral diagnosis or special communication needs. Of 458 families who completed the screening, 96 answered positively to at least one of the questions, and 79, or 17% of the cohort, indicated a behavioral diagnosis.

Such information previously had been missed, Dr. Friedlaender said, because “many families didn’t consider autism part of a medical history – if we didn’t ask about it, they didn’t share it.”

Her group also conducted a study on the effectiveness of self-reported pain scales in 43 verbal ASD children aged 6-17 who had undergone surgical procedures. Dr. Friedlaender said she suspected that it was impractical to ask children with ASD to use only pictures of facial expressions to indicate their pain.

The subjects were asked to circle images of faces with expressions corresponding to their pain. They also were asked to locate their pain by drawing it on tablet computers, and given poker chips to represent their degree of pain, with one chip the least and four the most. Caregivers were recruited to assist with questioning and interpreting responses.

All children in the study were able to describe and locate their pain. “We learned that there isn’t one universal pain tool that works for all kids,” Dr. Friedlaender said, “but that facial expressions and body language don’t often match pain scores” in ASD children. The study also revealed that parent or caregiver mediation is helpful in discerning the location and intensity of pain.

Why ED use is high

Other research presented at AACAP sought to grasp the scope of, and reasons behind, the increase in ASD youth seen in hospital emergency departments.

Michael J. Murray, MD, of Pennsylvania State University in Hershey, found using commercial insurance data from large employers showing that ED visits increased from 3% in 2005 to nearly 16% in 2013 among youth diagnosed with ASD, while a non-ASD comparison cohort saw a far more consistent rate of ED visits across the same time period, of about 3%. Adolescents with ASD were nearly five times more likely to have had an ED visit than were non-ASD adolescents (95% confidence interval, 4.678-4.875).

Dr. Murray said in an interview that the ASD cohort identified in his study “was smaller than it should have been,” compared with Centers for Disease Control and Prevention prevalence data. One likely reason is that not all the insurers had to cover ASD in the first years of the study period. Dr. Murray said he thinks a new study using public insurance data might provide a fuller picture.

Dr. Murray and colleagues’ study, which looked at youth aged 12-21, revealed that being older increased the likelihood of an ED visit. “We think it may have to do with the whole transition out of school,” he said. “This is the first generation with ASD that’s accustomed to having good school-based supports.” The transition to adulthood “is a really important time, and that’s when we’re pulling away from them.”

Sarah Lytle, MD, of University Hospitals Cleveland Medical Center, presented a literature review of ASD youth in the ED from 2006 through 2015. Dr. Lytle found that children with ASD were more likely to visit the ED than were those without ASD. In addition, the review showed a higher proportion of ED visits for psychiatric problems (13% of visits vs. 2% for non-ASD youth). Youth with ASD were more likely to be admitted to a psychiatric unit or medically boarded in the ED, she found. They also were more likely to have public insurance.

Dr. Lytle’s study drew from a dozen published studies in different age groups (subjects ranged from 0 to 24 years across studies). Though it was difficult to draw conclusions related to which saw the highest ED use, one study found the risk of ED use higher in adolescents, compared with younger children, she said. “One thing I see clinically is that when kids hit the age of 12, pediatric psychiatric units often won’t take them,” she said, as children are physically bigger and may be harder to manage. “And then they’re cycled into the ED,” she said.

Creating the ‘ASD care pathway’

Clinicians from New York shared their experiences designing and implementing an autism care pathway within the state’s only pediatric psychiatric emergency department.

At NYU Health and Hospitals/Bellevue, a public hospital, clinicians found themselves struggling to manage ASD patients, who comprise between 10% and 20% of children seen. “Most of our staff, and even our child psychiatrists, had previously had very little experience working with kids with autism, and that was true for most of our child psychiatrists as well,” said Ruth S. Gerson, MD, who oversees the hospital’s Children’s Comprehensive Psychiatric Emergency Program.

NEW YORK – Emergency departments are seeing more pediatric and adolescent patients with autism spectrum disorder, and are struggling to meet their needs, experts say.

At the annual meeting of the American Academy of Child and Adolescent Psychiatry, researchers presented results from studies attempting to quantify and better understand the uptick in ED visits, while clinicians shared strategies aimed at improving care in a setting that, nearly all agreed, presents unique obstacles for treating children with ASD.

Bright lights, excess noise, frequently changing care staff, and a lack of training in nonverbal communication strategies were among the problems the clinicians highlighted.

“There’s been a huge increase in recent years in the number of children with ASD that are coming into the ED because of either behavioral crises or general pediatric medical concerns that require us to intervene,” said Eron Y. Friedlaender, MD, MPH, of Children’s Hospital of Philadelphia (CHOP). “Yet, we struggle to offer kids with challenging behaviors or communication vulnerabilities the same standard of care that we’re used to offering.”

John J. McGonigle, PhD, head of the autism center at the University of Pittsburgh, noted that incidents tied to safety issues, such as disruptive behavior, aggression, and self-injury, were occurring among young ASD patients in the ED. In 2015, he said, Pennsylvania’s statewide patient safety data reporting system reviewed hospital records from 2004 to 2014 and recorded 138 events in the ED involving patients with ASD, 86 of them involving children and adolescents.

Finding barriers to care

Dr. Friedlaender described a pilot study she and her colleagues conducted in her institution’s sedation unit that was designed to help them understand the barriers to optimal care for ASD patients, and to find ways around them. Many of the studies the investigators consulted “came from the dental literature, where there is a significant number of special-needs kids who need support during procedural care. [Dentists] were among the first to publish on how to make this a reasonable experience.”

One key insight gleaned from this literature, Dr. Friedlaender said, was that a simple screening question – whether the child could sit still for a haircut – proved sensitive in indicating a need for accommodation.

The CHOP researchers created a three-question universal screening tool that schedulers asked of all caregivers when a child presented to the ED. In addition to asking whether the child could sit still, schedulers asked whether he or she had a behavioral diagnosis or special communication needs. Of 458 families who completed the screening, 96 answered positively to at least one of the questions, and 79, or 17% of the cohort, indicated a behavioral diagnosis.

Such information previously had been missed, Dr. Friedlaender said, because “many families didn’t consider autism part of a medical history – if we didn’t ask about it, they didn’t share it.”

Her group also conducted a study on the effectiveness of self-reported pain scales in 43 verbal ASD children aged 6-17 who had undergone surgical procedures. Dr. Friedlaender said she suspected that it was impractical to ask children with ASD to use only pictures of facial expressions to indicate their pain.

The subjects were asked to circle images of faces with expressions corresponding to their pain. They also were asked to locate their pain by drawing it on tablet computers, and given poker chips to represent their degree of pain, with one chip the least and four the most. Caregivers were recruited to assist with questioning and interpreting responses.

All children in the study were able to describe and locate their pain. “We learned that there isn’t one universal pain tool that works for all kids,” Dr. Friedlaender said, “but that facial expressions and body language don’t often match pain scores” in ASD children. The study also revealed that parent or caregiver mediation is helpful in discerning the location and intensity of pain.

Why ED use is high

Other research presented at AACAP sought to grasp the scope of, and reasons behind, the increase in ASD youth seen in hospital emergency departments.

Michael J. Murray, MD, of Pennsylvania State University in Hershey, found using commercial insurance data from large employers showing that ED visits increased from 3% in 2005 to nearly 16% in 2013 among youth diagnosed with ASD, while a non-ASD comparison cohort saw a far more consistent rate of ED visits across the same time period, of about 3%. Adolescents with ASD were nearly five times more likely to have had an ED visit than were non-ASD adolescents (95% confidence interval, 4.678-4.875).

Dr. Murray said in an interview that the ASD cohort identified in his study “was smaller than it should have been,” compared with Centers for Disease Control and Prevention prevalence data. One likely reason is that not all the insurers had to cover ASD in the first years of the study period. Dr. Murray said he thinks a new study using public insurance data might provide a fuller picture.

Dr. Murray and colleagues’ study, which looked at youth aged 12-21, revealed that being older increased the likelihood of an ED visit. “We think it may have to do with the whole transition out of school,” he said. “This is the first generation with ASD that’s accustomed to having good school-based supports.” The transition to adulthood “is a really important time, and that’s when we’re pulling away from them.”

Sarah Lytle, MD, of University Hospitals Cleveland Medical Center, presented a literature review of ASD youth in the ED from 2006 through 2015. Dr. Lytle found that children with ASD were more likely to visit the ED than were those without ASD. In addition, the review showed a higher proportion of ED visits for psychiatric problems (13% of visits vs. 2% for non-ASD youth). Youth with ASD were more likely to be admitted to a psychiatric unit or medically boarded in the ED, she found. They also were more likely to have public insurance.

Dr. Lytle’s study drew from a dozen published studies in different age groups (subjects ranged from 0 to 24 years across studies). Though it was difficult to draw conclusions related to which saw the highest ED use, one study found the risk of ED use higher in adolescents, compared with younger children, she said. “One thing I see clinically is that when kids hit the age of 12, pediatric psychiatric units often won’t take them,” she said, as children are physically bigger and may be harder to manage. “And then they’re cycled into the ED,” she said.

Creating the ‘ASD care pathway’

Clinicians from New York shared their experiences designing and implementing an autism care pathway within the state’s only pediatric psychiatric emergency department.

At NYU Health and Hospitals/Bellevue, a public hospital, clinicians found themselves struggling to manage ASD patients, who comprise between 10% and 20% of children seen. “Most of our staff, and even our child psychiatrists, had previously had very little experience working with kids with autism, and that was true for most of our child psychiatrists as well,” said Ruth S. Gerson, MD, who oversees the hospital’s Children’s Comprehensive Psychiatric Emergency Program.

NEW YORK – Emergency departments are seeing more pediatric and adolescent patients with autism spectrum disorder, and are struggling to meet their needs, experts say.

At the annual meeting of the American Academy of Child and Adolescent Psychiatry, researchers presented results from studies attempting to quantify and better understand the uptick in ED visits, while clinicians shared strategies aimed at improving care in a setting that, nearly all agreed, presents unique obstacles for treating children with ASD.

Bright lights, excess noise, frequently changing care staff, and a lack of training in nonverbal communication strategies were among the problems the clinicians highlighted.

“There’s been a huge increase in recent years in the number of children with ASD that are coming into the ED because of either behavioral crises or general pediatric medical concerns that require us to intervene,” said Eron Y. Friedlaender, MD, MPH, of Children’s Hospital of Philadelphia (CHOP). “Yet, we struggle to offer kids with challenging behaviors or communication vulnerabilities the same standard of care that we’re used to offering.”

John J. McGonigle, PhD, head of the autism center at the University of Pittsburgh, noted that incidents tied to safety issues, such as disruptive behavior, aggression, and self-injury, were occurring among young ASD patients in the ED. In 2015, he said, Pennsylvania’s statewide patient safety data reporting system reviewed hospital records from 2004 to 2014 and recorded 138 events in the ED involving patients with ASD, 86 of them involving children and adolescents.

Finding barriers to care

Dr. Friedlaender described a pilot study she and her colleagues conducted in her institution’s sedation unit that was designed to help them understand the barriers to optimal care for ASD patients, and to find ways around them. Many of the studies the investigators consulted “came from the dental literature, where there is a significant number of special-needs kids who need support during procedural care. [Dentists] were among the first to publish on how to make this a reasonable experience.”

One key insight gleaned from this literature, Dr. Friedlaender said, was that a simple screening question – whether the child could sit still for a haircut – proved sensitive in indicating a need for accommodation.

The CHOP researchers created a three-question universal screening tool that schedulers asked of all caregivers when a child presented to the ED. In addition to asking whether the child could sit still, schedulers asked whether he or she had a behavioral diagnosis or special communication needs. Of 458 families who completed the screening, 96 answered positively to at least one of the questions, and 79, or 17% of the cohort, indicated a behavioral diagnosis.

Such information previously had been missed, Dr. Friedlaender said, because “many families didn’t consider autism part of a medical history – if we didn’t ask about it, they didn’t share it.”

Her group also conducted a study on the effectiveness of self-reported pain scales in 43 verbal ASD children aged 6-17 who had undergone surgical procedures. Dr. Friedlaender said she suspected that it was impractical to ask children with ASD to use only pictures of facial expressions to indicate their pain.

The subjects were asked to circle images of faces with expressions corresponding to their pain. They also were asked to locate their pain by drawing it on tablet computers, and given poker chips to represent their degree of pain, with one chip the least and four the most. Caregivers were recruited to assist with questioning and interpreting responses.

All children in the study were able to describe and locate their pain. “We learned that there isn’t one universal pain tool that works for all kids,” Dr. Friedlaender said, “but that facial expressions and body language don’t often match pain scores” in ASD children. The study also revealed that parent or caregiver mediation is helpful in discerning the location and intensity of pain.

Why ED use is high

Other research presented at AACAP sought to grasp the scope of, and reasons behind, the increase in ASD youth seen in hospital emergency departments.

Michael J. Murray, MD, of Pennsylvania State University in Hershey, found using commercial insurance data from large employers showing that ED visits increased from 3% in 2005 to nearly 16% in 2013 among youth diagnosed with ASD, while a non-ASD comparison cohort saw a far more consistent rate of ED visits across the same time period, of about 3%. Adolescents with ASD were nearly five times more likely to have had an ED visit than were non-ASD adolescents (95% confidence interval, 4.678-4.875).

Dr. Murray said in an interview that the ASD cohort identified in his study “was smaller than it should have been,” compared with Centers for Disease Control and Prevention prevalence data. One likely reason is that not all the insurers had to cover ASD in the first years of the study period. Dr. Murray said he thinks a new study using public insurance data might provide a fuller picture.

Dr. Murray and colleagues’ study, which looked at youth aged 12-21, revealed that being older increased the likelihood of an ED visit. “We think it may have to do with the whole transition out of school,” he said. “This is the first generation with ASD that’s accustomed to having good school-based supports.” The transition to adulthood “is a really important time, and that’s when we’re pulling away from them.”

Sarah Lytle, MD, of University Hospitals Cleveland Medical Center, presented a literature review of ASD youth in the ED from 2006 through 2015. Dr. Lytle found that children with ASD were more likely to visit the ED than were those without ASD. In addition, the review showed a higher proportion of ED visits for psychiatric problems (13% of visits vs. 2% for non-ASD youth). Youth with ASD were more likely to be admitted to a psychiatric unit or medically boarded in the ED, she found. They also were more likely to have public insurance.

Dr. Lytle’s study drew from a dozen published studies in different age groups (subjects ranged from 0 to 24 years across studies). Though it was difficult to draw conclusions related to which saw the highest ED use, one study found the risk of ED use higher in adolescents, compared with younger children, she said. “One thing I see clinically is that when kids hit the age of 12, pediatric psychiatric units often won’t take them,” she said, as children are physically bigger and may be harder to manage. “And then they’re cycled into the ED,” she said.

Creating the ‘ASD care pathway’

Clinicians from New York shared their experiences designing and implementing an autism care pathway within the state’s only pediatric psychiatric emergency department.

At NYU Health and Hospitals/Bellevue, a public hospital, clinicians found themselves struggling to manage ASD patients, who comprise between 10% and 20% of children seen. “Most of our staff, and even our child psychiatrists, had previously had very little experience working with kids with autism, and that was true for most of our child psychiatrists as well,” said Ruth S. Gerson, MD, who oversees the hospital’s Children’s Comprehensive Psychiatric Emergency Program.

Fear and anxiety, economic disadvantage, and recent psychosocial adversity contribute significantly to the onset of major depressive disorder in children and adolescents with a strong family history of the condition.

A 4-year longitudinal study followed the offspring of 279 families in which one parent had experienced at least two episodes of major depressive disorder (MDD) and in which there was a biologically related child living with that index parent.

Fear and anxiety showed a strong and significant association with new-onset major depressive disorder, as did irritability. Furthermore, the association between the two symptoms was low but significant, suggesting that they do not often co-occur (JAMA Psychiatry. 2016 Dec 7. doi: 10.1001/jamapsychiatry.2016.3140).

“The results suggested that generalized anxiety symptoms were driving the predictive effect of fear/anxiety on new-onset MDD and that fear/anxiety (and not irritability) predicted an especially early MDD onset,” wrote Frances Rice, PhD, of the division of psychological medicine and clinical neurosciences at Cardiff University, Wales, and coauthors.

Recent psychosocial adversity – stressful events such as the death of a friend, illness, bullying, or parents fighting – also showed a strong association with new-onset major depressive disorder, while economic disadvantage had a lesser but still significant contribution. Both of these also were associated with fear and anxiety, and irritability.

Greater family history and more severe parental depression also contributed significantly to the emergence of depression in the offspring, although those factors were not associated with the clinical antecedents such as fear and anxiety.

“Therefore, the indicators of social risk predicted MDD independent of correlated familial risk, parental depression severity, and clinical antecedents in the child,” the authors wrote. “This result has important implications for treatment and prevention and highlights the need to resolve not only clinical phenomena in the child but also wider contextual difficulties.”

The study also suggested that neither disruptive behavior nor low mood were significantly associated with new-onset MDD in children and adolescents.

The children and adolescents in the study had a mean of 1.85 DSM-IV major depressive disorder symptoms at follow-up, and 20 of them – six males and 14 females – had new-onset MDD, with a mean age of onset of 14.4 years.

“Our findings suggest that primary prevention methods for depression in groups with high familial risk will need to include effective treatment of parental depression, irritability, and fear/anxiety in the child and consider social risk factors,” Dr. Rice and her coauthors wrote.

The research and researchers were supported by the Sir Jules Thorn Charitable Trust, the Medical Research Council, the Economic and Social Research Council, the British Academy, and the British Medical Association. No conflicts of interest were declared.

Fear and anxiety, economic disadvantage, and recent psychosocial adversity contribute significantly to the onset of major depressive disorder in children and adolescents with a strong family history of the condition.

A 4-year longitudinal study followed the offspring of 279 families in which one parent had experienced at least two episodes of major depressive disorder (MDD) and in which there was a biologically related child living with that index parent.

Fear and anxiety showed a strong and significant association with new-onset major depressive disorder, as did irritability. Furthermore, the association between the two symptoms was low but significant, suggesting that they do not often co-occur (JAMA Psychiatry. 2016 Dec 7. doi: 10.1001/jamapsychiatry.2016.3140).

“The results suggested that generalized anxiety symptoms were driving the predictive effect of fear/anxiety on new-onset MDD and that fear/anxiety (and not irritability) predicted an especially early MDD onset,” wrote Frances Rice, PhD, of the division of psychological medicine and clinical neurosciences at Cardiff University, Wales, and coauthors.

Recent psychosocial adversity – stressful events such as the death of a friend, illness, bullying, or parents fighting – also showed a strong association with new-onset major depressive disorder, while economic disadvantage had a lesser but still significant contribution. Both of these also were associated with fear and anxiety, and irritability.

Greater family history and more severe parental depression also contributed significantly to the emergence of depression in the offspring, although those factors were not associated with the clinical antecedents such as fear and anxiety.

“Therefore, the indicators of social risk predicted MDD independent of correlated familial risk, parental depression severity, and clinical antecedents in the child,” the authors wrote. “This result has important implications for treatment and prevention and highlights the need to resolve not only clinical phenomena in the child but also wider contextual difficulties.”

The study also suggested that neither disruptive behavior nor low mood were significantly associated with new-onset MDD in children and adolescents.

The children and adolescents in the study had a mean of 1.85 DSM-IV major depressive disorder symptoms at follow-up, and 20 of them – six males and 14 females – had new-onset MDD, with a mean age of onset of 14.4 years.

“Our findings suggest that primary prevention methods for depression in groups with high familial risk will need to include effective treatment of parental depression, irritability, and fear/anxiety in the child and consider social risk factors,” Dr. Rice and her coauthors wrote.

The research and researchers were supported by the Sir Jules Thorn Charitable Trust, the Medical Research Council, the Economic and Social Research Council, the British Academy, and the British Medical Association. No conflicts of interest were declared.

Fear and anxiety, economic disadvantage, and recent psychosocial adversity contribute significantly to the onset of major depressive disorder in children and adolescents with a strong family history of the condition.

A 4-year longitudinal study followed the offspring of 279 families in which one parent had experienced at least two episodes of major depressive disorder (MDD) and in which there was a biologically related child living with that index parent.

Fear and anxiety showed a strong and significant association with new-onset major depressive disorder, as did irritability. Furthermore, the association between the two symptoms was low but significant, suggesting that they do not often co-occur (JAMA Psychiatry. 2016 Dec 7. doi: 10.1001/jamapsychiatry.2016.3140).

“The results suggested that generalized anxiety symptoms were driving the predictive effect of fear/anxiety on new-onset MDD and that fear/anxiety (and not irritability) predicted an especially early MDD onset,” wrote Frances Rice, PhD, of the division of psychological medicine and clinical neurosciences at Cardiff University, Wales, and coauthors.

Recent psychosocial adversity – stressful events such as the death of a friend, illness, bullying, or parents fighting – also showed a strong association with new-onset major depressive disorder, while economic disadvantage had a lesser but still significant contribution. Both of these also were associated with fear and anxiety, and irritability.

Greater family history and more severe parental depression also contributed significantly to the emergence of depression in the offspring, although those factors were not associated with the clinical antecedents such as fear and anxiety.

“Therefore, the indicators of social risk predicted MDD independent of correlated familial risk, parental depression severity, and clinical antecedents in the child,” the authors wrote. “This result has important implications for treatment and prevention and highlights the need to resolve not only clinical phenomena in the child but also wider contextual difficulties.”

The study also suggested that neither disruptive behavior nor low mood were significantly associated with new-onset MDD in children and adolescents.

The children and adolescents in the study had a mean of 1.85 DSM-IV major depressive disorder symptoms at follow-up, and 20 of them – six males and 14 females – had new-onset MDD, with a mean age of onset of 14.4 years.

“Our findings suggest that primary prevention methods for depression in groups with high familial risk will need to include effective treatment of parental depression, irritability, and fear/anxiety in the child and consider social risk factors,” Dr. Rice and her coauthors wrote.

The research and researchers were supported by the Sir Jules Thorn Charitable Trust, the Medical Research Council, the Economic and Social Research Council, the British Academy, and the British Medical Association. No conflicts of interest were declared.

Young children and infants who require cardiac valve replacement are limited to fixed-diameter prostheses that cannot accommodate their growth, but researchers at Boston Children’s Hospital have reinforced an expandable bovine jugular vein graft using an external stent and implanted it in 42 patients with acceptable short-term results, according to a report in the Journal of Thoracic and Cardiovascular Surgery.

In 4 years, the modified Melody valve (Medtronic) has proved amenable to enlargement via catheterization as the child grows, Sitaram M. Emani, MD, and coauthors said. “The valve was competent with low gradient acutely postoperatively in all patients,” Dr. Emani and his coauthors said (J Thorac Cardiovasc Surg. 2016 Dec;152[6]:1514-23).

Young children and infants who require cardiac valve replacement are limited to fixed-diameter prostheses that cannot accommodate their growth, but researchers at Boston Children’s Hospital have reinforced an expandable bovine jugular vein graft using an external stent and implanted it in 42 patients with acceptable short-term results, according to a report in the Journal of Thoracic and Cardiovascular Surgery.

In 4 years, the modified Melody valve (Medtronic) has proved amenable to enlargement via catheterization as the child grows, Sitaram M. Emani, MD, and coauthors said. “The valve was competent with low gradient acutely postoperatively in all patients,” Dr. Emani and his coauthors said (J Thorac Cardiovasc Surg. 2016 Dec;152[6]:1514-23).

Young children and infants who require cardiac valve replacement are limited to fixed-diameter prostheses that cannot accommodate their growth, but researchers at Boston Children’s Hospital have reinforced an expandable bovine jugular vein graft using an external stent and implanted it in 42 patients with acceptable short-term results, according to a report in the Journal of Thoracic and Cardiovascular Surgery.

In 4 years, the modified Melody valve (Medtronic) has proved amenable to enlargement via catheterization as the child grows, Sitaram M. Emani, MD, and coauthors said. “The valve was competent with low gradient acutely postoperatively in all patients,” Dr. Emani and his coauthors said (J Thorac Cardiovasc Surg. 2016 Dec;152[6]:1514-23).

Illicit substance use among teenagers has dropped to the lowest rate in decades, with the exception of marijuana, according to results of the 2016 Monitoring the Future survey released on Dec. 13 by the National Institute on Drug Abuse.

Overall, 14% of 12th graders reported using an illicit drug (other than marijuana), compared with 18% in 2013 (the highest rate in the history of the survey).

Illicit substance use among teenagers has dropped to the lowest rate in decades, with the exception of marijuana, according to results of the 2016 Monitoring the Future survey released on Dec. 13 by the National Institute on Drug Abuse.

Overall, 14% of 12th graders reported using an illicit drug (other than marijuana), compared with 18% in 2013 (the highest rate in the history of the survey).

Illicit substance use among teenagers has dropped to the lowest rate in decades, with the exception of marijuana, according to results of the 2016 Monitoring the Future survey released on Dec. 13 by the National Institute on Drug Abuse.

Overall, 14% of 12th graders reported using an illicit drug (other than marijuana), compared with 18% in 2013 (the highest rate in the history of the survey).

Johns Hopkins clinicians caring

for a child in the pediatric ICU

Photo courtesy of

Johns Hopkins Medicine

New research suggests clinical practice guidelines can reduce the number of potentially unnecessary blood culture draws in critically ill children without endangering doctors’ ability to diagnose and treat sepsis.

The guidelines consist of 2 documents—a screening checklist and a decision algorithm.

In a single-center study, clinicians consulted these documents when considering ordering blood cultures for patients in a pediatric intensive care unit (ICU).

The clinicians said there was an immediate reduction in unnecessary blood draws after they began using these guidelines, and they were able to sustain the reduction over time.

Aaron Milstone, MD, of the Johns Hopkins University School of Medicine in Baltimore, Maryland, and his colleagues described these results in JAMA Pediatrics.

The guidelines were created by a team of nurses, vascular access specialists, and physicians across specialties. The team created a fever/sepsis screening checklist and an accompanying decision-making flow chart designed to guide clinicians in the decision to draw blood.

These tools were posted in the pediatric ICU at The Johns Hopkins Hospital with instructions to be completed at the bedside by nurses and physicians. Each week, the team would meet to evaluate the data gathered, review how many cultures were sent from the unit, and discuss in detail individual cases where blood draws were necessary.

The researchers compared patient length of stay, mortality, readmission, and the number of episodes of suspected septic shock at the hospital before and after this intervention was implemented.

In the year before the team introduced the tools, there were 2204 patient visits to the pediatric ICU and 1807 blood cultures drawn.

After the intervention, there were 984 blood cultures drawn for 2356 patient visits, almost halving the number of blood cultures per patient day.

Comparing the pre- and post-intervention periods, there was no statistical difference in the occurrence of septic shock, hospital mortality, or hospital readmission.

Dr Milstone said this means patients experienced no increased risk of a missed sepsis diagnosis because of the intervention.

He and his colleagues said the future directions of this research include further exploring the implications this intervention may have for antibiotic use as well as working to implement the tools in other ICUs. The tools are already being tried at Johns Hopkins All Children’s Hospital in Florida and in the pediatric ICU at the University of Virginia.

Johns Hopkins clinicians caring

for a child in the pediatric ICU

Photo courtesy of

Johns Hopkins Medicine

New research suggests clinical practice guidelines can reduce the number of potentially unnecessary blood culture draws in critically ill children without endangering doctors’ ability to diagnose and treat sepsis.

The guidelines consist of 2 documents—a screening checklist and a decision algorithm.

In a single-center study, clinicians consulted these documents when considering ordering blood cultures for patients in a pediatric intensive care unit (ICU).

The clinicians said there was an immediate reduction in unnecessary blood draws after they began using these guidelines, and they were able to sustain the reduction over time.

Aaron Milstone, MD, of the Johns Hopkins University School of Medicine in Baltimore, Maryland, and his colleagues described these results in JAMA Pediatrics.

The guidelines were created by a team of nurses, vascular access specialists, and physicians across specialties. The team created a fever/sepsis screening checklist and an accompanying decision-making flow chart designed to guide clinicians in the decision to draw blood.

These tools were posted in the pediatric ICU at The Johns Hopkins Hospital with instructions to be completed at the bedside by nurses and physicians. Each week, the team would meet to evaluate the data gathered, review how many cultures were sent from the unit, and discuss in detail individual cases where blood draws were necessary.

The researchers compared patient length of stay, mortality, readmission, and the number of episodes of suspected septic shock at the hospital before and after this intervention was implemented.

In the year before the team introduced the tools, there were 2204 patient visits to the pediatric ICU and 1807 blood cultures drawn.

After the intervention, there were 984 blood cultures drawn for 2356 patient visits, almost halving the number of blood cultures per patient day.

Comparing the pre- and post-intervention periods, there was no statistical difference in the occurrence of septic shock, hospital mortality, or hospital readmission.

Dr Milstone said this means patients experienced no increased risk of a missed sepsis diagnosis because of the intervention.

He and his colleagues said the future directions of this research include further exploring the implications this intervention may have for antibiotic use as well as working to implement the tools in other ICUs. The tools are already being tried at Johns Hopkins All Children’s Hospital in Florida and in the pediatric ICU at the University of Virginia.

Johns Hopkins clinicians caring

for a child in the pediatric ICU

Photo courtesy of

Johns Hopkins Medicine

New research suggests clinical practice guidelines can reduce the number of potentially unnecessary blood culture draws in critically ill children without endangering doctors’ ability to diagnose and treat sepsis.

The guidelines consist of 2 documents—a screening checklist and a decision algorithm.

In a single-center study, clinicians consulted these documents when considering ordering blood cultures for patients in a pediatric intensive care unit (ICU).

The clinicians said there was an immediate reduction in unnecessary blood draws after they began using these guidelines, and they were able to sustain the reduction over time.

Aaron Milstone, MD, of the Johns Hopkins University School of Medicine in Baltimore, Maryland, and his colleagues described these results in JAMA Pediatrics.

The guidelines were created by a team of nurses, vascular access specialists, and physicians across specialties. The team created a fever/sepsis screening checklist and an accompanying decision-making flow chart designed to guide clinicians in the decision to draw blood.

These tools were posted in the pediatric ICU at The Johns Hopkins Hospital with instructions to be completed at the bedside by nurses and physicians. Each week, the team would meet to evaluate the data gathered, review how many cultures were sent from the unit, and discuss in detail individual cases where blood draws were necessary.

The researchers compared patient length of stay, mortality, readmission, and the number of episodes of suspected septic shock at the hospital before and after this intervention was implemented.

In the year before the team introduced the tools, there were 2204 patient visits to the pediatric ICU and 1807 blood cultures drawn.

After the intervention, there were 984 blood cultures drawn for 2356 patient visits, almost halving the number of blood cultures per patient day.

Comparing the pre- and post-intervention periods, there was no statistical difference in the occurrence of septic shock, hospital mortality, or hospital readmission.

Dr Milstone said this means patients experienced no increased risk of a missed sepsis diagnosis because of the intervention.

He and his colleagues said the future directions of this research include further exploring the implications this intervention may have for antibiotic use as well as working to implement the tools in other ICUs. The tools are already being tried at Johns Hopkins All Children’s Hospital in Florida and in the pediatric ICU at the University of Virginia.

Colombia experienced a fourfold increase in cases of microcephaly following the Zika virus outbreak in 2016, with temporal evidence suggesting that infection in the first months of pregnancy poses the greatest risk to the fetus of microcephaly.

From January 31 through mid-November 2016, there were 476 cases of microcephaly reported in Colombia, four times the rate of cases reported during the same period in 2015. In July 2016, there was a ninefold increase in Colombian microcephaly cases reported, compared with July 2015, according to data published in the Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report.

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

Colombia experienced a fourfold increase in cases of microcephaly following the Zika virus outbreak in 2016, with temporal evidence suggesting that infection in the first months of pregnancy poses the greatest risk to the fetus of microcephaly.

From January 31 through mid-November 2016, there were 476 cases of microcephaly reported in Colombia, four times the rate of cases reported during the same period in 2015. In July 2016, there was a ninefold increase in Colombian microcephaly cases reported, compared with July 2015, according to data published in the Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report.

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

Colombia experienced a fourfold increase in cases of microcephaly following the Zika virus outbreak in 2016, with temporal evidence suggesting that infection in the first months of pregnancy poses the greatest risk to the fetus of microcephaly.

From January 31 through mid-November 2016, there were 476 cases of microcephaly reported in Colombia, four times the rate of cases reported during the same period in 2015. In July 2016, there was a ninefold increase in Colombian microcephaly cases reported, compared with July 2015, according to data published in the Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report.

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

A mass spectrometry test was able to rapidly measure lung maturity in premature infants at risk for respiratory distress syndrome (RDS), according to Henrik Verder, MD, of Holbaek (Denmark) University Hospital, and his associates.

Samples of gastric aspirates were taken from 136 infants with gestation periods of 24-31 weeks, and analyzed with mass spectrometry. Of this group, 61 developed RDS, and 7 died before the end of the study period. With a lecithin/sphingomyelin (L/S) cut-off ratio of 2.2, sensitivity of the mass spectrometry test was 92%, specificity was 73%, positive predictive value was 74%, and negative predictive was value of 92%. Sensitivity was high for all gestational age groups, the investigators noted.

Oropharyngeal secretions were sampled from an additional group of 59 infants and analyzed using spectrometry, with an L/S cut-off value of 3.7; however sensitivity and specificity were lower than for gastric aspirates.

“This test could help identify which infants will benefit from very early surfactant treatment, with the potential to significantly improve clinical outcomes resulting in less severe RDS, less need of mechanical ventilation and oxygen and less severe bronchopulmonary dysplasia,” the investigators concluded.

Find the study in Acta Paediatrica (2016. doi: 10.1111/apa.13683)

lfranki@frontlinemedcom.com

A mass spectrometry test was able to rapidly measure lung maturity in premature infants at risk for respiratory distress syndrome (RDS), according to Henrik Verder, MD, of Holbaek (Denmark) University Hospital, and his associates.

Samples of gastric aspirates were taken from 136 infants with gestation periods of 24-31 weeks, and analyzed with mass spectrometry. Of this group, 61 developed RDS, and 7 died before the end of the study period. With a lecithin/sphingomyelin (L/S) cut-off ratio of 2.2, sensitivity of the mass spectrometry test was 92%, specificity was 73%, positive predictive value was 74%, and negative predictive was value of 92%. Sensitivity was high for all gestational age groups, the investigators noted.

Oropharyngeal secretions were sampled from an additional group of 59 infants and analyzed using spectrometry, with an L/S cut-off value of 3.7; however sensitivity and specificity were lower than for gastric aspirates.

“This test could help identify which infants will benefit from very early surfactant treatment, with the potential to significantly improve clinical outcomes resulting in less severe RDS, less need of mechanical ventilation and oxygen and less severe bronchopulmonary dysplasia,” the investigators concluded.

Find the study in Acta Paediatrica (2016. doi: 10.1111/apa.13683)

lfranki@frontlinemedcom.com

A mass spectrometry test was able to rapidly measure lung maturity in premature infants at risk for respiratory distress syndrome (RDS), according to Henrik Verder, MD, of Holbaek (Denmark) University Hospital, and his associates.

Samples of gastric aspirates were taken from 136 infants with gestation periods of 24-31 weeks, and analyzed with mass spectrometry. Of this group, 61 developed RDS, and 7 died before the end of the study period. With a lecithin/sphingomyelin (L/S) cut-off ratio of 2.2, sensitivity of the mass spectrometry test was 92%, specificity was 73%, positive predictive value was 74%, and negative predictive was value of 92%. Sensitivity was high for all gestational age groups, the investigators noted.

Oropharyngeal secretions were sampled from an additional group of 59 infants and analyzed using spectrometry, with an L/S cut-off value of 3.7; however sensitivity and specificity were lower than for gastric aspirates.

“This test could help identify which infants will benefit from very early surfactant treatment, with the potential to significantly improve clinical outcomes resulting in less severe RDS, less need of mechanical ventilation and oxygen and less severe bronchopulmonary dysplasia,” the investigators concluded.

Find the study in Acta Paediatrica (2016. doi: 10.1111/apa.13683)

lfranki@frontlinemedcom.com