Pediatrics

The results of two previously published meta-analyses supporting a shortening of hospital length of stay following the use of hypertonic saline in infants with acute viral bronchiolitis are unreliable, according to a study published in JAMA Pediatrics.

Hypertonic saline should not be expected to shorten the length of hospital stay for those with acute viral bronchiolitis in typical hospital settings in the United States, Dr. Corinne G. Brooks of the Leadership in Preventive Medicine and Pediatrics Residencies at the Dartmouth-Hitchcock Medical Center in Lebanon, N.H., and her associates concluded.

The investigators reached this conclusion after reanalyzing data from the 18 randomized clinical trials using hypertonic saline in infants with bronchiolitis reporting hospital length of stay as an outcome measure in the two previously published meta-analyses, after finding no additional data sources through a literature search. The studies included 2,063 infants (63% male), with a mean age of 4.2 months and a mean length of stay of 3.6 days (JAMA Pediatr. 2016 Apr 18. doi: 10.1001/jamapediatrics.2016.0079).

Dr. Brooks explained the rationale behind the study by pointing out that the previously published analyses failed to address and account for the large amount of study heterogeneity in the assessed cohort of studies, necessitating a reanalysis of the full data set to investigate factors with the potential to introduce such heterogeneity.

The reanalysis produced two significant findings, which collectively accounted for all of the heterogeneity between the assessed studies. First, one of the study populations was determined to be a significant outlier with very different criteria for discharge and substantially longer expected hospital length of stay. Because the statistical significance of the weighted mean difference in hospital length of stay attributable to the use of hypertonic saline was sensitive to the removal of this study population, heterogeneity was found to resolve to moderate to acceptable levels. Second, an important baseline difference between the treatment arms in day of illness at study enrollment was found. Patients presenting later in their illness were more likely to be allocated to the hypertonic saline treatment arm in 6 of the 18 studies assessed, most of which were small positive studies. Therefore, this difference accounted for a systematic bias favoring treatment groups.

Based on their reanalysis of the available data, Dr. Brooks and her associates said that the appearance of a meaningful reduction in the length of hospital stay for infants with acute viral bronchiolitis was a direct result of the inappropriate combination of studies with clinically significant differences in outcome definitions, and the previously unnoticed systematic bias in treatment group allocation.

No external funding was provided. None of the authors reported any conflicts of interest.

The results of two previously published meta-analyses supporting a shortening of hospital length of stay following the use of hypertonic saline in infants with acute viral bronchiolitis are unreliable, according to a study published in JAMA Pediatrics.

Hypertonic saline should not be expected to shorten the length of hospital stay for those with acute viral bronchiolitis in typical hospital settings in the United States, Dr. Corinne G. Brooks of the Leadership in Preventive Medicine and Pediatrics Residencies at the Dartmouth-Hitchcock Medical Center in Lebanon, N.H., and her associates concluded.

The investigators reached this conclusion after reanalyzing data from the 18 randomized clinical trials using hypertonic saline in infants with bronchiolitis reporting hospital length of stay as an outcome measure in the two previously published meta-analyses, after finding no additional data sources through a literature search. The studies included 2,063 infants (63% male), with a mean age of 4.2 months and a mean length of stay of 3.6 days (JAMA Pediatr. 2016 Apr 18. doi: 10.1001/jamapediatrics.2016.0079).

Dr. Brooks explained the rationale behind the study by pointing out that the previously published analyses failed to address and account for the large amount of study heterogeneity in the assessed cohort of studies, necessitating a reanalysis of the full data set to investigate factors with the potential to introduce such heterogeneity.

The reanalysis produced two significant findings, which collectively accounted for all of the heterogeneity between the assessed studies. First, one of the study populations was determined to be a significant outlier with very different criteria for discharge and substantially longer expected hospital length of stay. Because the statistical significance of the weighted mean difference in hospital length of stay attributable to the use of hypertonic saline was sensitive to the removal of this study population, heterogeneity was found to resolve to moderate to acceptable levels. Second, an important baseline difference between the treatment arms in day of illness at study enrollment was found. Patients presenting later in their illness were more likely to be allocated to the hypertonic saline treatment arm in 6 of the 18 studies assessed, most of which were small positive studies. Therefore, this difference accounted for a systematic bias favoring treatment groups.

Based on their reanalysis of the available data, Dr. Brooks and her associates said that the appearance of a meaningful reduction in the length of hospital stay for infants with acute viral bronchiolitis was a direct result of the inappropriate combination of studies with clinically significant differences in outcome definitions, and the previously unnoticed systematic bias in treatment group allocation.

No external funding was provided. None of the authors reported any conflicts of interest.

The results of two previously published meta-analyses supporting a shortening of hospital length of stay following the use of hypertonic saline in infants with acute viral bronchiolitis are unreliable, according to a study published in JAMA Pediatrics.

Hypertonic saline should not be expected to shorten the length of hospital stay for those with acute viral bronchiolitis in typical hospital settings in the United States, Dr. Corinne G. Brooks of the Leadership in Preventive Medicine and Pediatrics Residencies at the Dartmouth-Hitchcock Medical Center in Lebanon, N.H., and her associates concluded.

The investigators reached this conclusion after reanalyzing data from the 18 randomized clinical trials using hypertonic saline in infants with bronchiolitis reporting hospital length of stay as an outcome measure in the two previously published meta-analyses, after finding no additional data sources through a literature search. The studies included 2,063 infants (63% male), with a mean age of 4.2 months and a mean length of stay of 3.6 days (JAMA Pediatr. 2016 Apr 18. doi: 10.1001/jamapediatrics.2016.0079).

Dr. Brooks explained the rationale behind the study by pointing out that the previously published analyses failed to address and account for the large amount of study heterogeneity in the assessed cohort of studies, necessitating a reanalysis of the full data set to investigate factors with the potential to introduce such heterogeneity.

The reanalysis produced two significant findings, which collectively accounted for all of the heterogeneity between the assessed studies. First, one of the study populations was determined to be a significant outlier with very different criteria for discharge and substantially longer expected hospital length of stay. Because the statistical significance of the weighted mean difference in hospital length of stay attributable to the use of hypertonic saline was sensitive to the removal of this study population, heterogeneity was found to resolve to moderate to acceptable levels. Second, an important baseline difference between the treatment arms in day of illness at study enrollment was found. Patients presenting later in their illness were more likely to be allocated to the hypertonic saline treatment arm in 6 of the 18 studies assessed, most of which were small positive studies. Therefore, this difference accounted for a systematic bias favoring treatment groups.

Based on their reanalysis of the available data, Dr. Brooks and her associates said that the appearance of a meaningful reduction in the length of hospital stay for infants with acute viral bronchiolitis was a direct result of the inappropriate combination of studies with clinically significant differences in outcome definitions, and the previously unnoticed systematic bias in treatment group allocation.

No external funding was provided. None of the authors reported any conflicts of interest.

Pregnancy rates among Hispanic and black teens are at an all-time low, reflecting overall declines in teen birth rates, new data show.

The Centers for Disease Control and Prevention reported on April 28 that the rate of Hispanic teens giving birth in the United States has dropped by more than half since 2006. During that same time period, there was a 44% drop in the birth rate for black teens.

Although these dramatic declines occurred against the backdrop of an overall decrease of about 40% in teen birth rates during the last decade, the CDC also reported that birth rates among Hispanics and black teens are still twice as high as they are for whites.

“The United States has made remarkable progress in reducing both teen pregnancy and racial and ethnic differences, but the reality is, too many American teens are still having babies,” Dr. Tom Frieden, CDC director, said in a statement. “By better understanding the many factors that contribute to teen pregnancy, we can better design, implement, evaluate, and improve prevention interventions and further reduce disparities.”

Overall, the birth rate among girls aged 15-19 years dropped from 41.1 to 24.2 per 1,000 from 2006 to 2014. The largest decline occurred in Hispanics, going from 77.4 to 38.0 per 1,000. The next biggest rate decline was in black teens, which fell from 61.9 to 34.9 per 1,000. The rate for white teens declined by 35%, falling from 26.7 to 17.3 per 1,000 (MMWR Morb Mortal Wkly Rep. 2016 Apr;65:409-14).

The CDC report indicated state- and community-level patterns, including that rates were notably higher among all races and ethnicities where unemployment is also high, but income and education levels are low. In some states with low overall birth rates, certain counties experienced higher rates. The highest rates nationwide tended to be in counties located in southern and southwestern states.

“These data underscore that the solution to our nation’s teen pregnancy problem is not going to be a one-size-fits-all – teen birth rates vary greatly across state lines and even within states,” Lisa Romero, Dr.P.H., a health scientist in the CDC’s Division of Reproductive Health, and the report’s lead author, said in a statement. “We can ensure the success of teen pregnancy prevention efforts by capitalizing on the expertise of our state and local public health colleagues. Together, we can work to implement proven prevention programs that take into account unique, local needs.”

The study is based on statistics for births to girls aged 15-19 years occurring between 2006 and 2014, taken from the National Vital Statistics System (NVSS). County-level NVSS data from 2013 and 2014 was also used, as were data from the American Community Survey between 2010 and 2014.

Pregnancy rates among Hispanic and black teens are at an all-time low, reflecting overall declines in teen birth rates, new data show.

The Centers for Disease Control and Prevention reported on April 28 that the rate of Hispanic teens giving birth in the United States has dropped by more than half since 2006. During that same time period, there was a 44% drop in the birth rate for black teens.

Although these dramatic declines occurred against the backdrop of an overall decrease of about 40% in teen birth rates during the last decade, the CDC also reported that birth rates among Hispanics and black teens are still twice as high as they are for whites.

“The United States has made remarkable progress in reducing both teen pregnancy and racial and ethnic differences, but the reality is, too many American teens are still having babies,” Dr. Tom Frieden, CDC director, said in a statement. “By better understanding the many factors that contribute to teen pregnancy, we can better design, implement, evaluate, and improve prevention interventions and further reduce disparities.”

Overall, the birth rate among girls aged 15-19 years dropped from 41.1 to 24.2 per 1,000 from 2006 to 2014. The largest decline occurred in Hispanics, going from 77.4 to 38.0 per 1,000. The next biggest rate decline was in black teens, which fell from 61.9 to 34.9 per 1,000. The rate for white teens declined by 35%, falling from 26.7 to 17.3 per 1,000 (MMWR Morb Mortal Wkly Rep. 2016 Apr;65:409-14).

The CDC report indicated state- and community-level patterns, including that rates were notably higher among all races and ethnicities where unemployment is also high, but income and education levels are low. In some states with low overall birth rates, certain counties experienced higher rates. The highest rates nationwide tended to be in counties located in southern and southwestern states.

“These data underscore that the solution to our nation’s teen pregnancy problem is not going to be a one-size-fits-all – teen birth rates vary greatly across state lines and even within states,” Lisa Romero, Dr.P.H., a health scientist in the CDC’s Division of Reproductive Health, and the report’s lead author, said in a statement. “We can ensure the success of teen pregnancy prevention efforts by capitalizing on the expertise of our state and local public health colleagues. Together, we can work to implement proven prevention programs that take into account unique, local needs.”

The study is based on statistics for births to girls aged 15-19 years occurring between 2006 and 2014, taken from the National Vital Statistics System (NVSS). County-level NVSS data from 2013 and 2014 was also used, as were data from the American Community Survey between 2010 and 2014.

Pregnancy rates among Hispanic and black teens are at an all-time low, reflecting overall declines in teen birth rates, new data show.

The Centers for Disease Control and Prevention reported on April 28 that the rate of Hispanic teens giving birth in the United States has dropped by more than half since 2006. During that same time period, there was a 44% drop in the birth rate for black teens.

Although these dramatic declines occurred against the backdrop of an overall decrease of about 40% in teen birth rates during the last decade, the CDC also reported that birth rates among Hispanics and black teens are still twice as high as they are for whites.

“The United States has made remarkable progress in reducing both teen pregnancy and racial and ethnic differences, but the reality is, too many American teens are still having babies,” Dr. Tom Frieden, CDC director, said in a statement. “By better understanding the many factors that contribute to teen pregnancy, we can better design, implement, evaluate, and improve prevention interventions and further reduce disparities.”

Overall, the birth rate among girls aged 15-19 years dropped from 41.1 to 24.2 per 1,000 from 2006 to 2014. The largest decline occurred in Hispanics, going from 77.4 to 38.0 per 1,000. The next biggest rate decline was in black teens, which fell from 61.9 to 34.9 per 1,000. The rate for white teens declined by 35%, falling from 26.7 to 17.3 per 1,000 (MMWR Morb Mortal Wkly Rep. 2016 Apr;65:409-14).

The CDC report indicated state- and community-level patterns, including that rates were notably higher among all races and ethnicities where unemployment is also high, but income and education levels are low. In some states with low overall birth rates, certain counties experienced higher rates. The highest rates nationwide tended to be in counties located in southern and southwestern states.

“These data underscore that the solution to our nation’s teen pregnancy problem is not going to be a one-size-fits-all – teen birth rates vary greatly across state lines and even within states,” Lisa Romero, Dr.P.H., a health scientist in the CDC’s Division of Reproductive Health, and the report’s lead author, said in a statement. “We can ensure the success of teen pregnancy prevention efforts by capitalizing on the expertise of our state and local public health colleagues. Together, we can work to implement proven prevention programs that take into account unique, local needs.”

The study is based on statistics for births to girls aged 15-19 years occurring between 2006 and 2014, taken from the National Vital Statistics System (NVSS). County-level NVSS data from 2013 and 2014 was also used, as were data from the American Community Survey between 2010 and 2014.

Pregnancy rates among Hispanic and black teens are at an all-time low, reflecting overall declines in teen birth rates, new data show.

The Centers for Disease Control and Prevention reported on April 28 that the rate of Hispanic teens giving birth in the United States has dropped by more than half since 2006. During that same time period, there was a 44% drop in the birth rate for black teens.

Although these dramatic declines occurred against the backdrop of an overall decrease of about 40% in teen birth rates during the last decade, the CDC also reported that birth rates among Hispanics and black teens are still twice as high as they are for whites.

“The United States has made remarkable progress in reducing both teen pregnancy and racial and ethnic differences, but the reality is, too many American teens are still having babies,” Dr. Tom Frieden, CDC director, said in a statement. “By better understanding the many factors that contribute to teen pregnancy, we can better design, implement, evaluate, and improve prevention interventions and further reduce disparities.”

Overall, the birth rate among girls aged 15-19 years dropped from 41.1 to 24.2 per 1,000 from 2006 to 2014. The largest decline occurred in Hispanics, going from 77.4 to 38.0 per 1,000. The next biggest rate decline was in black teens, which fell from 61.9 to 34.9 per 1,000. The rate for white teens declined by 35%, falling from 26.7 to 17.3 per 1,000 (MMWR Morb Mortal Wkly Rep. 2016 Apr;65:409-14).

The CDC report indicated state- and community-level patterns, including that rates were notably higher among all races and ethnicities where unemployment is also high, but income and education levels are low. In some states with low overall birth rates, certain counties experienced higher rates. The highest rates nationwide tended to be in counties located in southern and southwestern states.

“These data underscore that the solution to our nation’s teen pregnancy problem is not going to be a one-size-fits-all – teen birth rates vary greatly across state lines and even within states,” Lisa Romero, Dr.P.H., a health scientist in the CDC’s Division of Reproductive Health, and the report’s lead author, said in a statement. “We can ensure the success of teen pregnancy prevention efforts by capitalizing on the expertise of our state and local public health colleagues. Together, we can work to implement proven prevention programs that take into account unique, local needs.”

The study is based on statistics for births to girls aged 15-19 years occurring between 2006 and 2014, taken from the National Vital Statistics System (NVSS). County-level NVSS data from 2013 and 2014 was also used, as were data from the American Community Survey between 2010 and 2014.

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

Pregnancy rates among Hispanic and black teens are at an all-time low, reflecting overall declines in teen birth rates, new data show.

The Centers for Disease Control and Prevention reported on April 28 that the rate of Hispanic teens giving birth in the United States has dropped by more than half since 2006. During that same time period, there was a 44% drop in the birth rate for black teens.

Although these dramatic declines occurred against the backdrop of an overall decrease of about 40% in teen birth rates during the last decade, the CDC also reported that birth rates among Hispanics and black teens are still twice as high as they are for whites.

“The United States has made remarkable progress in reducing both teen pregnancy and racial and ethnic differences, but the reality is, too many American teens are still having babies,” Dr. Tom Frieden, CDC director, said in a statement. “By better understanding the many factors that contribute to teen pregnancy, we can better design, implement, evaluate, and improve prevention interventions and further reduce disparities.”

Overall, the birth rate among girls aged 15-19 years dropped from 41.1 to 24.2 per 1,000 from 2006 to 2014. The largest decline occurred in Hispanics, going from 77.4 to 38.0 per 1,000. The next biggest rate decline was in black teens, which fell from 61.9 to 34.9 per 1,000. The rate for white teens declined by 35%, falling from 26.7 to 17.3 per 1,000 (MMWR Morb Mortal Wkly Rep. 2016 Apr;65:409-14).

The CDC report indicated state- and community-level patterns, including that rates were notably higher among all races and ethnicities where unemployment is also high, but income and education levels are low. In some states with low overall birth rates, certain counties experienced higher rates. The highest rates nationwide tended to be in counties located in southern and southwestern states.

“These data underscore that the solution to our nation’s teen pregnancy problem is not going to be a one-size-fits-all – teen birth rates vary greatly across state lines and even within states,” Lisa Romero, Dr.P.H., a health scientist in the CDC’s Division of Reproductive Health, and the report’s lead author, said in a statement. “We can ensure the success of teen pregnancy prevention efforts by capitalizing on the expertise of our state and local public health colleagues. Together, we can work to implement proven prevention programs that take into account unique, local needs.”

The study is based on statistics for births to girls aged 15-19 years occurring between 2006 and 2014, taken from the National Vital Statistics System (NVSS). County-level NVSS data from 2013 and 2014 was also used, as were data from the American Community Survey between 2010 and 2014.

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

Pregnancy rates among Hispanic and black teens are at an all-time low, reflecting overall declines in teen birth rates, new data show.

The Centers for Disease Control and Prevention reported on April 28 that the rate of Hispanic teens giving birth in the United States has dropped by more than half since 2006. During that same time period, there was a 44% drop in the birth rate for black teens.

Although these dramatic declines occurred against the backdrop of an overall decrease of about 40% in teen birth rates during the last decade, the CDC also reported that birth rates among Hispanics and black teens are still twice as high as they are for whites.

“The United States has made remarkable progress in reducing both teen pregnancy and racial and ethnic differences, but the reality is, too many American teens are still having babies,” Dr. Tom Frieden, CDC director, said in a statement. “By better understanding the many factors that contribute to teen pregnancy, we can better design, implement, evaluate, and improve prevention interventions and further reduce disparities.”

Overall, the birth rate among girls aged 15-19 years dropped from 41.1 to 24.2 per 1,000 from 2006 to 2014. The largest decline occurred in Hispanics, going from 77.4 to 38.0 per 1,000. The next biggest rate decline was in black teens, which fell from 61.9 to 34.9 per 1,000. The rate for white teens declined by 35%, falling from 26.7 to 17.3 per 1,000 (MMWR Morb Mortal Wkly Rep. 2016 Apr;65:409-14).

The CDC report indicated state- and community-level patterns, including that rates were notably higher among all races and ethnicities where unemployment is also high, but income and education levels are low. In some states with low overall birth rates, certain counties experienced higher rates. The highest rates nationwide tended to be in counties located in southern and southwestern states.

“These data underscore that the solution to our nation’s teen pregnancy problem is not going to be a one-size-fits-all – teen birth rates vary greatly across state lines and even within states,” Lisa Romero, Dr.P.H., a health scientist in the CDC’s Division of Reproductive Health, and the report’s lead author, said in a statement. “We can ensure the success of teen pregnancy prevention efforts by capitalizing on the expertise of our state and local public health colleagues. Together, we can work to implement proven prevention programs that take into account unique, local needs.”

The study is based on statistics for births to girls aged 15-19 years occurring between 2006 and 2014, taken from the National Vital Statistics System (NVSS). County-level NVSS data from 2013 and 2014 was also used, as were data from the American Community Survey between 2010 and 2014.

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

VANCOUVER – A new transcranial Doppler platform that analyzes subtle changes in the cerebral blood flow waveform performed well in detecting sports-related concussion in a cohort study of 238 Los Angeles high school athletes.

The investigational headset device was able to differentiate between those with and without a recent concussion 83% of the time, investigators reported at the annual meeting of the American Academy of Neurology. In contrast, traditional transcranial Doppler analysis detected a recent concussion only 50%-60% of the time.

“Over the last few years, there has been growing evidence that cerebral hemodynamics are altered following sports-related concussion,” senior author Robert Hamilton, Ph.D., cofounder and chief science officer of Neural Analytics in Los Angeles, commented in a session and interview.

Most studies in this area have used MRI or traditional transcranial Doppler analysis, he said. However, the former is costly, time consuming, and not portable, and the latter has not proven very accurate.

As traditional Doppler analysis disregards the majority of waveform data, Dr. Hamilton and his colleagues developed an advanced platform that uses machine learning to analyze the entire shape of the cerebral blood flow velocity waveform through quantitative cerebral hemodynamics.

They compared the advanced analysis with traditional analysis among 69 high school athletes in contact sports who had sustained a concussion an average of 6 days earlier and a control group of 169 unaffected age-matched high school athletes from contact and noncontact sports.

Both groups had bilateral monitoring of blood flow in the middle cerebral artery with transcranial Doppler while they followed a standard cerebrovascular reactivity protocol that included rest and breath holding.

Results showed that for differentiating between athletes who did and did not have concussion, the advanced analysis had an area under the receiver operating characteristic curve of 83%. (Sensitivity was 72%, specificity was 82%, and overall accuracy was 80%.)

In comparison, the area under the curve was substantially lower for the traditional analysis measures: It was 55% for mean velocity (100% sensitivity, 0% specificity, 76% accuracy), 52% for the pulsatility index (86% sensitivity, 23% specificity, 61% accuracy), and 60% for the cerebrovascular reactivity index (51% sensitivity, 68% specificity, 64% accuracy).

“Unfortunately, concussion diagnostics and management today are basically subjective,” Dr. Hamilton commented. The advanced analysis may therefore improve the situation by providing objective evidence of blood flow dysfunction after injury.

The new analysis platform “is easy to use and portable, and [testing] can be done very quickly, within 5 minutes,” he noted. “The nice thing is it can be done on the sideline, in the emergency room, or in a doctor’s office.”

The investigators will next use the advanced analysis to track recovery of blood flow regulation after sports-related concussion and will compare its performance with that of additional modalities, such as MRI, according to Dr. Hamilton. Furthermore, they are testing it in various other populations: adolescents, college athletes, and members of the military.

“Ultimately, blood flow dysfunction is also important in a wide variety of conditions, such as stroke and dementia,” he pointed out. “So those are conditions that we are looking at to study this year and moving forward in the future.”

The research was supported by the National Institutes of Health and the National Science Foundation.

VANCOUVER – A new transcranial Doppler platform that analyzes subtle changes in the cerebral blood flow waveform performed well in detecting sports-related concussion in a cohort study of 238 Los Angeles high school athletes.

The investigational headset device was able to differentiate between those with and without a recent concussion 83% of the time, investigators reported at the annual meeting of the American Academy of Neurology. In contrast, traditional transcranial Doppler analysis detected a recent concussion only 50%-60% of the time.

“Over the last few years, there has been growing evidence that cerebral hemodynamics are altered following sports-related concussion,” senior author Robert Hamilton, Ph.D., cofounder and chief science officer of Neural Analytics in Los Angeles, commented in a session and interview.

Most studies in this area have used MRI or traditional transcranial Doppler analysis, he said. However, the former is costly, time consuming, and not portable, and the latter has not proven very accurate.

As traditional Doppler analysis disregards the majority of waveform data, Dr. Hamilton and his colleagues developed an advanced platform that uses machine learning to analyze the entire shape of the cerebral blood flow velocity waveform through quantitative cerebral hemodynamics.

They compared the advanced analysis with traditional analysis among 69 high school athletes in contact sports who had sustained a concussion an average of 6 days earlier and a control group of 169 unaffected age-matched high school athletes from contact and noncontact sports.

Both groups had bilateral monitoring of blood flow in the middle cerebral artery with transcranial Doppler while they followed a standard cerebrovascular reactivity protocol that included rest and breath holding.

Results showed that for differentiating between athletes who did and did not have concussion, the advanced analysis had an area under the receiver operating characteristic curve of 83%. (Sensitivity was 72%, specificity was 82%, and overall accuracy was 80%.)

In comparison, the area under the curve was substantially lower for the traditional analysis measures: It was 55% for mean velocity (100% sensitivity, 0% specificity, 76% accuracy), 52% for the pulsatility index (86% sensitivity, 23% specificity, 61% accuracy), and 60% for the cerebrovascular reactivity index (51% sensitivity, 68% specificity, 64% accuracy).

“Unfortunately, concussion diagnostics and management today are basically subjective,” Dr. Hamilton commented. The advanced analysis may therefore improve the situation by providing objective evidence of blood flow dysfunction after injury.

The new analysis platform “is easy to use and portable, and [testing] can be done very quickly, within 5 minutes,” he noted. “The nice thing is it can be done on the sideline, in the emergency room, or in a doctor’s office.”

The investigators will next use the advanced analysis to track recovery of blood flow regulation after sports-related concussion and will compare its performance with that of additional modalities, such as MRI, according to Dr. Hamilton. Furthermore, they are testing it in various other populations: adolescents, college athletes, and members of the military.

“Ultimately, blood flow dysfunction is also important in a wide variety of conditions, such as stroke and dementia,” he pointed out. “So those are conditions that we are looking at to study this year and moving forward in the future.”

The research was supported by the National Institutes of Health and the National Science Foundation.

VANCOUVER – A new transcranial Doppler platform that analyzes subtle changes in the cerebral blood flow waveform performed well in detecting sports-related concussion in a cohort study of 238 Los Angeles high school athletes.

The investigational headset device was able to differentiate between those with and without a recent concussion 83% of the time, investigators reported at the annual meeting of the American Academy of Neurology. In contrast, traditional transcranial Doppler analysis detected a recent concussion only 50%-60% of the time.

“Over the last few years, there has been growing evidence that cerebral hemodynamics are altered following sports-related concussion,” senior author Robert Hamilton, Ph.D., cofounder and chief science officer of Neural Analytics in Los Angeles, commented in a session and interview.

Most studies in this area have used MRI or traditional transcranial Doppler analysis, he said. However, the former is costly, time consuming, and not portable, and the latter has not proven very accurate.

As traditional Doppler analysis disregards the majority of waveform data, Dr. Hamilton and his colleagues developed an advanced platform that uses machine learning to analyze the entire shape of the cerebral blood flow velocity waveform through quantitative cerebral hemodynamics.

They compared the advanced analysis with traditional analysis among 69 high school athletes in contact sports who had sustained a concussion an average of 6 days earlier and a control group of 169 unaffected age-matched high school athletes from contact and noncontact sports.

Both groups had bilateral monitoring of blood flow in the middle cerebral artery with transcranial Doppler while they followed a standard cerebrovascular reactivity protocol that included rest and breath holding.

Results showed that for differentiating between athletes who did and did not have concussion, the advanced analysis had an area under the receiver operating characteristic curve of 83%. (Sensitivity was 72%, specificity was 82%, and overall accuracy was 80%.)

In comparison, the area under the curve was substantially lower for the traditional analysis measures: It was 55% for mean velocity (100% sensitivity, 0% specificity, 76% accuracy), 52% for the pulsatility index (86% sensitivity, 23% specificity, 61% accuracy), and 60% for the cerebrovascular reactivity index (51% sensitivity, 68% specificity, 64% accuracy).

“Unfortunately, concussion diagnostics and management today are basically subjective,” Dr. Hamilton commented. The advanced analysis may therefore improve the situation by providing objective evidence of blood flow dysfunction after injury.

The new analysis platform “is easy to use and portable, and [testing] can be done very quickly, within 5 minutes,” he noted. “The nice thing is it can be done on the sideline, in the emergency room, or in a doctor’s office.”

The investigators will next use the advanced analysis to track recovery of blood flow regulation after sports-related concussion and will compare its performance with that of additional modalities, such as MRI, according to Dr. Hamilton. Furthermore, they are testing it in various other populations: adolescents, college athletes, and members of the military.

“Ultimately, blood flow dysfunction is also important in a wide variety of conditions, such as stroke and dementia,” he pointed out. “So those are conditions that we are looking at to study this year and moving forward in the future.”

The research was supported by the National Institutes of Health and the National Science Foundation.

IN THIS ARTICLE

• Complications of acute bacterial sinusitis
• What are the medical options?
• AAP 2013 recommendations for initial antimicrobial treatment

Acute bacterial sinusitis (ABS) is a common diagnosis in pediatric patients. Of children who are evaluated for respiratory complaints, 6% to 7% meet clinical criteria for ABS.¹ In addition to being a frequent complication of upper respiratory infection (URI), ABS in children has a significant financial impact. Direct health care expenditures attributed to sinusitis in children ages 12 or younger is $1.8 billion annually.²

Differentiating between viral URI and ABS is a diagnostic challenge for health care providers. In recent years, the American Academy of Pediatrics (AAP) and the Infectious Diseases Society of America (IDSA) have released clinical practice guidelines on the clinical diagnosis and management of ABS in children.^3,4

URI AND ABS MANIFESTATIONS
URIs manifest with a predictable pattern of symptoms. Children may experience one to two days of fever, accompanied by constitutional symptoms, such as fatigue, headache, decreased appetite, and myalgia. Nasal discharge typically begins clear and becomes mucopurulent over the next few days; subsequently, it either resolves or becomes serous again at the end of the URI. Cough, hoarseness, malodorous breath, and pharyngitis may be present.^3,5 Symptoms typically resolve over five to 10 days, with respiratory symptoms peaking at days 3 to 5. Importantly, in viral URIs, nasal congestion and cough improve toward the end of the illness.^1,3

Persistent illness. Patients with ABS may experience persistent illness with nasal discharge (of any quality) and/or daytime cough that persists more than 10 days without improvement.^3,4 These patients are differentiated from those with a viral URI by a lack of improvement in congestion and/or cough after 10 days of symptoms.³ While some children with viral illnesses may have persistant upper respiratory symptoms, these should be gradually resolving. Clinicians must take a thorough history to identify children who may have multiple consecutive URIs rather than one persistent illness that is not resolving.

Other diagnoses, such as allergic rhinitis, nasal foreign body, pertussis, influenza, and bacterial pharyngitis, must also be excluded. Children who present with persistent nasal congestion, with or without cough, after 10 days of illness without signs of improvement meet the criteria for ABS.³

Severe symptom onset. Children with ABS may experience severe onset of symptoms.^3,4 These children have purulent nasal discharge for at least three consecutive days at onset of illness and concurrent fever (temperature, ≥ 102.2°F). In contrast, a viral URI typically presents with fever for less than 48 hours and clear nasal discharge that becomes purulent after the first few days of symptoms.

“Double sickening.” Finally, children with ABS may have a worsening course of symptoms or a “double sickening.”^3,4 These patients experience typical URI symptoms that initially begin to improve, then worsen on day 6 or 7 of illness with increasing or new onset of considerable nasal drainage, daytime cough, or fever.

Continue for physical findings >>

PHYSICAL FINDINGS
Physical exam findings are not sufficient to distinguish between viral URI and ABS.^1,3,5 Typical findings on examination may include nasal congestion, postnasal drip, erythematous turbinates, and/or injected posterior oropharynx. Malodorous breath may be present but is not diagnostic.^3,5 The tympanic membranes should be examined for signs of concomitant acute otitis media (AOM) or otitis media with effusion. Swelling of the eyelids may be present. Facial pain may also be noted on physical exam.³

Clinicians should be mindful of the complications of sinusitis when performing the physical examination (see Table 1). The most common complications of ABS are orbital and may manifest with eyelid swelling, proptosis, or decreased extraocular movements. Patients with intracranial complications may present with headache, photophobia, seizure, meningeal signs, or focal neurologic signs.³

Continue to making the diagnosis >>

MAKING THE DIAGNOSIS
The diagnosis of ABS is a clinical one. Clinical guidelines from the AAP and IDSA for the diagnosis of ABS in children are very similar; both describe clinical presentations of persistent, severe, or worsening symptoms.^3,4 This display of expert consensus allows clinicians to confidently distinguish between viral URIs and ABS by adhering to the strict diagnostic criteria already discussed.

Imaging
Radiographs and CT scans are not necessary to confirm the diagnosis of ABS. Imaging studies may reveal current or recent upper respiratory symptoms, including mucosal inflammation, opacities, and air-fluid levels^6,7; however, no imaging study is available that can distinguish among mucosal inflammation and viral or bacterial infections. CT scans or MRI may be useful if clinicians suspect a complication of sinusitis.^3,7

Microbiology
Historically, the microbiology of ABS has been determined by maxillary sinus aspiration. The most recent studies of this method, published in the 1980s, identified Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis as the most common bacterial pathogens.^3,6,9 More recently, the microbiology of ABS has been linked with causative pathogens in AOM. The pathogenesis of ABS and AOM are similar, therefore allowing data from tympanocentesis in children with AOM to be used to determine the microbiology of children with ABS.¹⁰ Although S pneumoniae, H influenzae, and M catarrhalis remain common causative pathogens in ABS, the introduction of the 7- and 13-valent pneumococcal vaccines has altered the microbiology of AOM, and presumably ABS.¹¹

Importantly, numbers of cases of AOM attributed to S pneumoniae have decreased while those attributed to H influenzae have increased.^3,11 In addition, antimicrobial susceptibility of S pneumoniae and the prevalence of β-lactamase–positive H influenzae are important considerations when choosing appropriate antibiotics and can vary significantly by geographic region. Therefore, it is important that clinicians be aware of susceptibility patterns in the communities in which they practice.

Continue for the medical options >>

WHAT ARE THE MEDICAL OPTIONS?
Initial management of ABS in children is contingent on the symptom profile at presentation (persistent, worsening, or severe) and consideration of causative pathogens. While the consensus among experts is that children presenting with severe or worsening symptoms be treated initially with antibiotics,^3,4 children who present with mild symptoms consistent with persistent illness may initially be treated with antibiotics or observed for an additional three days. This decision should be made thoughtfully and in collaboration with the patient’s parents or guardians. Any child with ABS who presents with persistent symptoms of illness and is managed initially by observation alone should be reassessed or treated with an antibiotic if symptoms worsen, if new symptoms appear, or if the child fails to improve within 72 hours.

Amoxicillin with or without clavulanate is the antibiotic of choice when ABS has been diagnosed and antibiotic treatment is indicated.^1,3 AAP recommendations for antimicrobial treatment of ABS in children are stratified on the basis of age, severity of illness, day care attendance, and history of treatment with amoxicillin in the previous 30 days (see Table 2). Clinicians should rely on their knowledge of drug resistance in their community and judgment regarding severity of illness when choosing between amoxicillin and amoxicillin/clavulanate as initial treatment for ABS.³

Recommendations for duration of antimicrobial treatment for ABS vary considerably. A reasonable suggestion is to continue to treat patients until they are symptom-free for seven days. For many patients, this will mean a 10-day treatment course, with flexibility to increase the duration as needed.³

Children with ABS should be reassessed if there are worsening signs or symptoms or lack of clinical improvement within 72 hours of initial management. Clinicians should evaluate whether the patient has been appropriately diagnosed and assessed for complications of ABS. If the diagnosis is confirmed and ABS complications are not suspected, the clinician may change antibiotics or initiate antibiotic therapy if the child was previously managed by observation only.^3,4

A child who is vomiting or unable to tolerate PO medications may benefit from a single 50-gm/kg dose of ceftriaxone IV or IM with follow-up in 24 hours.³ Oral antibiotics may be started at the follow-up visit if the patient demonstrates clinical improvement.

When considering a change in antibiotic, the clinician should consider the possibility of drug resistance. If the child was initially treated with amoxicillin, high-dose amoxicillin/clavulanate may be prescribed. If high-dose amoxicillin/clavulanate was initially prescribed and the patient has not improved or is experiencing worsening symptoms, clindamycin with cefixime, linezolid with cefixime, or levofloxacin may be considered.^3,4

Penicillin allergy
Patients with a history of a non–type 1 hypersensitivity reaction to amoxicillin may be treated with cefdinir, cefuroxime, cefpodoxime, or combination therapy with clindamycin plus a third-generation oral cephalosporin. Allergist referral for penicillin or cephalosporin skin testing may be considered before initiation of therapy.^3,4,13

Adjuvant therapy
Decongestants, antihistamines, and nasal irrigation are frequently recommended in the management of ABS in children; however, the authors of a 2012 Coch­rane review found no properly designed studies to evaluate the effectiveness of these treatments.¹³ Furthermore, there is insufficient evidence to clearly recommend the use of intranasal steroids as an adjuvant therapy in the treatment of ABS in children (although several randomized controlled studies demonstrate their effectiveness in adolescents and adults).³

Continue for the conclusion >>

CONCLUSION
ABS in children is diagnosed clinically by following a strict set of clinical criteria. Patients commonly present with one of three types of symptoms: persistent URI; severe purulent nasal discharge and fever for at least three consecutive days; or a double sickening. Physical examination findings vary and will not differentiate viral URI symptoms from a diagnosis of ABS. Imaging is not recommended for diagnosis but may be helpful if an orbital or intracranial complication of ABS is suspected.

S pneumoniae, H influenzae, and M catarrhalis continue to be the most common pathogens associated with ABS. However, since the introduction of the 7-valent pneumococcal vaccine, prevalence of H influenzae and β-lactamase–positive H influenzae has increased.

Treatment recommendations vary, based on suspected causative pathogens and presenting symptoms. Amoxicillin or amoxicillin-clavulanate is recommended as firstline antimicrobial treatment for ABS, with alternate antibiotic choices for patients with worsening symptoms or lack of improvement within 72 hours. An awareness of the community’s susceptibility patterns is essential for the clinician who cares for children at risk for ABS.

REFERENCES
1. Wald ER, Nash D, Eickhoff J. Effectiveness of amoxicillin/clavulanate potassium in the treatment of acute bacterial sinusitis in children. ­Pediatrics. 2009;124(1):9-15.
2. Ray NF, Baraniuk JN, Thamer M, et al. Healthcare expenditures for sinusitis in 1996: contributions of asthma, rhinitis, and other airway disorders. J Allergy Clin Immunol. 1999;103(3 pt 1):408-414.
3. Wald ER, Applegate KE, Bordley C, et al. Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years. Pediatrics. 2013;132(1):e262-e280.
4. Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis. 2012;54(8):1041-1045.
5. Shaikh N, Hoberman A, Kearney DH, et al. Signs and symptoms that differentiate acute sinusitis from viral upper respiratory tract infection. Pediatr Infect Dis J. 2013;32(10):1061-1065.
6. Kovatch AL, Wald ER, Ledesma-Medina J, et al. Maxillary sinus radiographs in children with nonrespiratory complaints. Pediatrics. 1984; 73(3):306-308.
7. Triulzi F, Zirpoli S. Imaging techniques in the diagnosis and management of rhinosinusitis in children. Pediatr Allergy Immunol. 2007;18(suppl 18):46-49.
8. Wald ER, Milmoe GJ, Bowen A, et al. Acute maxillary sinusitis in children. N Engl J Med. 1981;304(13):749-754.
9. Wald ER, Reilly JS, Casselbrant M, et al. Treatment of acute maxillary sinusitis in childhood: a comparative study of amoxicillin and cefaclor. J Pediatr. 1984;104(2):297-302.
10. Wald ER. Acute otitis media and acute bacterial sinusitis. Clin Infect Dis. 2011;52(suppl 4):S277-S283.
11. Casey JR, Adlowitz DG, Pichichero ME. New patterns in the otopathogens causing acute otitis media six to eight years after introduction of pneumococcal conjugate vaccine. Pediatr Infect Dis J. 2010;29(4):304-309.
12. Pichichero ME. A review of evidence supporting the American Academy of Pediatrics recommendation for prescribing cephalosporin antibiotics for penicillin-allergic patients. Pediatrics. 2004;115(4):1048-1057.
13. Shaikh N, Wald ER, Pi M. Decongestants, antihistamines and nasal irrigation for acute sinusitis in children. Cochrane Database Syst Rev. 2012;9:CD007909.

IN THIS ARTICLE

• Complications of acute bacterial sinusitis
• What are the medical options?
• AAP 2013 recommendations for initial antimicrobial treatment

Acute bacterial sinusitis (ABS) is a common diagnosis in pediatric patients. Of children who are evaluated for respiratory complaints, 6% to 7% meet clinical criteria for ABS.¹ In addition to being a frequent complication of upper respiratory infection (URI), ABS in children has a significant financial impact. Direct health care expenditures attributed to sinusitis in children ages 12 or younger is $1.8 billion annually.²

Differentiating between viral URI and ABS is a diagnostic challenge for health care providers. In recent years, the American Academy of Pediatrics (AAP) and the Infectious Diseases Society of America (IDSA) have released clinical practice guidelines on the clinical diagnosis and management of ABS in children.^3,4

URI AND ABS MANIFESTATIONS
URIs manifest with a predictable pattern of symptoms. Children may experience one to two days of fever, accompanied by constitutional symptoms, such as fatigue, headache, decreased appetite, and myalgia. Nasal discharge typically begins clear and becomes mucopurulent over the next few days; subsequently, it either resolves or becomes serous again at the end of the URI. Cough, hoarseness, malodorous breath, and pharyngitis may be present.^3,5 Symptoms typically resolve over five to 10 days, with respiratory symptoms peaking at days 3 to 5. Importantly, in viral URIs, nasal congestion and cough improve toward the end of the illness.^1,3

Persistent illness. Patients with ABS may experience persistent illness with nasal discharge (of any quality) and/or daytime cough that persists more than 10 days without improvement.^3,4 These patients are differentiated from those with a viral URI by a lack of improvement in congestion and/or cough after 10 days of symptoms.³ While some children with viral illnesses may have persistant upper respiratory symptoms, these should be gradually resolving. Clinicians must take a thorough history to identify children who may have multiple consecutive URIs rather than one persistent illness that is not resolving.

Other diagnoses, such as allergic rhinitis, nasal foreign body, pertussis, influenza, and bacterial pharyngitis, must also be excluded. Children who present with persistent nasal congestion, with or without cough, after 10 days of illness without signs of improvement meet the criteria for ABS.³

Severe symptom onset. Children with ABS may experience severe onset of symptoms.^3,4 These children have purulent nasal discharge for at least three consecutive days at onset of illness and concurrent fever (temperature, ≥ 102.2°F). In contrast, a viral URI typically presents with fever for less than 48 hours and clear nasal discharge that becomes purulent after the first few days of symptoms.

“Double sickening.” Finally, children with ABS may have a worsening course of symptoms or a “double sickening.”^3,4 These patients experience typical URI symptoms that initially begin to improve, then worsen on day 6 or 7 of illness with increasing or new onset of considerable nasal drainage, daytime cough, or fever.

Continue for physical findings >>

PHYSICAL FINDINGS
Physical exam findings are not sufficient to distinguish between viral URI and ABS.^1,3,5 Typical findings on examination may include nasal congestion, postnasal drip, erythematous turbinates, and/or injected posterior oropharynx. Malodorous breath may be present but is not diagnostic.^3,5 The tympanic membranes should be examined for signs of concomitant acute otitis media (AOM) or otitis media with effusion. Swelling of the eyelids may be present. Facial pain may also be noted on physical exam.³

Clinicians should be mindful of the complications of sinusitis when performing the physical examination (see Table 1). The most common complications of ABS are orbital and may manifest with eyelid swelling, proptosis, or decreased extraocular movements. Patients with intracranial complications may present with headache, photophobia, seizure, meningeal signs, or focal neurologic signs.³

Continue to making the diagnosis >>

MAKING THE DIAGNOSIS
The diagnosis of ABS is a clinical one. Clinical guidelines from the AAP and IDSA for the diagnosis of ABS in children are very similar; both describe clinical presentations of persistent, severe, or worsening symptoms.^3,4 This display of expert consensus allows clinicians to confidently distinguish between viral URIs and ABS by adhering to the strict diagnostic criteria already discussed.

Imaging
Radiographs and CT scans are not necessary to confirm the diagnosis of ABS. Imaging studies may reveal current or recent upper respiratory symptoms, including mucosal inflammation, opacities, and air-fluid levels^6,7; however, no imaging study is available that can distinguish among mucosal inflammation and viral or bacterial infections. CT scans or MRI may be useful if clinicians suspect a complication of sinusitis.^3,7

Microbiology
Historically, the microbiology of ABS has been determined by maxillary sinus aspiration. The most recent studies of this method, published in the 1980s, identified Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis as the most common bacterial pathogens.^3,6,9 More recently, the microbiology of ABS has been linked with causative pathogens in AOM. The pathogenesis of ABS and AOM are similar, therefore allowing data from tympanocentesis in children with AOM to be used to determine the microbiology of children with ABS.¹⁰ Although S pneumoniae, H influenzae, and M catarrhalis remain common causative pathogens in ABS, the introduction of the 7- and 13-valent pneumococcal vaccines has altered the microbiology of AOM, and presumably ABS.¹¹

Importantly, numbers of cases of AOM attributed to S pneumoniae have decreased while those attributed to H influenzae have increased.^3,11 In addition, antimicrobial susceptibility of S pneumoniae and the prevalence of β-lactamase–positive H influenzae are important considerations when choosing appropriate antibiotics and can vary significantly by geographic region. Therefore, it is important that clinicians be aware of susceptibility patterns in the communities in which they practice.

Continue for the medical options >>

WHAT ARE THE MEDICAL OPTIONS?
Initial management of ABS in children is contingent on the symptom profile at presentation (persistent, worsening, or severe) and consideration of causative pathogens. While the consensus among experts is that children presenting with severe or worsening symptoms be treated initially with antibiotics,^3,4 children who present with mild symptoms consistent with persistent illness may initially be treated with antibiotics or observed for an additional three days. This decision should be made thoughtfully and in collaboration with the patient’s parents or guardians. Any child with ABS who presents with persistent symptoms of illness and is managed initially by observation alone should be reassessed or treated with an antibiotic if symptoms worsen, if new symptoms appear, or if the child fails to improve within 72 hours.

Amoxicillin with or without clavulanate is the antibiotic of choice when ABS has been diagnosed and antibiotic treatment is indicated.^1,3 AAP recommendations for antimicrobial treatment of ABS in children are stratified on the basis of age, severity of illness, day care attendance, and history of treatment with amoxicillin in the previous 30 days (see Table 2). Clinicians should rely on their knowledge of drug resistance in their community and judgment regarding severity of illness when choosing between amoxicillin and amoxicillin/clavulanate as initial treatment for ABS.³

Recommendations for duration of antimicrobial treatment for ABS vary considerably. A reasonable suggestion is to continue to treat patients until they are symptom-free for seven days. For many patients, this will mean a 10-day treatment course, with flexibility to increase the duration as needed.³

Children with ABS should be reassessed if there are worsening signs or symptoms or lack of clinical improvement within 72 hours of initial management. Clinicians should evaluate whether the patient has been appropriately diagnosed and assessed for complications of ABS. If the diagnosis is confirmed and ABS complications are not suspected, the clinician may change antibiotics or initiate antibiotic therapy if the child was previously managed by observation only.^3,4

A child who is vomiting or unable to tolerate PO medications may benefit from a single 50-gm/kg dose of ceftriaxone IV or IM with follow-up in 24 hours.³ Oral antibiotics may be started at the follow-up visit if the patient demonstrates clinical improvement.

When considering a change in antibiotic, the clinician should consider the possibility of drug resistance. If the child was initially treated with amoxicillin, high-dose amoxicillin/clavulanate may be prescribed. If high-dose amoxicillin/clavulanate was initially prescribed and the patient has not improved or is experiencing worsening symptoms, clindamycin with cefixime, linezolid with cefixime, or levofloxacin may be considered.^3,4

Penicillin allergy
Patients with a history of a non–type 1 hypersensitivity reaction to amoxicillin may be treated with cefdinir, cefuroxime, cefpodoxime, or combination therapy with clindamycin plus a third-generation oral cephalosporin. Allergist referral for penicillin or cephalosporin skin testing may be considered before initiation of therapy.^3,4,13

Adjuvant therapy
Decongestants, antihistamines, and nasal irrigation are frequently recommended in the management of ABS in children; however, the authors of a 2012 Coch­rane review found no properly designed studies to evaluate the effectiveness of these treatments.¹³ Furthermore, there is insufficient evidence to clearly recommend the use of intranasal steroids as an adjuvant therapy in the treatment of ABS in children (although several randomized controlled studies demonstrate their effectiveness in adolescents and adults).³

Continue for the conclusion >>

CONCLUSION
ABS in children is diagnosed clinically by following a strict set of clinical criteria. Patients commonly present with one of three types of symptoms: persistent URI; severe purulent nasal discharge and fever for at least three consecutive days; or a double sickening. Physical examination findings vary and will not differentiate viral URI symptoms from a diagnosis of ABS. Imaging is not recommended for diagnosis but may be helpful if an orbital or intracranial complication of ABS is suspected.

S pneumoniae, H influenzae, and M catarrhalis continue to be the most common pathogens associated with ABS. However, since the introduction of the 7-valent pneumococcal vaccine, prevalence of H influenzae and β-lactamase–positive H influenzae has increased.

Treatment recommendations vary, based on suspected causative pathogens and presenting symptoms. Amoxicillin or amoxicillin-clavulanate is recommended as firstline antimicrobial treatment for ABS, with alternate antibiotic choices for patients with worsening symptoms or lack of improvement within 72 hours. An awareness of the community’s susceptibility patterns is essential for the clinician who cares for children at risk for ABS.

REFERENCES
1. Wald ER, Nash D, Eickhoff J. Effectiveness of amoxicillin/clavulanate potassium in the treatment of acute bacterial sinusitis in children. ­Pediatrics. 2009;124(1):9-15.
2. Ray NF, Baraniuk JN, Thamer M, et al. Healthcare expenditures for sinusitis in 1996: contributions of asthma, rhinitis, and other airway disorders. J Allergy Clin Immunol. 1999;103(3 pt 1):408-414.
3. Wald ER, Applegate KE, Bordley C, et al. Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years. Pediatrics. 2013;132(1):e262-e280.
4. Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis. 2012;54(8):1041-1045.
5. Shaikh N, Hoberman A, Kearney DH, et al. Signs and symptoms that differentiate acute sinusitis from viral upper respiratory tract infection. Pediatr Infect Dis J. 2013;32(10):1061-1065.
6. Kovatch AL, Wald ER, Ledesma-Medina J, et al. Maxillary sinus radiographs in children with nonrespiratory complaints. Pediatrics. 1984; 73(3):306-308.
7. Triulzi F, Zirpoli S. Imaging techniques in the diagnosis and management of rhinosinusitis in children. Pediatr Allergy Immunol. 2007;18(suppl 18):46-49.
8. Wald ER, Milmoe GJ, Bowen A, et al. Acute maxillary sinusitis in children. N Engl J Med. 1981;304(13):749-754.
9. Wald ER, Reilly JS, Casselbrant M, et al. Treatment of acute maxillary sinusitis in childhood: a comparative study of amoxicillin and cefaclor. J Pediatr. 1984;104(2):297-302.
10. Wald ER. Acute otitis media and acute bacterial sinusitis. Clin Infect Dis. 2011;52(suppl 4):S277-S283.
11. Casey JR, Adlowitz DG, Pichichero ME. New patterns in the otopathogens causing acute otitis media six to eight years after introduction of pneumococcal conjugate vaccine. Pediatr Infect Dis J. 2010;29(4):304-309.
12. Pichichero ME. A review of evidence supporting the American Academy of Pediatrics recommendation for prescribing cephalosporin antibiotics for penicillin-allergic patients. Pediatrics. 2004;115(4):1048-1057.
13. Shaikh N, Wald ER, Pi M. Decongestants, antihistamines and nasal irrigation for acute sinusitis in children. Cochrane Database Syst Rev. 2012;9:CD007909.

IN THIS ARTICLE

• Complications of acute bacterial sinusitis
• What are the medical options?
• AAP 2013 recommendations for initial antimicrobial treatment

Acute bacterial sinusitis (ABS) is a common diagnosis in pediatric patients. Of children who are evaluated for respiratory complaints, 6% to 7% meet clinical criteria for ABS.¹ In addition to being a frequent complication of upper respiratory infection (URI), ABS in children has a significant financial impact. Direct health care expenditures attributed to sinusitis in children ages 12 or younger is $1.8 billion annually.²

Differentiating between viral URI and ABS is a diagnostic challenge for health care providers. In recent years, the American Academy of Pediatrics (AAP) and the Infectious Diseases Society of America (IDSA) have released clinical practice guidelines on the clinical diagnosis and management of ABS in children.^3,4

URI AND ABS MANIFESTATIONS
URIs manifest with a predictable pattern of symptoms. Children may experience one to two days of fever, accompanied by constitutional symptoms, such as fatigue, headache, decreased appetite, and myalgia. Nasal discharge typically begins clear and becomes mucopurulent over the next few days; subsequently, it either resolves or becomes serous again at the end of the URI. Cough, hoarseness, malodorous breath, and pharyngitis may be present.^3,5 Symptoms typically resolve over five to 10 days, with respiratory symptoms peaking at days 3 to 5. Importantly, in viral URIs, nasal congestion and cough improve toward the end of the illness.^1,3

Persistent illness. Patients with ABS may experience persistent illness with nasal discharge (of any quality) and/or daytime cough that persists more than 10 days without improvement.^3,4 These patients are differentiated from those with a viral URI by a lack of improvement in congestion and/or cough after 10 days of symptoms.³ While some children with viral illnesses may have persistant upper respiratory symptoms, these should be gradually resolving. Clinicians must take a thorough history to identify children who may have multiple consecutive URIs rather than one persistent illness that is not resolving.

Other diagnoses, such as allergic rhinitis, nasal foreign body, pertussis, influenza, and bacterial pharyngitis, must also be excluded. Children who present with persistent nasal congestion, with or without cough, after 10 days of illness without signs of improvement meet the criteria for ABS.³

Severe symptom onset. Children with ABS may experience severe onset of symptoms.^3,4 These children have purulent nasal discharge for at least three consecutive days at onset of illness and concurrent fever (temperature, ≥ 102.2°F). In contrast, a viral URI typically presents with fever for less than 48 hours and clear nasal discharge that becomes purulent after the first few days of symptoms.

“Double sickening.” Finally, children with ABS may have a worsening course of symptoms or a “double sickening.”^3,4 These patients experience typical URI symptoms that initially begin to improve, then worsen on day 6 or 7 of illness with increasing or new onset of considerable nasal drainage, daytime cough, or fever.

Continue for physical findings >>

PHYSICAL FINDINGS
Physical exam findings are not sufficient to distinguish between viral URI and ABS.^1,3,5 Typical findings on examination may include nasal congestion, postnasal drip, erythematous turbinates, and/or injected posterior oropharynx. Malodorous breath may be present but is not diagnostic.^3,5 The tympanic membranes should be examined for signs of concomitant acute otitis media (AOM) or otitis media with effusion. Swelling of the eyelids may be present. Facial pain may also be noted on physical exam.³

Clinicians should be mindful of the complications of sinusitis when performing the physical examination (see Table 1). The most common complications of ABS are orbital and may manifest with eyelid swelling, proptosis, or decreased extraocular movements. Patients with intracranial complications may present with headache, photophobia, seizure, meningeal signs, or focal neurologic signs.³

Continue to making the diagnosis >>

MAKING THE DIAGNOSIS
The diagnosis of ABS is a clinical one. Clinical guidelines from the AAP and IDSA for the diagnosis of ABS in children are very similar; both describe clinical presentations of persistent, severe, or worsening symptoms.^3,4 This display of expert consensus allows clinicians to confidently distinguish between viral URIs and ABS by adhering to the strict diagnostic criteria already discussed.

Imaging
Radiographs and CT scans are not necessary to confirm the diagnosis of ABS. Imaging studies may reveal current or recent upper respiratory symptoms, including mucosal inflammation, opacities, and air-fluid levels^6,7; however, no imaging study is available that can distinguish among mucosal inflammation and viral or bacterial infections. CT scans or MRI may be useful if clinicians suspect a complication of sinusitis.^3,7

Microbiology
Historically, the microbiology of ABS has been determined by maxillary sinus aspiration. The most recent studies of this method, published in the 1980s, identified Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis as the most common bacterial pathogens.^3,6,9 More recently, the microbiology of ABS has been linked with causative pathogens in AOM. The pathogenesis of ABS and AOM are similar, therefore allowing data from tympanocentesis in children with AOM to be used to determine the microbiology of children with ABS.¹⁰ Although S pneumoniae, H influenzae, and M catarrhalis remain common causative pathogens in ABS, the introduction of the 7- and 13-valent pneumococcal vaccines has altered the microbiology of AOM, and presumably ABS.¹¹

Importantly, numbers of cases of AOM attributed to S pneumoniae have decreased while those attributed to H influenzae have increased.^3,11 In addition, antimicrobial susceptibility of S pneumoniae and the prevalence of β-lactamase–positive H influenzae are important considerations when choosing appropriate antibiotics and can vary significantly by geographic region. Therefore, it is important that clinicians be aware of susceptibility patterns in the communities in which they practice.

Continue for the medical options >>

WHAT ARE THE MEDICAL OPTIONS?
Initial management of ABS in children is contingent on the symptom profile at presentation (persistent, worsening, or severe) and consideration of causative pathogens. While the consensus among experts is that children presenting with severe or worsening symptoms be treated initially with antibiotics,^3,4 children who present with mild symptoms consistent with persistent illness may initially be treated with antibiotics or observed for an additional three days. This decision should be made thoughtfully and in collaboration with the patient’s parents or guardians. Any child with ABS who presents with persistent symptoms of illness and is managed initially by observation alone should be reassessed or treated with an antibiotic if symptoms worsen, if new symptoms appear, or if the child fails to improve within 72 hours.

Amoxicillin with or without clavulanate is the antibiotic of choice when ABS has been diagnosed and antibiotic treatment is indicated.^1,3 AAP recommendations for antimicrobial treatment of ABS in children are stratified on the basis of age, severity of illness, day care attendance, and history of treatment with amoxicillin in the previous 30 days (see Table 2). Clinicians should rely on their knowledge of drug resistance in their community and judgment regarding severity of illness when choosing between amoxicillin and amoxicillin/clavulanate as initial treatment for ABS.³

Recommendations for duration of antimicrobial treatment for ABS vary considerably. A reasonable suggestion is to continue to treat patients until they are symptom-free for seven days. For many patients, this will mean a 10-day treatment course, with flexibility to increase the duration as needed.³

Children with ABS should be reassessed if there are worsening signs or symptoms or lack of clinical improvement within 72 hours of initial management. Clinicians should evaluate whether the patient has been appropriately diagnosed and assessed for complications of ABS. If the diagnosis is confirmed and ABS complications are not suspected, the clinician may change antibiotics or initiate antibiotic therapy if the child was previously managed by observation only.^3,4

A child who is vomiting or unable to tolerate PO medications may benefit from a single 50-gm/kg dose of ceftriaxone IV or IM with follow-up in 24 hours.³ Oral antibiotics may be started at the follow-up visit if the patient demonstrates clinical improvement.

When considering a change in antibiotic, the clinician should consider the possibility of drug resistance. If the child was initially treated with amoxicillin, high-dose amoxicillin/clavulanate may be prescribed. If high-dose amoxicillin/clavulanate was initially prescribed and the patient has not improved or is experiencing worsening symptoms, clindamycin with cefixime, linezolid with cefixime, or levofloxacin may be considered.^3,4

Penicillin allergy
Patients with a history of a non–type 1 hypersensitivity reaction to amoxicillin may be treated with cefdinir, cefuroxime, cefpodoxime, or combination therapy with clindamycin plus a third-generation oral cephalosporin. Allergist referral for penicillin or cephalosporin skin testing may be considered before initiation of therapy.^3,4,13

Adjuvant therapy
Decongestants, antihistamines, and nasal irrigation are frequently recommended in the management of ABS in children; however, the authors of a 2012 Coch­rane review found no properly designed studies to evaluate the effectiveness of these treatments.¹³ Furthermore, there is insufficient evidence to clearly recommend the use of intranasal steroids as an adjuvant therapy in the treatment of ABS in children (although several randomized controlled studies demonstrate their effectiveness in adolescents and adults).³

Continue for the conclusion >>

CONCLUSION
ABS in children is diagnosed clinically by following a strict set of clinical criteria. Patients commonly present with one of three types of symptoms: persistent URI; severe purulent nasal discharge and fever for at least three consecutive days; or a double sickening. Physical examination findings vary and will not differentiate viral URI symptoms from a diagnosis of ABS. Imaging is not recommended for diagnosis but may be helpful if an orbital or intracranial complication of ABS is suspected.

S pneumoniae, H influenzae, and M catarrhalis continue to be the most common pathogens associated with ABS. However, since the introduction of the 7-valent pneumococcal vaccine, prevalence of H influenzae and β-lactamase–positive H influenzae has increased.

Treatment recommendations vary, based on suspected causative pathogens and presenting symptoms. Amoxicillin or amoxicillin-clavulanate is recommended as firstline antimicrobial treatment for ABS, with alternate antibiotic choices for patients with worsening symptoms or lack of improvement within 72 hours. An awareness of the community’s susceptibility patterns is essential for the clinician who cares for children at risk for ABS.

REFERENCES
1. Wald ER, Nash D, Eickhoff J. Effectiveness of amoxicillin/clavulanate potassium in the treatment of acute bacterial sinusitis in children. ­Pediatrics. 2009;124(1):9-15.
2. Ray NF, Baraniuk JN, Thamer M, et al. Healthcare expenditures for sinusitis in 1996: contributions of asthma, rhinitis, and other airway disorders. J Allergy Clin Immunol. 1999;103(3 pt 1):408-414.
3. Wald ER, Applegate KE, Bordley C, et al. Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years. Pediatrics. 2013;132(1):e262-e280.
4. Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis. 2012;54(8):1041-1045.
5. Shaikh N, Hoberman A, Kearney DH, et al. Signs and symptoms that differentiate acute sinusitis from viral upper respiratory tract infection. Pediatr Infect Dis J. 2013;32(10):1061-1065.
6. Kovatch AL, Wald ER, Ledesma-Medina J, et al. Maxillary sinus radiographs in children with nonrespiratory complaints. Pediatrics. 1984; 73(3):306-308.
7. Triulzi F, Zirpoli S. Imaging techniques in the diagnosis and management of rhinosinusitis in children. Pediatr Allergy Immunol. 2007;18(suppl 18):46-49.
8. Wald ER, Milmoe GJ, Bowen A, et al. Acute maxillary sinusitis in children. N Engl J Med. 1981;304(13):749-754.
9. Wald ER, Reilly JS, Casselbrant M, et al. Treatment of acute maxillary sinusitis in childhood: a comparative study of amoxicillin and cefaclor. J Pediatr. 1984;104(2):297-302.
10. Wald ER. Acute otitis media and acute bacterial sinusitis. Clin Infect Dis. 2011;52(suppl 4):S277-S283.
11. Casey JR, Adlowitz DG, Pichichero ME. New patterns in the otopathogens causing acute otitis media six to eight years after introduction of pneumococcal conjugate vaccine. Pediatr Infect Dis J. 2010;29(4):304-309.
12. Pichichero ME. A review of evidence supporting the American Academy of Pediatrics recommendation for prescribing cephalosporin antibiotics for penicillin-allergic patients. Pediatrics. 2004;115(4):1048-1057.
13. Shaikh N, Wald ER, Pi M. Decongestants, antihistamines and nasal irrigation for acute sinusitis in children. Cochrane Database Syst Rev. 2012;9:CD007909.

Research shows that the foundation of lifelong health is established during a child’s earliest years, including the prenatal period, and is also determined by the health of the future mother before she becomes pregnant. Much like the foundation of a house, if a child’s early years are filled with nurturing experiences and limited exposure to toxic stress, a child is set to succeed and withstand future challenges. However, adverse childhood experiences and toxic stress can disproportionately derail a child’s developmental growth and can lead to negative impacts throughout the lifespan, including social, emotional, and cognitive impairment; adoption of health risk behaviors; disease, disability, and social problems; and potentially early death.

Furthermore, data from the National Comorbidity Survey–Replication Sample (NCS-R) found that the prevalence of various mental health disorders – including disorders related to mood, anxiety, impulse control, and substance abuse – increases with the cumulative number of adverse childhood experiences. Persons with four or more childhood adversities had an odds ratio of 7.3 for four disorder categories.

Combined with recent data from the World Health Organization suggesting that the global cost of untreated mental health disorders is approximately $1 trillion, there is a clear public health crisis on our doorstep. Seeing our vulnerable patient population in the Bronx, family after family struggling to cope, I asked myself – is the solution on our doorstep too?

The role of the pediatrician

During a child’s early years, a pediatrician’s role is to identify signs of early childhood adversity and toxic stress, and to provide targeted support for parents and caregivers (Pediatrics. 2012 Jan. doi: 10.1542/peds.2011-2662). Given this, child primary care providers face the following challenges:

• Is there an opportunity for us to identify children at risk of developing mental health problems within the primary care setting?

• If so, how early can we identify children who would benefit from specific preventive or therapeutic interventions to optimize their developmental and behavioral potential?

• What tools are available in primary care to accomplish this function, and how should we administer them?

Healthy Steps program evaluation

At Montefiore Medical Group, we have developed a program that helps pediatricians overcome these challenges. Based on the national Healthy Steps program, Montefiore offers integrated mental health services in pediatric primary care settings, and provides universal screening, assessment, and treatment of young children and their caregivers.

A quasiexperimental longitudinal study was conducted, involving follow-up of 124 children enrolled in Healthy Steps at their primary care pediatric setting and a comparison group from a clinic that did not receive this intervention. The aim of the study was to determine the relationship between maternal adverse childhood experiences (ACES) and child social-emotional development, as measured via the Ages and States Questionnaire: Social Emotional (ASQ:SE) at age 36 months.

Social-emotional development is thought to be critical in terms of a child’s ability to learn and get along with others. It is also a precursor to mental health. Our results showed that, without intervention, there was a dramatic link between maternal ACES score and at-risk social-emotional development for children at age 3 years. However, our Healthy Steps program appeared to moderate this otherwise powerful link, as children who received Healthy Steps, even if their mother had experienced abuse or neglect in her own childhood, had healthy social-emotional development at age 3 years.

As a result of the success of Healthy Steps at Montefiore, in 2014 we expanded our pediatric integrated behavioral health program to also include school age and adolescent patients. Today, we are serving approximately 90,000 pediatric patients at more than 21 sites in the Bronx and surrounding area. We provide universal behavioral health screening, including for autism and maternal depression, at well-child visits. We provide parental mental health services, within pediatrics, to parents of infants and toddlers struggling with perinatal mental health challenges, and we devote significant time to education of our primary care providers, to increase their confidence and competence regarding pediatric behavioral health.

Initial results for school age, adolescent program

Our early results regarding feasibility are promising. We found that more than 26% of children presenting to the primary care practices, well beyond national averages, were referred to our program during a 6-month study period. And while a referral unfortunately rarely leads to actual treatment in mental health, we found that more than half of referred patients attended at least one therapy session, and a warm hand-off (a unique feature of integrated care in which psychologists meet with a referred patient during the well-child visit in order to establish a level of trust between patient and provider) increased this to 63%.

Future steps

Our efforts suggest that integration of pediatric behavioral health specialists into primary care is feasible, efficacious, and beneficial to children and parents. We have had success at identifying children at risk for exposure to toxic stress early in their lifetimes and providing multigenerational treatment to these children to ensure healthy social-emotional development. We have shown that when we offer mental health treatment within primary care, even in an urban setting where stigma around mental illness runs high, we almost triple the national average of successful linkage to mental health services for school age and adolescent children. However, payment reform is needed to truly achieve population health. We must ensure preventive and multigenerational services are covered so that we may continue to treat children and families within the nonstigmatized and universally accessed setting of primary care.

Dr. Briggs is director of pediatric behavioral health services and Healthy Steps at Montefiore Medical Group and associate professor of clinical pediatrics at Albert Einstein College of Medicine, both in New York.

Research shows that the foundation of lifelong health is established during a child’s earliest years, including the prenatal period, and is also determined by the health of the future mother before she becomes pregnant. Much like the foundation of a house, if a child’s early years are filled with nurturing experiences and limited exposure to toxic stress, a child is set to succeed and withstand future challenges. However, adverse childhood experiences and toxic stress can disproportionately derail a child’s developmental growth and can lead to negative impacts throughout the lifespan, including social, emotional, and cognitive impairment; adoption of health risk behaviors; disease, disability, and social problems; and potentially early death.

Furthermore, data from the National Comorbidity Survey–Replication Sample (NCS-R) found that the prevalence of various mental health disorders – including disorders related to mood, anxiety, impulse control, and substance abuse – increases with the cumulative number of adverse childhood experiences. Persons with four or more childhood adversities had an odds ratio of 7.3 for four disorder categories.

Combined with recent data from the World Health Organization suggesting that the global cost of untreated mental health disorders is approximately $1 trillion, there is a clear public health crisis on our doorstep. Seeing our vulnerable patient population in the Bronx, family after family struggling to cope, I asked myself – is the solution on our doorstep too?

The role of the pediatrician

During a child’s early years, a pediatrician’s role is to identify signs of early childhood adversity and toxic stress, and to provide targeted support for parents and caregivers (Pediatrics. 2012 Jan. doi: 10.1542/peds.2011-2662). Given this, child primary care providers face the following challenges:

• Is there an opportunity for us to identify children at risk of developing mental health problems within the primary care setting?

• If so, how early can we identify children who would benefit from specific preventive or therapeutic interventions to optimize their developmental and behavioral potential?

• What tools are available in primary care to accomplish this function, and how should we administer them?

Healthy Steps program evaluation

At Montefiore Medical Group, we have developed a program that helps pediatricians overcome these challenges. Based on the national Healthy Steps program, Montefiore offers integrated mental health services in pediatric primary care settings, and provides universal screening, assessment, and treatment of young children and their caregivers.

A quasiexperimental longitudinal study was conducted, involving follow-up of 124 children enrolled in Healthy Steps at their primary care pediatric setting and a comparison group from a clinic that did not receive this intervention. The aim of the study was to determine the relationship between maternal adverse childhood experiences (ACES) and child social-emotional development, as measured via the Ages and States Questionnaire: Social Emotional (ASQ:SE) at age 36 months.

Social-emotional development is thought to be critical in terms of a child’s ability to learn and get along with others. It is also a precursor to mental health. Our results showed that, without intervention, there was a dramatic link between maternal ACES score and at-risk social-emotional development for children at age 3 years. However, our Healthy Steps program appeared to moderate this otherwise powerful link, as children who received Healthy Steps, even if their mother had experienced abuse or neglect in her own childhood, had healthy social-emotional development at age 3 years.

As a result of the success of Healthy Steps at Montefiore, in 2014 we expanded our pediatric integrated behavioral health program to also include school age and adolescent patients. Today, we are serving approximately 90,000 pediatric patients at more than 21 sites in the Bronx and surrounding area. We provide universal behavioral health screening, including for autism and maternal depression, at well-child visits. We provide parental mental health services, within pediatrics, to parents of infants and toddlers struggling with perinatal mental health challenges, and we devote significant time to education of our primary care providers, to increase their confidence and competence regarding pediatric behavioral health.

Initial results for school age, adolescent program

Our early results regarding feasibility are promising. We found that more than 26% of children presenting to the primary care practices, well beyond national averages, were referred to our program during a 6-month study period. And while a referral unfortunately rarely leads to actual treatment in mental health, we found that more than half of referred patients attended at least one therapy session, and a warm hand-off (a unique feature of integrated care in which psychologists meet with a referred patient during the well-child visit in order to establish a level of trust between patient and provider) increased this to 63%.

Future steps

Our efforts suggest that integration of pediatric behavioral health specialists into primary care is feasible, efficacious, and beneficial to children and parents. We have had success at identifying children at risk for exposure to toxic stress early in their lifetimes and providing multigenerational treatment to these children to ensure healthy social-emotional development. We have shown that when we offer mental health treatment within primary care, even in an urban setting where stigma around mental illness runs high, we almost triple the national average of successful linkage to mental health services for school age and adolescent children. However, payment reform is needed to truly achieve population health. We must ensure preventive and multigenerational services are covered so that we may continue to treat children and families within the nonstigmatized and universally accessed setting of primary care.

Dr. Briggs is director of pediatric behavioral health services and Healthy Steps at Montefiore Medical Group and associate professor of clinical pediatrics at Albert Einstein College of Medicine, both in New York.

Research shows that the foundation of lifelong health is established during a child’s earliest years, including the prenatal period, and is also determined by the health of the future mother before she becomes pregnant. Much like the foundation of a house, if a child’s early years are filled with nurturing experiences and limited exposure to toxic stress, a child is set to succeed and withstand future challenges. However, adverse childhood experiences and toxic stress can disproportionately derail a child’s developmental growth and can lead to negative impacts throughout the lifespan, including social, emotional, and cognitive impairment; adoption of health risk behaviors; disease, disability, and social problems; and potentially early death.

Furthermore, data from the National Comorbidity Survey–Replication Sample (NCS-R) found that the prevalence of various mental health disorders – including disorders related to mood, anxiety, impulse control, and substance abuse – increases with the cumulative number of adverse childhood experiences. Persons with four or more childhood adversities had an odds ratio of 7.3 for four disorder categories.

Combined with recent data from the World Health Organization suggesting that the global cost of untreated mental health disorders is approximately $1 trillion, there is a clear public health crisis on our doorstep. Seeing our vulnerable patient population in the Bronx, family after family struggling to cope, I asked myself – is the solution on our doorstep too?

The role of the pediatrician

During a child’s early years, a pediatrician’s role is to identify signs of early childhood adversity and toxic stress, and to provide targeted support for parents and caregivers (Pediatrics. 2012 Jan. doi: 10.1542/peds.2011-2662). Given this, child primary care providers face the following challenges:

• Is there an opportunity for us to identify children at risk of developing mental health problems within the primary care setting?

• If so, how early can we identify children who would benefit from specific preventive or therapeutic interventions to optimize their developmental and behavioral potential?

• What tools are available in primary care to accomplish this function, and how should we administer them?

Healthy Steps program evaluation

At Montefiore Medical Group, we have developed a program that helps pediatricians overcome these challenges. Based on the national Healthy Steps program, Montefiore offers integrated mental health services in pediatric primary care settings, and provides universal screening, assessment, and treatment of young children and their caregivers.

A quasiexperimental longitudinal study was conducted, involving follow-up of 124 children enrolled in Healthy Steps at their primary care pediatric setting and a comparison group from a clinic that did not receive this intervention. The aim of the study was to determine the relationship between maternal adverse childhood experiences (ACES) and child social-emotional development, as measured via the Ages and States Questionnaire: Social Emotional (ASQ:SE) at age 36 months.

Social-emotional development is thought to be critical in terms of a child’s ability to learn and get along with others. It is also a precursor to mental health. Our results showed that, without intervention, there was a dramatic link between maternal ACES score and at-risk social-emotional development for children at age 3 years. However, our Healthy Steps program appeared to moderate this otherwise powerful link, as children who received Healthy Steps, even if their mother had experienced abuse or neglect in her own childhood, had healthy social-emotional development at age 3 years.

As a result of the success of Healthy Steps at Montefiore, in 2014 we expanded our pediatric integrated behavioral health program to also include school age and adolescent patients. Today, we are serving approximately 90,000 pediatric patients at more than 21 sites in the Bronx and surrounding area. We provide universal behavioral health screening, including for autism and maternal depression, at well-child visits. We provide parental mental health services, within pediatrics, to parents of infants and toddlers struggling with perinatal mental health challenges, and we devote significant time to education of our primary care providers, to increase their confidence and competence regarding pediatric behavioral health.

Initial results for school age, adolescent program

Our early results regarding feasibility are promising. We found that more than 26% of children presenting to the primary care practices, well beyond national averages, were referred to our program during a 6-month study period. And while a referral unfortunately rarely leads to actual treatment in mental health, we found that more than half of referred patients attended at least one therapy session, and a warm hand-off (a unique feature of integrated care in which psychologists meet with a referred patient during the well-child visit in order to establish a level of trust between patient and provider) increased this to 63%.

Future steps

Our efforts suggest that integration of pediatric behavioral health specialists into primary care is feasible, efficacious, and beneficial to children and parents. We have had success at identifying children at risk for exposure to toxic stress early in their lifetimes and providing multigenerational treatment to these children to ensure healthy social-emotional development. We have shown that when we offer mental health treatment within primary care, even in an urban setting where stigma around mental illness runs high, we almost triple the national average of successful linkage to mental health services for school age and adolescent children. However, payment reform is needed to truly achieve population health. We must ensure preventive and multigenerational services are covered so that we may continue to treat children and families within the nonstigmatized and universally accessed setting of primary care.

Dr. Briggs is director of pediatric behavioral health services and Healthy Steps at Montefiore Medical Group and associate professor of clinical pediatrics at Albert Einstein College of Medicine, both in New York.