Infant Acetaminophen Dosage Change May Cause Confusion

From WebMD Health News Jennifer Warner December 23, 2011 — Double check the label on liquid acetaminophen before giving it to a child or infant to avoid giving your child the wrong dose. The FDA is urging parents and caregivers to carefully read the label on liquid acetaminophen marketed to infants and children as a new, less concentrated form of the popular pain reliever arrives on store shelves. Acetaminophen products include several over-the-counter brands, including Little Fevers, PediaCare, Triaminic, Tylenol, and store brands or generic versions of the drug. While the new 160 mg per 5 mL concentration is now arriving in drugstores, much of the older, more concentrated 80 mg per 1 mL or 80 mg per 0.8 mL versions may still be in people’s medicine cabinets. “There is still some on store shelves; there is still some in homes; and there is still some in distribution,” Carol Holquist, director of the FDA’s Division of Medical Error Prevention and Analysis, says in a news release. “Be very careful when you’re giving your infant acetaminophen.” Giving too little liquid acetaminophen could cause the drug to be ineffective. Giving too much could possibly lead to death. The drug is used to temporarily reduce fever and relieve minor aches and pains from the common cold, flu, headache, minor sore throat, and toothache. Why the New Version? Until recently, liquid acetaminophen marketed for infants was available only in the stronger 80 mg per 1 mL or 80 mg per 0.8 mL concentrations that don’t require giving infants as much liquid with each dose. Meanwhile, the less concentrated 160 mg per 5 mL version was marketed for children. Earlier this year, a report from the FDA showed that confusion caused by the different concentrations of liquid acetaminophen for infants and children was leading to overdoses that made infants seriously ill, and some died from liver failure. To avoid these dosing errors, some manufacturers voluntarily changed the concentration of liquid acetaminophen for infants to the same concentration as the liquid acetaminophen marketed to children. The new, less concentrated 160 mg per 5 mL liquid acetaminophen for infants has new dosing instructions and may have a new dosing device in the box, such as an oral syringe rather than a dropper. What You Should Do The FDA advises parents and caregivers to read the “Active ingredient” section of the Drug Facts label on liquid acetaminophen marketed to infants or children to tell the difference between the two products. Other tips for ensuring safe and accurate dosing of liquid acetaminophen include: Do not depend on a banner proclaiming that the product is “new” to determine the drug’s concentration. Some medicines with the old concentration also have this word on their packaging. Use only the dosing device provided with the purchased product in order to correctly measure the right amount of liquid acetaminophen. Consult your pediatrician before giving this medication and make sure you’re talking about the same concentration. If the dosing instructions provided by your health care provider differ from what is on the label, check with a health care professional before administering the medication. Do not rely on dosing information provided from other sources, such as the Internet, old dosing charts, or family members. FDA officials say it is important to note that there is no dosing amount specified for children younger than 2 years of age. If you have an infant or child younger than 2 years old, always check with your health care provider for dosing instructions.

Concussions, Our Patients, and You

Gregory Lawton, MD, Pediatrics, General, 09:24AM Dec 19, 2011 Recently, the New York Times chronicled the life and death of hockey's premier enforcer, Derek Boogaard, who died at the age of 28 in April from an overdose of pain killers. His brain, subjected to hundreds of bare-knuckle fights over from the age of fourteen years, demonstrated pronounced evidence of chronic traumatic encephalopathy (CTE). I was dumbfounded at how matter of fact, even nonchalant, his parents were, as they described their late son's career, and their acceptance of his job, to deliver (and receive) physical punishment. His father was more concerned about the toll of fighting on his hands. Last month, a new study detailed the potential destructive effects on the brain's white matter resulting from the frequent heading of soccer balls. According to the study, adults who actively played soccer and acknowledged heading the ball more than 1,100 times in the previous twelve months had radiological and cognitive evidence of a decline. While the study was on adults, it raises more than a few questions concerning the effects of heading on the developing brains of children and adolescents. Finally, a December National Geographic piece visually quantifies the 537 head shots a college football player sustained during a single season. Two hits resulted in concussions, and interestingly enough, the hits that resulted in concussions were not the hardest of the bunch. This adds to the complexity of concussions and their prevention, with the notion of rotational as well as direct forces. What to do? We are parents, coaches, as well as pediatricians. We go to hockey and football games and pay good money for the tickets. Some measures are within our reach but are quixotic in nature. Others are hopelessly naïve. Let's start small. As parents, just say no to some things. My father forbade me to play football (so I became a baseball catcher instead). Ditto for my son. Is this a bit inconsistent, trading a blitzing linebacker's helmet for a foul ball off the facemask? Probably, but I would like to think that neither myself nor my parents were as "bewildered" by their son's activities as Derek Boogaard's parents. Life and sports are both associated with risks. The only risk-free option is not to play. To choose one sport over another is to exercise our judgment and choose one set of risks over another. As coaches, we have the opportunity to combine personal interest and professional knowledge as it relates to developing athletes. A growing consensus seems to be developing that heading should be discouraged in players under the age of twelve. For older players, teaching chest trapping (especially on punts) may make for better ball control as well as fewer concussions. Keeping an eye out for concussive symptoms such as headaches, dizziness, or nausea in our players should decrease the incidence of second concussion syndrome, regardless of the sport. As pediatricians, we need to continue to educate parents and players about the signs, symptoms, and CONSEQUENCES of concussions. We need to impress upon them that no practice, scrimmage, game, or playoff, is worth the risk of a second concussion. How many kids in our practices have gone on to professional football, lacrosse, or hockey careers? Compare that to the number of future teachers, business owners, or managers we see. The reality is that the vast majority of our patients will make their future mortgage payments not with their athletic prowess, but with their more prosaic communication, organization, decision-making skills. Brain cells are our patients' most precious collateral. We must emphasize this fact with regard to concussions as strenuously as we do with drug and alcohol counseling. Finally, what are we to make of our football season tickets or our interest in a Flyers-Rangers game? Both sports are physical, often violent. Both are also punctuated with moments, indeed entire sequences that are mesmerizing for their grace, speed, and superb athleticism. What is closer to the essence of each sport, the violence or the elegance? Perhaps we should aspire to cheer that which is closer to the essence. Chris Nowinski, of the Center for the Study of Tramatic Encephalopathy at Boston University Medical School, is a former Harvard football player (as well as professional wrestler). He has suffered post-concussion syndrome. He still loves his Bruins; however, he tends to remain seated during the fights. Enforcers in hockey, football players who lead with their helmets and soccer players who take the hard shots out of the air with their heads are doing one thing, according to Nowinski. "They are trading money for brain cells." We don't see professional athletes in our offices. We see student athletes. Let's asked them to be smart, to play tough, but to play fair. Concussions will happen, but we need to be proactive in both prevention and treatment. When we counsel about second concussions, we need to modify the Nowinski's quote. Don't trade brain cells for glory. Look for me on Facebook at A Musing Pediatrician, http://www.facebook.com/profile.php?id=100003267241424

An Infant is not Just a Small Child

From Expert Review of Clinical Pharmacology Clinical Pharmacology in Neonates and Young Infants The Benefit of a Population-tailored Approach John van den Anker; Karel Allegaert Authors and Disclosures Posted: 12/22/2011; Expert Rev Clin Pharmacol. 2012;5(1):5-8. © 2012 Expert Reviews Ltd. Print This Email this An Infant is not Just a Small Child Tailored Pharmacokinetic Studies in Infancy: Improved Sampling Strategies & Data An Infant is not Just a Small Child John van den Anker; Karel Allegaert Posted: 12/22/2011; Expert Rev Clin Pharmacol. 2012;5(1):5-8. © 2012 Expert Reviews Ltd. The most essential characteristics of childhood are growth and maturation. Both phenomena are most prominent during infancy, making the claim that 'an infant is not just a small child' as relevant as the more commonly used paradigm that 'a child is not just a small adult'. There is already one log size difference in weight (0.5–5 kg) within the neonatal population, quite similar to the log size spectrum (5–50 kg) of childhood. The birth weight increases by 50% in the first 6 weeks of life, and doubles in the first 4 months to be three-times higher at the end of infancy. In this same time interval, there is a fourfold increase in caloric needs. As a consequence, the first year of human life is characterized by a very dynamic biological system where growth, maturation and extensive variability are the key issues. From a clinical pharmacology perspective, the consequence of such a dynamic setting is extensive interindividual variability throughout infancy in both the pharmacokinetics and pharmacodynamics of xenobiotics. Instead of median values for pharmacokinetic estimates or outcome variables, the range and its contributing covariates are crucial. Body composition and compartment sizes change during infancy, and all phase I (e.g., cytochromes) and phase II (e.g., glucuronidation) metabolic processes mature in an iso-enzyme-specific pattern, while renal function (glomerular filtration rate and tubular absorption/excretion) also displays age-dependent capacity. The phenotypic variability in either drug disposition or effects during infancy is further affected by the contribution of other, non-ontogeny-related covariates (e.g., perinatal asphyxia with whole body cooling, comedication, genetic polymorphisms, sepsis or inflammation, and congenital renal impairment). History provides the community with compound-specific observations to illustrate the negative impact of exposure to chloramphenicol (deficient glucuronidation capacity resulting in chloramphenicol accumulation and gray baby syndrome), benzyl alcohol (deficient alcohol dehydrogenase activity resulting in benzyl alcohol accumulation and gasping syndrome) or – much more recently – dexamethasone (specific vulnerability of neonatal cortical and subcortical nervous tissues, resulting in cerebral palsy and blunted brain growth) in neonates. All these anecdotic observations can be considered as illustrations of failure to consider the specific characteristics of this vulnerable population. However, optimism is a moral duty. Implementation of the pediatric regulation in the USA in 1997 has resulted in a rebirth of pediatric product development, including drugs for infants. Subsequent implementation of a similar pediatric legislation initiative in the EU (2007) and in WHO initiatives (e.g., the WHO 'make drugs child size' program, which is an ongoing program of the WHO and resulted in an essential medicines list for children in 2011) further stimulated all stakeholders (industry, academia, governmental and research organizations) to develop focused pediatric research activities. As an illustration, a search for 'newborn/infant' on the clinicaltrials.gov website in early October 2011 resulted in 1318 protocols for interventional studies, of which 899 were initiated (based on the sponsor's location) in the USA and 376 in Europe. Although this is only a snapshot of the ongoing clinical research activities, it suggests that there is growing research activity aiming to further improve pharmacotherapy.In addition to compound-specific observations, such studies also stimulated the development and validation of research tools in the field of pharmacokinetics (e.g., analytical techniques and population pharmacokinetics) and pharmacodynamics (population-specific 'biomarkers') adapted to newborns and infants.

Caffeine Intake May Negatively Affect Children

From Medscape Medical News Laurie Barclay, MD December 22, 2010 — Caffeine intake is prevalent in children and may have negative effects on sleep duration, according to the results of a study reported online in the December 16 issue of the Journal of Pediatrics. "Caffeine's diuretic properties have encouraged behavioural health practitioners to eliminate caffeine from the diet of children with enuresis," write William Warzak, MD, from the Munroe-Meyer Institute and the Department of Pediatrics, University of Nebraska Medical Center in Omaha, and colleagues. "The Food and Drug Administration has not developed pediatric guidelines for caffeine consumption, but Canadian guidelines recommend that children aged 4 to 6 years old consume no more than 45 mg/d, approximately equivalent to the amount of caffeine found in a 12-ounce can of cola.... The most recent caffeine consumption data for children living in the United States is almost a decade old, and most of this research has been conducted with older children, adolescents, and adults." The study goals were to obtain current data for caffeine intake in children, to evaluate the associations between caffeine, enuresis, and sleep, and to assess cross-cultural differences in caffeine consumption by Spanish- and English-speaking children aged 5 to 12 years. During routine clinical visits at a pediatric clinic in Omaha, parents were surveyed about their child's daily consumption of various types of snacks and beverages. Of 228 young children whose parents were surveyed, about three quarters regularly consumed caffeine. Mean daily caffeine intake was approximately 52 mg in children aged 5 to 7 years and approximately 109 mg in children aged 8 to 12 years. Older children drank more caffeinated beverages than younger children. "Some children as young as 5 years old were consuming the equivalent of a can of soda a day," Dr. Warzak said in a news release. "Children between the ages of 8 and 12 years consumed an average of 109 mg a day, the equivalent of almost 3 12-ounce cans of soda." This study authors note that 109 mg caffeine daily is almost twice the amount recommended by Canadian pediatric guidelines and in excess of the amount shown to create physiological effects in adults. Although caffeine intake was significantly negatively correlated with hours slept, caffeine consumption and enuresis were not significantly correlated. Compared with English-speaking parents, Spanish-speaking parents reported fewer events of enuresis in their children. "Contrary to popular belief, children were not more likely to wet the bed if they consumed caffeine, despite the fact that caffeine is a diuretic," said coauthor Shelby Evans, PhD, also from the University of Nebraska Medical Center. Children aged 5 to 7 years slept an average of 9.46 hours per night, which is above the minimum 9 hours recommended by the US Centers for Disease Control and Prevention (CDC), but approximately one quarter of these children slept less than 9 hours per night. Children aged 8 to 12 years old slept an average of 8.47 hours per night, which is below the minimum proposed by the CDC. Limitations of this study include the inability to determine causal relationships, potential recall and parental bias, and a modest sample size of Spanish-speaking children. In addition, this study did not address the specific physiological and psychological effects of caffeine consumption on young children. "Parents should be aware of the potentially negative influence of caffeine on a child's sleep quality and daily functioning," Dr. Warzak concluded. The study authors have disclosed no relevant financial relationships. J Pediatr. Published online December 16, 2010.

Kids' Leukemia Risk Tied to Dads' Smoking

From Reuters Health Information By Kerry Grens NEW YORK (Reuters Health) Dec 15 - Children whose fathers smoked have at least a 15% higher risk of developing acute lymphoblastic leukemia, a new Australian study finds. "Paternal smoking seems to be real" as a risk factor, said Dr. Patricia Buffler, a professor at the University of California, Berkeley, who was not involved in the current analysis. "The importance of tobacco exposure and children's cancers has been overlooked until recently," Dr. Buffler told Reuters Health. "So I think this paper is important" in adding to the growing body of evidence. The research team, led by Dr. Elizabeth Milne at the Telethon Institute for Child Health Research in Australia, surveyed the families of nearly 400 children with ALL. Although ALL is the most common childhood cancer, it is still rare, affecting about three to five children out of every 100,000, according to the National Cancer Institute. The survey asked about the smoking habits of both parents. Dr. Milne and her colleagues compared these families to the families of more than 800 children of similar ages who did not have leukemia. They found that the mothers' smoking behavior had no impact on the kids' risk of developing the cancer. The researchers then added their results to those of nine earlier studies. When they did that, they found that kids whose fathers smoked at all around the time of their conception were 15% more likely to develop leukemia. Those whose dads smoked at least 20 cigarettes per day around that time were 44% more likely to be diagnosed with the cancer, according to a report published online December 5 in the American Journal of Epidemiology. Because of the toxins in tobacco smoke, Dr. Buffler said, "it's not unlikely that you'd have damage" in the cells that produce sperm. "Sperm containing DNA (damage) can still reach and fertilize an ovum, which may lead to disease in the offspring," Dr. Milne wrote in an email to Reuters Health. The study did not prove that DNA damage in the sperm caused by smoking is responsible for the children's increased risk of cancer. "The causes of ALL are likely to be multifactorial, and our findings relate to just one of the possible contributing factors," said Dr. Milne. Several other environmental factors are also tied to a greater chance of developing childhood leukemia, including ionizing radiation and the mother's exposure to paint or pesticides while pregnant. Dr. Milne said that many of the studies regarding these potential causes have been small, and not conclusive. Dr. Buffler is leading an international consortium of researchers tracking thousands of cases of childhood leukemia to determine the influence of environmental, genetic, and other biological factors on developing the disease. SOURCE: http://bit.ly/snq3sL

Lower Asthma Risk in Chubby Tots Who Slim Down

From Reuters Health Information By Amy Norton NEW YORK (Reuters Health) Dec 21 - Overweight preschoolers who don't slim down are at a higher asthma risk at age seven, but the baby fat doesn't seem to matter for kids who lose the extra weight, a new study suggests. Of more than 2,000 Swedish children followed to age eight, those who were overweight or obese at age seven - that is, with a body mass index at or above the 85th percentile -- were more likely to have asthma than their thinner peers -- whether or not they were overweight earlier in life. In contrast, children who were heavy as toddlers or at age four, but not at age seven, were no more prone to asthma than kids who'd always been normal-weight. Children who are chubby early in life often see their weight normalize by school age, according to lead researcher Jessica Ohman Magnusson, of the Karolinska Institute in Stockholm. But if the extra weight persists after age four, she told Reuters Health in an email, parents may need help in managing their child's weight in a healthy way. A number of studies have found that heavy children have a higher risk of asthma, or more severe symptoms. But whether the extra pounds are the cause is not clear. "We don't think we can say that overweight is causally associated with asthma," Magnusson said. That's because early-childhood pounds were not tied to asthma risk in cases where children eventually became normal-weight, she said. It's possible that other factors, and not weight itself, explain why children who remain heavy have an increased asthma risk. As reported online December 19th in Pediatrics, 6% of the total cohort of eight-year-olds had asthma, compared to 10% of the kids who were overweight at age seven. When the researchers accounted for parents' history of allergies, maternal smoking during pregnancy, and other factors, they found that being overweight at age seven was linked to a doubling in the risk of asthma. That was true regardless of whether the kids were normal weight or heavy at age four. Around 300 children in the study were overweight at some point. But fewer were persistently heavy; 122 children remained overweight from the age of one to age seven. So parents should feel reassured, Magnusson said, that those early extra pounds often do not last. And based on these findings, children whose weight normalizes may not have an increased asthma risk. SOURCE: http://bit.ly/tVwsye

Atopic Dermatitis : Diagnosis & Pathogenesis

Cases in Atopic Dermatitis Medscape Pediatrics CME Lawrence F. Eichenfield, MD Professor of Clinical Pediatrics and Medicine (Dermatology), University of California Pathogenesis and Diagnosis of Atopic Dermatitis Atopic dermatitis (AD) is a common inflammatory skin disorder affecting 10%-20% of children during their first decade of life. It is characterized by a pruritic, scaling rash that follows a fluctuating course. In approximately 60% of patients, AD starts in the first year of life. Newborns and infants usually have involvement on the cheeks, chin, and extremities. As the child ages, the rash typically transitions to classic involvement of the flexural antecubital and popliteal fossae. Fortunately, AD frequently resolves when the patient grows older. The pathogenesis of AD is complex and multifactorial. Acute AD is characterized by strong type 2 T-helper (TH2) cell responses with production of interleukin (IL)-4, IL-5, and IgE antibodies, whereas chronic AD has immunologic features more consistent with TH1-mediated responses. Recent evidence also suggests a possible role for TH17 cells. There is a significant barrier defect in people with AD. Many have mutations in the epidermal proteins that result in epidermal barrier dysfunction. The epidermis of skin affected with AD often has decreased levels of filaggrin, a protein responsible for aggregation and adhesion of the cornified envelope; ceramides, the predominant lipids of the cornified envelope; and antimicrobial peptides, such as beta-defensins and cathelicidins, proteins of the innate immune system that resist cutaneous colonization and infection. Further exacerbating the epidermal barrier of people with AD is increased transepidermal water loss. As a result of these barrier defects, allergen absorption and bacterial colonization and infection are enhanced, which further potentiates the immunologic dysfunction present in skin affected by AD. The diagnosis of AD is usually not challenging. However, other diagnoses should be considered if the presentation is atypical. Differential diagnoses include scabies, psoriasis, allergic contact dermatitis, immunodeficiency diseases, metabolic conditions, nutritional disorders, Langerhans cell histiocytosis, and various other disorders as suggested by the patient's presentation. Because AD is part of an atopic triad that includes asthma and allergic rhinitis, it is important to ask patients and parents whether there is a history of any of these in the patient or family. If there is such a history, AD is more likely. A child has a 20% risk for AD if one parent is affected and a 50% risk if both parents are affected. Furthermore, the concordance rate between monozygotic twins is 80%, and the concordance rate between dizygotic twins is 20%. Findings on physical examination that support a diagnosis of AD include typical pruritic eczematous dermatitis, hyperlinear palmar dermatoglyphics (increased fine skin lines), Dennie-Morgan fold (infraorbital line caused by edema), allergic shiners (dark periorbital skin due to sinus congestion and venous congestion), allergic salute (horizontal crease on the dorsal nose secondary to chronic allergies and rubbing), keratosis pilaris (spiny papules on the anterolateral upper arms), and ichthyosis vulgaris (fish-like scales on the skin). The diaper area of infants and toddlers with AD is characteristically spared, partially due to the occlusive hydration effect of diapers. The presence of significant rash in this area should prompt the consideration of other etiologies. There are many proposed diagnostic criteria for AD. Perhaps the most practical, sensitive, and validated for use in epidemiologic studies are the UK Working Party's Diagnostic Criteria for Atopic Dermatitis (Table 1). To meet these criteria, the patient must have pruritus and 3 or more minor criteria. Table 1. UK Working Party's Diagnostic Criteria for Atopic Dermatitis A. Required Criterion 1. Pruritus B. Minor Criteria (≥ 3 of the following must be present) 1. Onset < 2 years of age 2. History of flexural involvement 3. History of asthma or hay fever (or history of these conditions in parent or sibling if patient is < 4 years of age) 4. History of general dry skin in the last year 5. Visible flexural eczema (or eczema involving the cheeks/forehead and outer limbs in children < 4 years of age) Similarly, the American Academy of Dermatology Consensus Conference stated that AD is best thought of as a syndrome with features classified as "essential," "important," and "associated" (Table 2). Table 2. American Academy of Dermatology Consensus Conference Definition of Atopic Dermatitis A. Essential Features (must be present) 1. Pruritus 2. Eczema (acute, subacute, chronic) a. Typical morphology and age-specific patterns* b. Chronic or relapsing history B. Important Features (seen in most cases, adding support to the diagnosis) 1. Early age at onset 2. Atopy a. Personal and/or family history b. IgE reactivity 3. Xerosis C. Associated Features (helpful in suggesting the diagnosis but too nonspecific for defining or detecting AD for research or epidemiologic studies) 1. Atypical vascular responses (eg, facial pallor, white dermographism, delayed blanch response) 2. Keratosis pilaris/hyperlinear palms/ichthyosis 3. Ocular/periorbital changes 4. Other regional findings (eg, perioral changes/periauricular lesions) 5. Perifollicular accentuation/lichenification/prurigo lesions Exclusionary Conditions Diagnosis of AD depends on excluding such conditions as scabies, seborrheic dermatitis, allergic contact dermatitis, ichthyosis, cutaneous lymphoma, psoriasis, and immune deficiency diseases * Patterns include (1) facial, neck, and extensor involvement in infants and children; (2) current or prior flexural lesions in any age group; and (3) sparing of groin and axillary regions.

Parents' Smoking May Cause Vascular Damage in Children

From Medscape Medical News Laurie Barclay, MD December 26, 2011 — Parental smoking during pregnancy may cause vascular damage when the children reach 5 years of age, according to the results of a birth cohort study published online December 26 and in the January 2012 print issue of Pediatrics. "Smoking during pregnancy has been related to thicker carotid intima media thickness in young adults, and this was also shown in neonates," write Caroline C. Geerts, MD, from the Julius Center for Health Sciences and Primary Care and University Medical Center Utrecht in the Netherlands and colleagues. "The relation between smoke exposure in early life, the prenatal period in particular, and the vascular development of young children is largely unknown." To evaluate the association between parental smoking during pregnancy and subsequent vascular characteristics in their children, the investigators used data from the birth cohort enrolled in the Wheezing Illnesses Study Leidsche Rijn (WHISTLER)-Cardio study. At 5 years of age, 259 participants underwent ultrasonographic measurement of carotid artery intima-media thickness (CIMT) and arterial wall distensibility. Parental smoking data were also updated. After adjustment for the child's age and sex, maternal age, and breast-feeding, children of mothers who had smoked throughout pregnancy had more vascular damage than children of mothers who did not smoke during pregnancy. CIMT was 18.8 μm thicker in the former group (95% confidence interval [CI], 1.1 - 36.5; P = .04), and distensibility was 15% lower (95% CI, −0.3 to −0.02; P = .02). Children of mothers who smoked after pregnancy, but not during pregnancy, did not have these adverse effects on CIMT and distensibility. If both parents smoked during pregnancy, the associations were even stronger than with only maternal smoking: CIMT was 27.7 μm thicker (95% CI, 0.2 - 55.3), and distensibility was 21% lower (95% CI, −0.4 to −0.03). "This study is the first to show that the effect of smoking during pregnancy on the vasculature of children is (still) visible at the age of 5 years," the study authors write. "Pregnancy appears to be the critical period for this damage to occur." Limitations of this study include slightly different profiles in participants than in nonparticipants, lack of cotinine measurements at birth, and reliance on parental self-report of smoking. "In view of the early origins of cardiovascular disease, preventive measures against smoking should be specifically directed at the gestational period," the study authors conclude. The Netherlands Organization for Health Research and Development supported the WHISTLER birth cohort. The University Medical Center Utrecht supported WHISTLER-Cardio. The authors have disclosed no relevant financial relationships. Pediatrics. Published online December 26, 2011. Abstract

Food Allergy in Kids Not Being Optimally Diagnosed

Medscape Medical News from the:American College of Allergy, Asthma & Immunology (ACAAI) 2011 Annual Scientific Meeting Fran Lowry November 14, 2011 (Boston, Massachusetts) — Oral food challenges are the gold standard for diagnosing food allergies in children, but only a small fraction of kids in the United States are getting them, researchers reported here at the American College of Allergy, Asthma & Immunology 2011 Annual Scientific Meeting. As a result, it is likely that childhood food allergy is seriously underdiagnosed, Ruchi Gupta, MD, from Northwestern University Children's Memorial Hospital in Chicago, Illinois, told Medscape Medical News. "Guidelines just came out in March of this year from the National Institutes of Health NIAID [National Institute of Allergy and Infectious Diseases] stating that oral food challenge is the proper test to diagnose food allergy, along with medical history and positive skin and blood testing," Dr. Gupta said. "Oral food challenge solidifies the fact that the child does indeed have that particular food allergy. It is also a way for us to determine whether they do not or whether they have become tolerant. In our study, just one fifth of the kids had one." Dr. Gupta and her colleagues conducted a randomized cross-sectional survey of American households from June 2009 to February 2010. Respondents were 18 years and older who lived in households with at least 1 child younger than 18 years and who could complete the survey in Spanish or English. The survey involved 40,104 children; of these, investigators identified 3339 children with food allergy. A formal physician diagnosis of food allergy was made in 61.5% of these children. Of these, 47% had a skin test and 40% had a blood test for food allergy. However, an oral food challenge was done in just 15.6% of children; it was done more commonly if the child had a severe food allergy or had multiple food allergies, Dr. Gupta said. Formal diagnoses were most frequently confirmed by oral food challenge for milk allergy (22.4%), soy (19.2%), peanut (16.1%), wheat (15.5%), shellfish (14.4%), tree nut (12.6%), egg (12.4%), sesame (11.2%), and fin fish (9.1%). "Overall, what this tells us is that food allergy is not being diagnosed optimally and oral food challenges are definitely not being done enough," Dr. Gupta said. However, she added, the test can be cumbersome for busy practitioners to do. This might be one reason why oral challenge is not used as often as it should be. "This lack of use is understandable because oral food challenges take a long time for physicians to do. A test can take a couple of hours, and that ties up a room for a long time. Plus, reimbursements are poor, so there are lots of reasons why allergists are not able to do as many as they probably would like to do," Dr. Gupta said. New strategies are needed to promote the appropriate diagnosis of food allergy in accordance with NIAID guidelines, she added. "We need to get the word out, especially to general physicians, to increase their awareness about the current food allergy guidelines, so that they can help getting children accurate diagnoses and getting them to allergists." John Oppenheimer, MD, an allergist in private practice in Cedar Knolls, New Jersey, and chair of the scientific program committee, told Medscape Medical News that this study reinforces the fact that care for individuals with food allergies is suboptimal. "Presently, some overrely on blood or skin testing, but the gold standard is the ability to ingest a full serving of a food," Dr. Oppenheimer said. "Blood and skin tests have a very high false-positive rate. This abstract reminds us that in some patients...oral food challenge can aid in determining a true allergy." "Despite the fact that it is almost 2012, we have no perfect test to determine if a patient is allergic to a specific food," Dr. Oppenheimer continued. "Both the blood and skin tests are solely confirmatory tools, based upon history. They function very poorly as a screening tool. Thus, the allergist is left to rely upon history and to layer these confirmatory tests to determine the best move forward. When it appears reasonable, from the standpoint of risk, they can then perform a food challenge. As noted by Dr. Gupta, these are very time consuming and are not without risk. In light of the complexity of this scenario, I always suggest involving the allergy specialist early in the care of a food-allergic patient. There is no better time to determine the likelihood of food allergy than just after the sentinel reaction," he said. New tests for food allergy are on the horizon, he added. "Peptide microarray immunoassays may help stratify prospective patients undergoing food challenge regarding the likelihood of reaction, as noted in a study by Cerecedo et al" (J Allergy Clin Immunol. 2008;1223:589-594). Dr. Gupta has disclosed no relevant financial relationships. Dr. Oppenheimer reports financial relationships with AstraZeneca, GlaxoSmithKline, Merck, and Novartis. American College of Allergy, Asthma & Immunology (ACAAI) 2011 Annual Scientific Meeting: Abstract 48. Presented November 7, 2011.

Panel Recommends Universal Cholesterol Screening for Kids

Medscape Medical News from American Heart Association (AHA) 2011 Scientific Sessions From Heartwire Michael O'Riordan November 13, 2011 (Orlando, Florida) — An expert panel is recommending that all children, regardless of family history, undergo universal screening for elevated cholesterol levels. The panel recommends that children undergo lipid screening for non fasting non–HDL-cholesterol levels or a fasting lipid panel between the ages of 9 and 11 years followed by another full lipid screening test between 18 and 21 years of age. The guidelines, from the Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents, appointed by the National Health, Lung, and Blood Institute (NHLBI) and endorsed by the American Academy of Pediatrics (AAP), also recommend measuring fasting glucose levels to test for diabetes in children 10 years of age (or at the onset of puberty) who are overweight with other risk factors, including a family history, for type 2 diabetes mellitus. "The goal of the expert panel was to develop comprehensive evidence-based guidelines that address the known risk factors for cardiovascular disease to assist all primary pediatric care providers in both the promotion of cardiovascular health and the identification and management of specific risk factors from infancy into young adult life," write panel chair Dr Stephen Daniels (University of Colorado School of Medicine, Denver) and colleagues in Pediatrics. The level of evidence supporting the "strongly recommended" cholesterol screening recommendation is graded B, meaning that it is based on consistent evidence from observational studies, genetic natural history studies, or diagnostic studies with minor limitations. However, as some critics have pointed out, there are no randomized, controlled, clinical trials showing that the treatment of elevated cholesterol levels in children has a long-term clinical impact on cardiovascular outcomes, as well as no data showing that the use of lipid-lowering drugs is safe in children this young or when used for decades. In addition to the publication, Daniels and members of the writing committee plan to present their report at the American Heart Association 2011 Scientific Sessions this week. Not Going to Have a Heart Attack Tomorrow Dr Steven Nissen (Cleveland Clinic, OH), who was not part of the writing committee, called the guidelines "irrational," saying pediatricians have pushed widespread cholesterol screening forward in the absence of evidence supporting pharmacologic interventions if children are found to have elevated LDL-cholesterol levels. Nissen told heartwire that while the guidelines stress dietary and lifestyle intervention in kids with elevated cholesterol levels, the temptation to use the drugs in this population will be too high. "Plus, what is the 20-year risk of cardiovascular disease in a patient who is 11 years old?" asked Nissen. "It's zero." What is the 20-year risk of cardiovascular disease in a patient who is 11 years old? It's zero. In their recommendations, the expert panel acknowledged that a focus on cardiovascular risk reduction in children and adolescents is tough, because the likelihood of a clinical end point of manifest cardiovascular disease is remote. Speaking with heartwire , Dr Daphne Hsu (The Children's Hospital at Montefiore, NY) took a different interpretation of the guidelines but acknowledged that pediatricians are forced to infer how risk factors might translate into clinical outcomes 30 to 40 years down the road. Still, she said there are data showing a risk of subclinical atherosclerosis in young patients with elevated cholesterol levels. Moreover, the new recommendations cull together the best data currently available, and based on her assessment of the risks of screening and the potential benefits, the new AAP/NHLBI guidelines make sense. As for the risks, Hsu does not believe that universal screening will lead to an increased use of cholesterol-lowering medications, such as statins. "If we find a patient has elevated cholesterol levels, we know their risk is not very high, and it is not going to be high enough to warrant treatment, but the screening could be enough to spur changes in behavior," said Hsu. "If they have elevated levels, we can then begin to look for why this is the case, and we can look for ways to change their eating habits, change what they eat, and change how often they exercise." Hsu said that it was "highly unlikely" that screening would lead to more children being treated with cholesterol-lowering medications, probably less than 1%. She said the greatest benefit would be to children with major lipid disorders who might have been missed with other screening tools. She said the 2008 AAP document on lipid screening and cardiovascular health provides guidance on treatment with pharmacologic agents. Written also by Daniels and Dr Frank Greer (University of Wisconsin Medical School, Madison), along with the Committee on Nutrition, the document says that treatment should be started if LDL-cholesterol levels are higher than 190 mg/dL [2]. The cutoff point for therapy is 160 mg/dL for children with other risk factors, with targets as low as 130 mg/dL or even 110 mg/dL when there is a strong family history of cardiovascular disease, especially with other risk factors, such as obesity, diabetes, metabolic syndrome, and other higher-risk situations. An Age When They'll Listen to You In her practice, Hsu said she sees firsthand the epidemic of childhood obesity, with many young children having pre-metabolic syndrome. With screening of children aged 9 to 11 years old, she believes they are at a vulnerable age that might be more responsive to recommendations from their family doctor, whereas older children, particularly teenagers, don't like being told what to eat or how much to exercise. She said cholesterol screening can signal potential long-term complications and can serve as an increased wake-up call for families. "We're not telling the kids or families that they're going to have a heart or stroke tomorrow but instead saying that we want them to live until they're 85 years old," said Hsu. "We want to see them live longer than their grandmother or grandfather." Nissen, on the other hand, isn't buying the argument, stating there is no evidence-based data showing that young patients or their families change their behavior when presented with evidence of a bad test result, such as increased cholesterol levels. Proponents of other screening modalities have made similar arguments in the past, suggesting that evidence of calcification or stenosis is a motivating factor to move toward heart-healthy behaviors, but the data do not bear this out. Earlier this year in the Journal of the American Society of Echocardiography, researchers reported that abnormal findings on an office-based carotid ultrasound test changed physician behavior, with doctors changing their use of aspirin and cholesterol-lowering medications, including setting more aggressive lipid and blood-pressure targets. Patients, on the other hand, failed to make changes to their diet or increase physical activity levels and, in some instances, even failed to quit smoking, despite an increased awareness of their cardiovascular-disease risk. "Shouldn't we be counseling children on the benefits of healthy eating and lots of physical exercise even without knowing their LDL-cholesterol levels?" said Nissen. "I don't see how screening changes this at all. We simply have no evidence that patients will change their behavior based on more screening." The expert panel also provides guidance on the assessment of family history of cardiovascular disease, tobacco exposure, nutrition and diet, growth and overweight/obesity assessments, blood pressure, and physical activity.

Updated AAP Policy: Turn Off the TV and Talk to Your Toddler

From Medscape Medical News Fran Lowry November 10, 2011 (Boston, Massachusetts) — An updated policy statement from the American Academy of Pediatrics (AAP) Council of Communications and Media recommends that media, particularly television, have potentially negative effects on children younger than 2 years, and recommends no media use in this age group. "We said this in 1999, and we're saying it 12 years later, in 2011," Ari Brown, MD, a pediatrician in private practice in Austin, Texas, who headed the council, said here at the AAP 2011 National Conference and Exhibition. "Kids should learn from play, not from a TV screen. This new policy statement reaffirms what we said back then," she told Medscape Medical News. The highlights of the policy statement were unveiled at the meeting. They include the following recommendations: The AAP discourages media use by kids younger than 2 years, and pediatricians should discuss these recommendations with parents. Discuss setting "media limits" before age 2 because many parents are not aware of the AAP recommendations. Pediatricians should explain the importance of unstructured, unplugged play in allowing a child's mind to grow, problem solve, think innovatively, and develop reasoning skills. The importance of parents sitting down to play with their children cannot be overstated. Encourage parents to read to their children to foster cognitive and language development. Don't place a TV in the child's bedroom. Don't watch adult TV when a young child is in the room. Dr. Ari Brown From 40% to 60% of American households with young children report that the TV is either always or often on when no one is watching, Dr. Brown said. "The truth is someone is watching, and that's the child. The effect is distracting; it reduces talk time, which we know is important for language development, and it disrupts the child's play," she said. Since the first policy statement, research has shown just how disruptive that TV can be. A child playing in a room where the TV was on and tuned to a show that was not even geared toward children looked up at the screen 3 times per minute. "So every 20 seconds, the child would actually look up and glance at the TV. They would be less concentrated on their playing, and they would move on to another activity more quickly," Dr. Brown said. "This proves that the TV is distracting the young child from their valuable play time." Parents are encouraged to turn off the TV when their young children are in the room because they tend not to focus as much on them, she added. TV is not educational for such young children; there are better ways to engage young children, she said. "You can't be playing with your child 24 hours a day, we get that.... But your child's time is actually quite valuable. When they are playing independently, they are learning how to problem solve and think creatively — these are important life skills. You are actually doing your child a service by letting them play on their own." There is also a concern that too much television can delay language development, Dr. Brown said. "There is a national children's study that has just started looking at the long-term effects of environmental exposures, including media use. We won't have the results of that study for 20 years, but at least somebody is looking at it now," she said. "We do know about short-term effects, and can see the short-term effects in language delays. Perhaps it's because parents and children are not talking to each other when the television is on; kids really need that." Tanya Altmann, MD, from the University of California at Los Angeles, agrees that studies are showing that when the television is on in the house, parents talk less and interact less with their children. Dr. Altmann, who was invited to comment on the updated policy statement, said that video screens are much more ubiquitous than they were in 1999 when the initial policy statement came out. "It's really hard to raise children today without keeping this in mind. Everywhere you go, parents are on their smart phones, there's TV, computers. Video plays a major role in our lives today," she said. "It's so important to keep in mind that the brains of children under the age of 2 are rapidly developing. The evidence is there that such young children can't learn from screens and there may be some harmful effects. Parents must be aware of this and set limits for their children under age 2. They should even consider not having the television on at all." American Academy of Pediatrics (AAP) 2011 National Conference and Exhibition. Presented October 17, 2011.

Is There an Up Side to Autism?

From Medscape Medical News > Psychiatrists in the News Society's Negative Bias Toward Autism Needs Rethinking, Expert Says "autism is a different way of being, not necessary a disordered way of being, and the difference can give us strengths and abilities that other people may not have." Yael Waknine November 7, 2011 — Autism may be an advantage in some settings and should not be viewed as a defect that needs suppressing, according to a provocative article published online November 2 in Nature. Dr. Laurent Mottron "Recent data and my own personal experience suggest it's time to start thinking of autism as an advantage in some spheres, not a cross to bear," author Laurent Mottron, MD, PhD, from the University of Montreal's Centre for Excellence in Pervasive Development Disorders, told Medscape Medical News. According to the article, the definition of autism itself is biased, being characterized by "a suite of negative characteristics," focusing on deficits that include problems with language and social interactions. However, in certain settings, such as scientific research, people with autism exhibit cognitive strength. "We think that the kind of strengths and cognitive profile that we find in autistics are much more specific than scientists usually acknowledge," said Dr. Mottron. "Unfortunately, there is no gold standard for the diagnosis of autism. Clinical diagnoses are reliable among scientists, but it is just a consensus...everybody may fail." He noted that as a result of a diagnosis, many individuals with autism end up working at repetitive, menial jobs despite their potential to make more significant contributions to society. "After 18 years of age they're not kids anymore, and they're forgotten," he said. "People have a cliché, that if he's autistic you can do nothing with him. That's not true. The fact that you have some terrible autistic life is not representative of autism in general." Advantages Autism should be described and investigated as an accepted variant within human species, not as a defect to be suppressed. Dr. Mottron has 8 individuals with autism people in his research group including 4 assistants, 3 students, and 1 researcher, Michelle Dawson, whom he met almost 10 years ago during a television documentary about autism. Following the show, Ms. Dawson experienced problems in her job as a postal worker and was asked by Dr. Mottron to edit some of his papers. "She gave exceptional feedback, and it was clear that she had read the entire bibliography," Dr. Mottron noted. Her single-minded autistic abilities to discern patterns out of mountains of data and instant recall of correct information made her perfectly suited to a career in science, he said. Though lacking a formal doctorate, Ms Dawson has since coauthored 13 papers and several book chapters. Dr. Mottron said Ms. Dawson and other individuals with autism have convinced him that more than anything, people with autism "need opportunities, [and] frequently support, but rarely treatment." As a result, he believes that "autism should be described and investigated as an accepted variant within human species, not as a defect to be suppressed." Dr. Mottron noted that autistic brains do function differently, relying less on verbal centers and demonstrating stimulation in regions that process both visual information and language. Advantages may include spotting a pattern in a distracting environment, auditory tasks such as discriminating sound pitches, detecting visual structures, and mentally manipulating complex 3-dimensional shapes. Individuals with autism also perform Raven's Matrices at an average of 40% faster than nonautistics, using their analytical skills to complete an ongoing visual pattern. Other benefits of autism include the ability to simultaneously process large amounts of perceptual information as data sets and the presence of instantaneous and correct recall. Because data and facts are of paramount importance to people with autism, they also tend not to get bogged down in career politics or seek popularity via promotional publishing; online essays such as those posted by Ms. Dawson in her blog may instead receive unintentional acclaim. Intellectual Disability Not Intrinsic What we know is that if we reach these individuals at a young age, when their brains are malleable, we can cognitively redirect the transmission of information via the corpus callosum to the speech areas in the left hemisphere of the brain and oftentimes speech and language will kick in. "I no longer believe intellectual disability is intrinsic to autism," Dr. Mottron said, noting that intelligence in people with autism should be measured with nonverbal tests. In his article, Dr. Mottron cites recent data, including an epidemiological study that showed the disorder is 3.5 times more prevalent than common statistics suggest. He noted that the study showed that many of those with autism have "no adaptive problems at all," and can function relatively normally. However, he added, a focus on "normocentrism" prevails in some countries. France, for example, has proposed mandatory interventions aimed at forcing children with autism to adopt "typical" learning and social behaviors, rather than allowing them to make the most of their differently wired brains. Dr. Mottron finds such a concept concerning. "There is no current treatment for autism, just educational strategies that do not put the emphasis on learning abilities for nonsocial information.... [W]e need to take their learning style for what it is and feed it," he said. Joanne Lara Some of these therapies may include engaging children with autism in a music and movement program, said Joanne Lara, MA, founder of Autism Movement Therapy, Inc, in an interview with Medscape Medical News. "What we know is that if we reach these individuals at a young age, when their brains are malleable, we can cognitively redirect the transmission of information via the corpus callosum to the speech areas in the left hemisphere of the brain, and oftentimes speech and language will kick in." She continued: "The audio processing of music in the brain combined with the forward, backward, and side-to-side movements stimulate and activate the dormant areas of the brain that, in autism, do not generally receive transmission of neurons. "Movement and music, when combined with gross motor and visual processing, oftentimes helps the areas of the brain of the individual with autism to work together to allow for a whole-brain processing approach," she added. Counterpoint "I think it's critically important to acknowledge the potential strengths associated with autism, but it's equally important, if not more important, to reiterate the notion of the right to effective treatment," Jonathan Tarbox, PhD, BCBA-D, director of research and development at the Center for Autism and Related Disorders, Tarzana, California, told Medscape Medical News. "If an individual with [autism] is having a difficult time in their life because they don't know how to do something that they want to do, and there is a proven effective method to teach that skill, then we as fellow humans have a moral and ethical responsibility to provide the treatment that addresses it," he said. Behavioral intervention programs, he said, should be used in a supportive environment to treat skill deficits in individuals with autism wanting to learn, similar to those used for literacy and mathematics. He added that autism is no different: People who have skill deficits and want to learn have a right to effective treatment. Dr. Tarbox took exception to Dr. Mottron's contention that individuals with autism need opportunity more than treatment. Environmental support, he said, does create opportunity. In addition, he noted that research shows that early intensive behavioral intervention increases the ability to communicate and function independently. "How can a newly found ability to communicate not be considered an opportunity?" he said. One of Dr. Mottron's main points is that the performance of individuals with autism on visual intelligence tests is often overlooked, showing that the true intelligence of people with autism is higher overall than verbal intelligence tests would indicate. "This is, of course, true, but true intelligence is of little relevance to a person's everyday quality of life. What really matters is one's ability to do what one wants to do in life independently; that is, without having to rely on support from others," said Dr. Tarbox. There are many people, autistic and nonautistic, who have superior intelligence, but still have much difficulty in life and suffer for it. "There are many people, autistic and nonautistic, who have superior intelligence but still have much difficulty in life and suffer for it. Unfortunately, vocal language is the medium with which most humans interact, so deficits in one's ability to vocally communicate are going to create barriers for people." Dr. Mottron also states that no education programs are tailored to the unique ways that people with autism learn. However, Dr. Tarbox noted that there are "many tens of thousands of special education teachers, speech and language pathologists, and applied behavior analysts working to change what they do to help individuals with autism learn." The aim of behavioral interventions, he added, is not to try to teach individuals with autism to adopt typical learning and behavior but, rather, to teach skills that help increase independence. Such programs, he said, "teach skills that open doors for individuals with autism, but they do not dictate which door to take." First-Hand Experience I think what Dr. Mottron was getting to is the idea that autism is a different way of being, not necessary a disordered way of being, and the difference can give us strengths and abilities that other people may not have. "I think what Dr. Mottron was getting to is the idea that autism is a different way of being, not necessary a disordered way of being, and the difference can give us strengths and abilities that other people may not have," said Stephen M. Shore, EdD, assistant professor at Adelphi University in Long Island, New York, in an interview with Medscape Medical News, citing the well-known accomplishments of Temple Grandin, PhD. "At the same time, there are many challenges that come with being on the autistic spectrum, such as sensory issues, communication, interacting with others. These things are challenges, and we do have to address them," Dr. Shore noted. Diagnosed himself with autism at age 2 and a half years, and nonverbal until age 4 years, Dr. Shore was originally recommended for institutionalization. With the help of family and others, he completed a doctoral dissertation at Boston University in Massachusetts that was focused on matching best practice to the needs of people on the autism spectrum. He now spends his time researching, teaching, writing books, and conducting autism workshops around the world. According to Dr. Shore, the best way to address those issues is to find a way to use a person's strengths to overcome their challenges. "There is a point in time when you have to get off the remediation and start moving on to finding a way the person can be successful in communication," he said. Methods may include use of a computer keyboard, rather than a pen, to write, or pointing at pictures to communicate, he said. Adjusting the environment also plays a vital role and often benefits people without autism. "Many autistics have sensory issues and perceive fluorescent lights as most people strobe lights, which will really affect productivity at work and school," Dr. Shore said. "Research shows that everybody's productivity is affected by fluorescent lamps, so everyone benefits by using alternate lighting." With respect to the plethora of methodologies used to address autism in children, Dr. Shore notes that the wide variety of diversity within the autism spectrum disorders necessitates a tailored approach. Parents and educators are encouraged to pick one or more approaches that best suits the child's needs and abilities. This may include use of Applied Behavioral Analysis, Treatment and Education of Autistic and Related Communication-Handicapped Children, Daily Life Therapy, the Miller Method, the Developmental/Individual Difference/Relationship-based method, relationship development intervention, and social communication/emotional regulation. "You can have a right or wrong approach on an individual basis, but not on a generic basis," he said. Nature. Published online November 2, 2011. Full text

How to talk with your teen

The teenage years are full of change for both parents and teenagers. Not only are teens growing and changing physically, but they are developing their identity and becoming more independent. The hormones that drive puberty and bring on its physical changes also affect how a teen thinks and feels. At the same time, major changes happen in the adolescent brain, influencing judgment, decision-making, and emotions. Teens test their limits and try very hard to fit into their peer groups. You might even think that your teen’s friends have become more important to him than you and your family. Why is healthy communication important? As your teen moves toward adulthood, it’s normal and natural for her to put distance between herself and family. But it’s more important than ever to keep the lines of communication open. If your teen feels she can talk to you, than she knows you will listen and consider his views, and chances are you have and will continue to have a healthy relationship. By encouraging open and honest conversation, your teen is more likely to come to you for the important stuff—like relationships, school, sex, drugs—rather than turning to friends for help and guidance or feeling alone. Here are some tips to help you communicate with your teen: Talk with your teen about his interests (music, sports, hobbies, plans for the weekend, future goals). Schedule family time. All teens need to feel that they’re a valued member of the family. Part of that will come from setting aside family time to do regular activities together, such as going to the movies, going for a hike or skating. Family meals are an excellent way to connect with each other and talk about the things that happened during the day. Research also shows that having at least one family meal a day can prevent your teen from experimenting with risky health behaviour. Spending time as a family will help you know your teen as he grows and develops. Listen. Teens want their parents to listen to their stories, concerns and feelings with patience, understanding, and acceptance. Your teen needs to believe he can share problems and issues, and know that you will support him. It’s also a good idea to repeat her own words when discussing what your teen tells you so that she knows you understand. Be prepared and willing to discuss the things he wants to talk about. Think about the things your teen might want to talk about (relationships, sex, drugs, alcohol) so that you are ready when he comes to you with difficult questions or ideas. Treat your teen with respect and don’t dismiss his feeling or opinions. Find ways to discuss and acknowledge your differences without judging. Listen to your teen’s point of view with an open mind. Active listening will help your teen feel important, know that you take her concerns seriously, and will strengthen your relationship. Be trustworthy. Don’t make fun of your teen, or share his personal stories with others. Respecting your teen’s desire for privacy is important. If you do, he is more likely to talk about issues like violence, abuse, harassment or severe mood problems. Stay calm, and try not to get frustrated. Your questions and tone of voice might put your teen on the defensive. Offer help, even if your teen doesn’t ask. The challenge is to be involved without intruding and to let your teen know you are always available. Avoid lectures. If your teen’s stories spark a lecture from you, she’ll be less likely to share with you another time. Express your concerns, but know that it’s normal for teens to experiment. Be upfront about the rules and consequences. Keep it short, and to the point. Teens generally won’t stay focused for long conversations. Plan. Set aside regular time to catch up, or talk about issues your teen is facing. Another good place to talk with your teen is while travelling together in the car, when you have a captive audience. Step away. If a conversation becomes emotional or heated, it is probably a good idea to step away and come back to it when everyone has calmed down. Be honest about your feelings. If you are, your teen may be more open with you. When should I call the doctor? Change is normal in the teenage years, but drastic or dramatic changes in your teen’s behaviour or routine may be cause for concern. Here are some warning signs to watch for: extreme weight gain or weight loss, sleep problems, significant irritability or ongoing problems with mood, sudden change in friends, or isolation, trouble at school, either with learning or behaviour, trouble with the law, overuse of electronic media like cell phones or smart phones, or signs of drug or alcohol use. If your teen is showing trouble with any of these things, talk to your doctor. For more information: Social media: What parents should know Your teen’s sexual orientation Reviewed by the CPS Adolescent Health Committee and Public Education Advisory Committee http://www.caringforkids.cps.ca/teenhealth/TalkWithTeen.htm

Tips for limiting screen time at home

“Media” is the term used to describe the many ways we communicate. Electronic media includes television, computers, cell phones, video games and movies. The amount of time we spend using them is sometimes called “screen time”. Children and teens have access to more kinds of electronic media than ever before. You can help your children develop healthy media habits by monitoring screen time and teaching them to use media safely and wisely. How can I set limits on my children’s screen time? Start encouraging good media habits when your children are young. Otherwise, it will get harder to enforce limits and influence their choices as they get older. Consider all electronic media when setting time limits for your family. Television, movies, the Internet (including social media), video games and gaming devices (whether hand-held, or played through a computer or television) all add to your child’s total screen time. Children learn many of their values and ideas from their parents. Be aware of your own media habits and change them if necessary. Limit television watching to less than 1 to 2 hours per day. Avoid making television watching part of your regular daily routine. Keep television, computers and gaming equipment out of your child’s bedroom. Keep them in common areas, where you can watch your children while they use them. Turn off the television or computer when you aren’t using it. Balance screen time with sports, hobbies, creative and outdoor play, both on their own and together as a family. Late-night chatting online, surfing and texting with friends shouldn’t cut into important sleep time. Ask your child or teen to give you their cell phone at a certain time at the end of they day so they aren’t interrupted with phone calls or text messages during family time. Talk about the importance of shutting off cell phones and the value of being unconnected at night. Find out about online protection for your family. Programs that provide parental controls can block websites, enforce time limits, monitor the websites your child visits, and their online conversations. Ask your child or teen where else she uses computers. Talk to teachers and caregivers about where and when your children are using electronic media. How can I help my child develop healthy electronic media habits? Get involved in your child’s media use — watch, play and listen with your child. Talk to her about it, find how what she enjoys and why. Share your own beliefs and values. Preview television shows, music and video games to see if they are okay. Encourage your child to try different media experiences. Help them make good choices. Learn about the Canadian and American ratings systems for television, music, movies and video games. They can help you choose appropriate media with your child. Talk to your child about stereotypes and violent images in the media. Educate him about the strategies that advertisers use to sell products to children. Limit the violent content your child is exposed to. Notice whether there are any changes in how he behaves after watching scary or violent shows, or playing video games. Speak out. If media content strikes you as inappropriate or offensive, tell the media organization. For more information: How to promote good television habits Impact of media use on children and youth: A position statement by the Canadian Paediatric Society. Media Awareness Network My Privacy, My Choice, My Life: A resource for children and teens about online privacy by the Office of the Privacy Commissioner of Canada. Concerned Children’s Advertisers: A website with tools to help children be media-wise. Reviewed by the CPS Community Paediatrics Committee and Public Education Advisory Committee Posted: June 2011 Canadian Paediatric Society

No Imaging Needed for Most Low Back Pain in Teens

Medscape Medical News from the:American Academy of Pediatrics (AAP) 2011 National Conference and Exhibition November 1, 2011 (Boston, Massachusetts) — Most cases of low back pain in children will get better with conservative management and do not need to be diagnosed with radiographic studies, researchers said here at the American Academy of Pediatrics (AAP) 2011 National Conference and Exhibition. Mechanical low back pain is common in the pediatric population, and recent studies have shown that undiagnosable mechanical low back pain accounts for up to 78% of cases in adolescents. The most common pathologic cause of back pain in this age group is spondylolysis and spondylolisthesis, senior author Denis Drummond, MD, from the Children’s Hospital of Philadelphia, Pennsylvania, said. Low back pain can appear very serious when a child presents, and kids can end up getting a big work-up with too many imaging studies, Dr. Drummond told Medscape Medical News.This exposes them to too much radiation, he said. "It’s bad enough to give radiation to an adult, but a child absorbs more and their metabolism is much greater than an adult’s. Radiation is accumulative and kids with low back pain get imaged close to the pelvis, which exposes the ovaries, bladder, and colon to potentially dangerous doses," he added. In the current study, Dr. Drummond and his team retrospectively reviewed the records of 2846 children aged 10 to 19 years who were seen at their institution with low back pain between 2000 and 2008. Most (63%) were female, and the average age was 14 years. In 79% of the patients (n = 2244), the cause of their low back pain went undiagnosed. Over 90% had 3 or fewer office visits. Spondylolysis, which was diagnosed in 272 patients (9.6%), was found by plain radiography in 234 patients (86%), by bone scanning in 34 patients (12.5%), and by computed tomography (CT) in 4 patients (1.5%). Two-view and 4-view radiography was equally sensitive in diagnosing spondylolysis. The sensitivity of 2-view was 78%, and that of 4-view was 72% (P = .39). The researchers also found that bone scans delivered significantly more radiation than both CT and 2- and 4-view radiography. "We didn’t think that bone scans would be associated with so much radiation when we started this study. But it turns out that it was the worst of all the imaging modalities. The dye from the scan sits in the bladder for 24 hours and that is enough to change some cells if done often enough," Dr. Drummond commented. "When we presented this, people said ‘Holy cow! I didn’t know bone scans were associated with so much radiation,’ and they told me they were now going to consider giving up doing them," he said. "Our message is try and treat the low back pain conservatively. If you want, you can do a 2-view x-ray at the first visit or else put them on physical therapy, and be patient. If they are 50% to 60% improved when you see them in 6 weeks, you’re probably on the right track. If the pain is all gone at 3 months, get them ready to go back to sports or usual activities. If there is just as much pain at 6 weeks, go back to the old system of more investigation, but the majority will get better by then," he said. American Academy of Pediatrics (AAP) 2011 National Conference and Exhibition; Abstract #14782. Presented October 14, 2011.

HBA1c Unreliable for Pediatric Screening

From Reuters Health Information By Will Boggs MD NEW YORK (Reuters Health) Oct 26 - Hemoglobin A1c is not a reliable marker of dysglycemia in overweight or obese children and adolescents, researchers say. "Despite the new guidelines recommending the use of hemoglobin A1c for diagnosis of diabetes, it is not as reliable a test for identifying children with diabetes or at high risk for diabetes," lead author Dr. Joyce M. Lee from University of Michigan in Ann Arbor told Reuters Health in an email. She suggests that doctors "consider ordering alternative tests, such as a random glucose or a 1 hour nonfasting glucose tolerance test." Dr. Lee and colleagues compared five nonfasting screening tests in 254 overweight or obese children and adolescents aged 10 to 17 years: HbA1c, urinalysis, fructosamine, a one-hour glucose challenge, and a random blood test. A formal two-hour oral glucose tolerance test showed that 39% of the youngsters had prediabetes and 1.2% had diabetes, according to a report online September 27th in Diabetes Care. Urinalysis had a very low sensitivity (but high specificity) for detecting dysglycemia. On the other tests, higher thresholds provided lower sensitivity and higher specificity, whereas lower thresholds had higher sensitivity but lower specificity. Discrimination was poor for HbA1c and fructosamine levels, as evidenced by relatively low likelihood ratios across test thresholds, as well as by low values for area under the curve (AUC). With random glucose and one-hour glucose challenge tests, however, discrimination was "closer to an acceptable range," the authors said. Both provided substantially higher AUC compared to HbA1c or fructosamine. The researchers say their findings are consistent with other recent studies of HbA1c tests in children. "Either the nonfasting one-hour glucose challenge test or the random glucose represent promising screening tests for use in the pediatric primary care setting, as these are tests that clinicians can easily order the same day of the visit," they conclude. Dr. Lee said she and her colleagues are now trying to learn "whether a clinical risk score based solely on clinical characteristics" would help screen children for diabetes. "This would be a convenient and cost-effective way to identify high-risk children," she said. SOURCE: http://bit.ly/sL0WJY Diabetes Care 2011.

Community-acquired Pneumonia in Children

From Thorax What's New? Anne Thomson; Michael Harris 10/27/2011; Thorax. 2011;66(10):927-928. © 2011 BMJ Publishing Group Ltd & British Thoracic Society Abstract The community-acquired pneumonia in children guidelines have just been updated with new evidence on incidence, aetiology and management. This guidance should improve patient care. Introduction The British Thoracic Society (BTS) guidelines have recently been updated, reflecting 10 years of new evidence.[1] What have we learned in that time? The past decade has brought new diagnostic techniques, the introduction of universal infant pneumococcal vaccination and new information on antibiotic delivery. Community-acquired pneumonia (CAP) is common and most is seen and treated in the community. The guideline confirms that no diagnostic tests are necessary in the community but emphasises the importance of providing families with information, including advice on management, identifying any deterioration and the importance of reassessment. The incidence of children admitted to hospital with CAP (defined as fever, clinical signs and chest radiograph infiltrate) in the prepneumococcal vaccine era was 33/10 000 aged 0–5 years and 14.5/10 000 aged 0–16 years evidenced from remarkably consistent prospective studies in Norway and the UK.[2 3] Infant vaccination with PCV 7 (seven-valent pneumococcal conjugate vaccination) started in the UK in 2007, and a national time trends study has shown a 19% decrease in admission rates between 2006 and 2008.[4] In countries such as the USA where PCV 7 has been available for longer, a decrease in hospital admissions of ~30% is reported. When establishing aetiology, new PCR techniques have improved diagnostic yield so that a pathogen can be detected in 65–86% of cases. This careful work has identified mixed viral–bacterial infection in 23–33% of CAP cases. Streptococcus pneumoniae remains by far the most common bacterial cause and is found in 30–40% of cases as a single or co-pathogen. Group A Streptococcus contributes 1–7% of cases. Mycoplasma and Chlamydia pneumoniae are found with variable frequency and are not uncommon in the preschool child. The common winter viruses respiratory syncytial virus (RSV), parainfluenza and influenza are frequent pathogens, but the newer identified viruses such as human metapneumovirus and human bocavirus are found in 8–12% and ~5%, respectively. Overall viruses account for 30–67% of cases and are most frequent in children <1 year of age.[5 6] In the 2002 guidance, clinicians were encouraged to search for a pathogen in all cases, but this has been revised to more practical guidance that aetiological investigation be restricted to those with either severe or complicated disease. Clinical features of pneumonia are not specific for aetiology, and the evidence is that chest radiograph findings do not help in this respect. The WHO produced a method for standardising the interpretation of chest radiographs in children, but, even using this, the concordance rate between trained reviewers was only 48%.[7] Little wonder that chest radiograph interpretation can create heated discussions on ward rounds! Investigation of the use of acute phase reactants as a means of differentiating aetiology and/or severity of CAP has continued over the past 10 years. There have been many publications and much heat, but no light. The outcome is simply to reinforce the guidance that they are not of clinical utility in distinguishing viral from bacterial infections and should not be a routine test. Oxygen saturation <92% is an indicator of severity and the need for oxygen therapy. No new studies on oxygen delivery were identified. Similarly, there were no new studies on physiotherapy, but good quality evidence already exists that it is not beneficial and should not be performed in children with pneumonia. The BTS paediatric pneumonia audit data from 2010 showed that 15% (of 2209 cases reported) were nevertheless receiving it. So how does this evidence help us decide who should receive antibiotics? We know that viruses are the most common cause of lower respiratory tract infection (LRTI) in young children. In a vaccine probe study, only 6% of children <2 years old with a clinical diagnosis of pneumonia had Pneumococcus identified.[8] With the introduction of PCV 13 the likelihood of bacterial pneumonia in a fully vaccinated child will fall further. Fully vaccinated children <2 years old presenting with mild symptoms of LRTI need not be treated with antibiotics, but should be reviewed if symptoms persist. The evidence is that bacterial and viral pneumonia cannot reliably be distinguished and therefore all other children with a clear clinical diagnosis of pneumonia should receive antibiotics. Which antibiotic should be used? On the basis of the known common bacterial pathogens in children and available randomised controlled trials of different antibiotics, amoxicillin is effective, well tolerated and cheap. In the past some paediatricians have been anxious that Mycoplasma pneumoniae be covered, and have in addition used macrolide antibiotics. However, a Cochrane review did not find enough evidence to indicate that antibiotics improved outcomes in children with M pneumoniae LRTI.[9] Studies using only amoxicillin have had very low failure rates. Macrolide antibiotics should not be first line but can be added at any age if there is no response to first-line empirical therapy. There is important new evidence on how those antibiotics should be given. The PIVOT trial randomised UK children over the age of 6 months to either oral amoxicillin or intravenous penicillin, and the outcomes were equivalent (with a shorter duration of hospital stay in the oral group).[10] Similar results have been reported in the developing world. Oral amoxicillin is therefore the antibiotic of choice both in the community and in hospital. Intravenous antibiotics should be reserved for children unable to absorb oral drugs or those presenting with septicaemia or complicated pneumonia. These recommendations should result in significant changes to practice and be welcomed in these financially challenged times as they should decrease costs with no change in effectiveness of treatment. Junior doctors are creatures of habit and feel (rightly or wrongly) that they are more likely to be criticised for underinvestigation than overinvestigation and usually send laboratory tests when inserting an intravenous line. Now: no intravenous line, no tests, no physiotherapy. Simple oral antibiotics and supportive care will be effective for the majority of children with CAP, who will also escape from hospital faster.

Maternal Hypertension Increases Risk for Birth Defects

From Medscape Education Clinical Briefs News Author: Ricki Lewis, PhD CME Author: Désirée Lie, MD, MSEd 10/21/2011 Clinical Context Some studies have suggested an increased risk for fetal malformations with the use of angiotensin-converting enzyme (ACE) inhibitors in the first trimester of pregnancy, but this observation has not been confirmed in other studies. This is a population-based examination of mother–infant pairs recruited between 1995 and 2008 to examine the risk for congenital malformations with use of ACE inhibitors, use of other antihypertensives, and no use of antihypertensives among pregnant women both with and without hypertension. Study Synopsis and Perspective Pregnant women with treated or untreated hypertension are at higher risk of carrying fetuses with congenital anomalies than are normotensive women. The finding points to elevated blood pressure as the teratogen, rather than the drugs used to treat it, according to a report published online October 18 in the British Medical Journal. ACE inhibitors are known to be teratogenic during the second and third trimesters. A 2006 study using data from the Tennessee Medicaid population associated first-trimester ACE inhibitor exposure with neural tube defects and cardiac malformations, but did not find association with other antihypertensives. Two subsequent studies implicated other drugs. The new investigation disentangles the effects of antihypertensive drugs from those of the condition they treat. De-Kun Li, MD, PhD, MPH, and colleagues at the Kaiser Foundation Research Institute in Oakland, California, conducted a population-based retrospective cohort study that evaluated 465,754 mother-infant pairs from northern California in the Kaiser Permanente database, from 1995 to 2008. This included electronic medical records of fetal malformations, maternal drug exposures, and potential confounding factors such as preexisting diabetes and overweight during pregnancy. The researchers compared 4 groups of pregnant women: those with hypertension who took ACE inhibitors during the first trimester, those with hypertension who took other antihypertensives during the first trimester, those with hypertension who took no antihypertensives during the first trimester, and pregnant women who did not have hypertension and did not receive antihypertensives for other indications. The offspring of women taking antihypertensives had elevated rates of cardiac anomalies and birth defects overall, but not of neural tube defects, compared with women not taking the drugs. However, the elevation was not seen when rates were compared with the cohort of women with untreated hypertension, implicating the underlying hypertension. Use of ACE inhibitors in women with hypertension was associated with increased risk for congenital heart defects compared with normal control participants (those with neither hypertension nor use of antihypertensives), at 15 of 381 (3.9%) v 6232 of 400,021 (1.6%) patients, with an odds ratio of 1.54 (95% confidence interval [CI], 0.90 - 2.62). Similar associations were found for other antihypertensives. However, compared with the 2.4% (708/29,735) of pairs with untreated hypertension that had congenital heart defects, the use of ACE inhibitors or other antihypertensives in the first trimester was not associated with increased risk (odds ratios, 1.14 [95% CI, 0.65 - 1.98] and 1.12 [95% CI, 0.76 - 1.64]). "Compared with the hypertension controls, there was no increased risk of malformation associated with use of either ACE inhibitors or other antihypertensive drugs," the investigators conclude. Limitations of the study include not controlling for influences of diet and exposures to other medications and not delineating more specific types of birth defects. In an editorial, Allen Mitchell, MD, from the Slone Epidemiology Center at Boston University, Massachusetts, supports the findings, adding that we still have much more to learn about the precise effects of elevated maternal blood pressure on the fetus. The study was funded by the Agency for Healthcare Research and Quality and the Food and Drug Administration. The authors have disclosed no relevant financial relationships. BMJ. Published online October 18, 2011. Full text

The Evolution of Bullying

Gregory Lawton, MD, Pediatrics, Sep 27, 2011 During the first recess on the first day in the first year of the first school (approximately 80,000 BC), an impressively hirsute Neanderthal pushed a smaller, more studious Neanderthal to the ground before depositing him into a trash container. The same thing happed on the second day, only before a larger crowd. And thus bullying began. In the year 2011, the basic characteristics of bullying remain the same. It's about one person or group acting in a manner that is intent on hurting, harming, or humiliating another person or group. It's about doing this on a regular basis. It's about doing this because one side is bigger or stronger than the other side. Might makes Right. So what's new? VOLUME. A single bully is a solo singer. There is one (really loud) singer and one speaker. Maybe the bully has a couple of sidekicks. Now it's a trio, but there is still only one speaker. Welcome to 2011. With the near ubiquity of social media (Facebook and Twitter) and smart phones that permit instant access, the number of speakers has multiplied. Throw in texting and the number of speakers multiplies again. Once upon a time, bullying might only take place on the bus, or at lunch, or after practice. Now, it can be a 24/7 event, whether in the car, at the mall, in the kitchen, or even while on a family vacation during the summer in another state. Cyber bullies can post a hateful message on Facebook or a vengeful text message anytime, anywhere. What's more, if it's done via a video upload to YouTube, the number of speakers increases exponentially. The volume can be devastating. This degree of now public (thanks to social media) humiliation can be realized in a number of horrific scenarios. Victims of bullying have taken revenge to heinous extremes at Columbine High School and Virginia Tech. According to the website Bullying Statistics, http://www.bullyingstatistics.org/ other victims, feeling isolated, resort to suicide. As pediatricians, we see bullies every day. They are our patients. The trouble is, they don't wear a sign announcing that they are bullies when they come in for a physical. Perhaps we are more observant of the victims of bullying. They are the kids with belly pain, headaches, slipping grades, or insidious school aversion. What can we do? What should we do? A recent article on Medscape, http://www.medscape.com/viewarticle/749448, offers a wealth of resources on programs to counter bullying. The trick, however, remains in recognizing it in our offices. What can we, as pediatricians do to prevent bullying? 1. Remain open to the idea that every child can be a bully, or a victim. Listening for clues when a patient indicates that he doesn't like school or doesn't "fit in" may indicate that could be a potential target. Ask about discipline issues at school. Are detentions for academic reasons or altercations? The answers could lead to insight that the patient may be more likely to bully others. 2. Caution parents about social media and the need to monitor its use in their home. Encourage them to know what is on their child's Facebook page. Look at the text posts periodically. Advise parents to keep computers and smart/cell phones out of the bedrooms at night so as to keep their child's room nominally safe from electronic intrusions, vicious or otherwise. 3. Consider speaking with parents separately before or after an appointment. Ask explicitly about school, it's social and academic aspects. Communicate that you are willing to work with the kids, their parents, and the schools as part of a coordinated anti-bullying effort. As with so many aspects of our professional lives, there are no easy answers, nor is there a one size fits all approach. We can make a difference however, as we always do, one patient at a time. By enforcing social media rules in our homes, we decrease the potential for cyber bullying in our personal lives. By listening a bit differently to our patients, we may unearth the real reason for school aversion. The Neanderthal will always be out there. But now he or she has evolved; Facebook and smart phones are the new weapons. Pediatricians can (and for the sake of our patients must) evolve faster.

Parents Can Detect, Contribute to, or be Affected by Critical Events During a Child's Hospitalization

From ISMP Medication Safety Alert!® Acute Care Edition Posted: 09/23/2011; ISMP Medication Safety Alert © 2011 Institute for Safe Medication Practices Problem Today, parents are often permitted around-the-clock visiting hours to stay with their hospitalized children, even in neonatal and pediatric intensive care units (ICUs). Many parents take advantage of this option and remain with their children as much as possible. For an ill child, this can be comforting and provides an important emotional benefit. At the same time, parents may be carefully watching and interacting with healthcare professionals, and observing the specialized equipment at their child's bedside, including infusion pumps, IV lines, and drainage systems. A study published by Frey et al. in 2009 suggests that parents who stay with their hospitalized children are inevitably involved in safety issues. In particular, the study showed that parents can help detect critical (harmful or potentially harmful) events precipitated by healthcare professionals. However, the study also showed that parents can contribute to a critical event and are often adversely affected by a critical event. The study was conducted over a 5½ year period in a neonatal-pediatric intensive care unit and a neonatal intermediate care unit in a university children's hospital. During the first 2 years of the study, visiting hours for parents were limited to afternoons and evenings; morning visitations were not allowed and overnight stays were strongly discouraged. Around-the-clock visiting hours were permitted during the last 3½ years of the study. During the span of the study, a total of 2,494 critical events were recorded; 101 of these events directly involved parents. In 18 cases, a parent contributed to the critical event. In 11 cases, a parent detected a critical event. In the remaining 72 cases, a parent was one of the affected individuals. For each event, the actual and potential severity was determined to be minor (requiring no interventions), moderate (requiring routine therapy available outside a critical care unit), or major (requiring therapeutic interventions specific to critical care units, or resulted in death). In the group of critical events that involved parents (n=101), medication events (38%) and line disconnections/reconnections (28%) were most prevalent. In the group of critical events that did not involve parents (n=2,393), events involving medications were again most prevalent (33%), but issues with line disconnections/reconnections (2.7%) were significantly lower. Most events precipitated by parents and subsequently detected by healthcare professionals caused actual harm determined to be of moderate severity, and some events had the potential to cause a high severity of harm. On the other hand, critical events detected by parents did not cause actual harm, although the events had the potential to cause harm of moderate severity. Further details about the study follow. Parents Detecting Safety Problems The most common safety problems detected by parents involved medication errors, tubes or drains that became disconnected, and respiratory distress. Examples include: A mother who realized that a physician had prescribed a five-fold overdose of carvedilol for her child (5 mg BID instead of 1 mg BID) A mother who noticed the wrong weight listed on her child's medical record used for prescribing medications Parents who called attention to their child's respiratory distress or failure. It took parents between 0–70 hours (median 10 hours) to detect a critical event precipitated by a healthcare professional. This suggests that without the parents' interventions, some critical events might have continued without correction. The authors determined the potential harm from continuation of the detected critical events to be severe in 4 cases, moderate in 6 cases, and minor in 1 case. All of the events detected by parents occurred only after around-the-clock visiting hours were made available. This observation suggests that it is easier for parents to detect safety problems if they spend more hours at their child's bedside, observing and participating in their care. Parents Contributing to Safety Problems The most common safety problems precipitated by parents involved the disconnection of tubes and drains, medication errors, and physical trauma. Examples include: A mother accidentally disconnected a central venous line while breast feeding her baby A mother accidentally disconnected a pleural drain while holding her infant A father fell off a chair with his child on his lap. All of the disconnected tubes and drains happened in young infants, from 4 days to 1½ years old. It took healthcare professionals between 0–29 hours (median 0.25 hours) to detect a critical event precipitated by a parent. The authors note that this finding suggests that healthcare professionals are providing appropriate supervision of parents and hospitalized children. Most of these events caused moderate harm (10 cases) before being detected. In all but one event, quick discovery of the problems averted severe harm. Parents Affected by Safety Events The most common types of problems affecting parents involved miscommunication and feeding mix-ups. One can expect parents to be emotionally affected by most critical events that involve their children, especially those leading to harm. However, with some critical events, parents were directly affected in ways that were not anticipated. One of the most common examples included mothers who were subjected to viral testing because their breast milk was accidentally fed to another child. Failures such as this increase parental stress during a child's hospitalization. Safe Practice Recommendations Consider the following recommendations to strengthen the partnership between the treatment team and a hospitalized child's parents, prevent parental contribution to critical events, promote parental detection of errors, and protect the hospitalized child from harm. Educate Parents. Teach parents about the disease/condition, medical tests, and treatment plan for their hospitalized child. Specifically tell parents about all the medications their child is receiving, the prescribed doses (including the fact that it differs from the dose taken at home, if applicable), potential side effects, and when and how they are given. Write down important information for parents to reference as needed. Parents who know what to expect can help recognize when something is not right. Update Parents. Provide parents with timely and comprehensive updates regarding their children in language they understand. Some children's hospitals encourage parents to be part of "family-centered" rounds, allowing them to gain a better understanding of their child's total treatment plan and current status since the entire medical team is available to answer questions and address concerns. Anticipate Involvement. Be aware of increasingly independent parental involvement in the medical care of their children. A 2001 study by Hurst showed that parents continuously analyze hospital procedures and develop an action plan to protect their babies.[2] A fundamental challenge for mothers in this study was to increase their position of authority relative to the medical team, thereby safeguarding their babies. Parents may intervene during the care of their children, which can lead to prevention and detection of a critical event, or contribution to a critical event despite good intentions. Close parental involvement in the child's treatment plan should be encouraged, supervised, and monitored. Encourage Parents to Speak up. Encourage parents to report any concerns or worries they have regarding their child's care. Frey et al. suggests periodically asking parents these two questions: "Are there aspects of your child's care that you find concerning?" and "What do you worry about when you leave your child?" Encourage parents to keep asking questions or voicing concerns until they receive an answer with which they are comfortable and fully understand. Remind parents that they know their child better than anyone on the medical team; thus, communication of their observations is extremely important. Respond to Parents' Queries Appropriately. Parents do not want to be labeled as being "difficult" or "demanding;" they fear no one will want to take care of their child if they are perceived this way.[2] Some may even view basic questions or requests for information about their child's condition as a slight to the medical team's competence. So, when parents do speak up, healthcare professionals should perceive and reflect their actions in a manner that fosters true collaboration and empowerment, and should encourage and reinforce the parents' role in making queries by providing thoughtful and complete answers. Provide Access to a Rapid Response Team. Allow parents to activate a rapid response team if they feel no one is addressing their expressed concerns regarding their child's condition and/or medical treatment. Instruct parents, upon their child's admission, regarding the purpose of the rapid response team and how to activate it. Establish Safe Handling Guidelines. To reduce the risk of tubing disconnections, establish guidelines for safe handling of infants and children with lines and drains, teach these guidelines to parents, and monitor adherence to the guidelines. Teach Parents Not to Reconnect Tubes. Orient parents to the tubes or drains attached to their child. Teach them about the dangers of reconnecting tubes and drains themselves and how to call for immediate help from a healthcare professional if their child's tubes or drains become dislodged or disconnected.