Thursday, July 12, 2012

Sexting a Reliable Indicator of Risky Sexual Behavior

From Medscape Medical News > Psychiatry

Fran Lowry
July 5, 2012 — The practice of sending sexually explicit photos or messages electronically, otherwise known as "sexting," is prevalent and may be linked to sexual behaviors of adolescents.
A study of 7 public high schools conducted by investigators at the University of Texas Medical Branch, in Galveston, showed that 1 in 4 teens sent a nude picture of themselves via electronic means, that about 50% have been asked to send a nude photograph, and that about one third asked for a nude picture to be sent to them.
"Sexting is fairly prevalent behavior among teens," lead researcher Jeff R. Temple, PhD, told Medscape Medical News. "And teens who engage in sexting behaviors may be more likely to have also had sex. In other words, sexting may be a fairly reliable indicator of sexual behaviors, although it may not necessarily be a cause or a consequence, just an association."
Lack of Knowledge 
The study was published online July 2 in Archives of Pediatrics & Adolescent Medicine.
The study was prompted by of a lack of empirical knowledge of sexting behaviors, said Dr. Temple.
"Pediatricians, parents, teachers, and policy makers were handicapped by insufficient information about the occurrence and nature of sexting, and I wanted to bring data to the conversation," he said.
The investigators conducted a longitudinal study that included 948 public high school students, most of whom (55.9%) were female. The study sample was 26.6% black, 30.3% white, 31.7% Hispanic, 3.4% Asian, and 8.0% of mixed or other ethnicities.
The participants ranged in age from 14 to 19 years and self-reported their history of dating, sexual behaviors, and sexting.
Boys were more likely to ask for a "sext" (a sexually explicit photo or message), and girls were more likely to have been asked for a sext, Dr. Temple said.
Specifics of the findings include the following:
  • 28% of boys and girls have sexted a nude picture of themselves
  • 21% of girls and 46% of boys asked another teen for a nude picture to be sent
  • 68% of girls and 42% of boys have been asked to send a nude picture of themselves
  • More than one half of all girls were bothered "a lot" by being asked
  • Boys were less bothered by being asked, but more than one half were bothered at least "a little bit"
Talk About Sex
The researchers also conclude that sexting behaviors may be a fairly reliable indicator of offline sexual behaviors. For both boys and girls, teens who sexted were more likely to have begun dating and to have had sex than those who did not sext (P < .001).
The study also found that white/non-Hispanic and black teens were more likely than the other racial/ethnic groups to have both been asked and to have sent a sext.
Dr. Temple had some advice for doctors when seeing their teen patients.
"After acknowledging that sexting is a fairly common behavior among teens, I would suggest talking with the patient about potential legal and social consequences of sexting and ask for their feedback," he said.
"I would also suggest using this as an opportunity to talk about sex and especially safe sex."
Dr. Temple hopes "more than anything" that the reporting of this study will encourage parents to talk with their children about sexting, sex, and safe sex.
"I hope some parents will ask their kids what they think of this study; is this happening with teens they know? Parents can use this as an opportunity to encourage their kids to think about potential consequences before pressing "send," and they can talk to them about how they would respond if someone asked them to send a nude picture.
"Parents need to be talking with their kids about sex and safe sex, and hopefully this study can act as a springboard to that conversation," he said.
New Opportunity
In an accompanying editorial, Megan A. Moreno, MD, from the University of Wisconsin-Madison, and Jennifer M. Whitehill, PhD, from the University of Washington, Seattle, state that pediatricians should view social media as part of the integrated self of the adolescent patient.
"Pediatricians have new opportunities to ask their patients about social media, including questions about how time is spent in this environment. Discussing social media with patients may provide new ways to identify intentions or engagements in risky health behaviors," they write.
Dr. Temple says he agrees wholeheartedly with his editorialists.
"Absolutely. Sexting appears to be an extension of existing offline relationships, and a reflection of adolescents' offline sexual intentions or behaviors. Pediatricians can use a conversation about sexting as an avenue to engage their patient in a conversation about other risky health behaviors."
Dr. Temple, Dr. Moreno, and Dr. Whitehill have disclosed no relevant financial relationships.
Arch Pediatr Adolesc Med. Published online July 2, 2012.Full articleEditorial

Tuesday, July 10, 2012

Headaches in Kids: Is An Eye Exam Necessary?

I would like to talk about when primary care practices should refer children with headaches for an eye examination.
Headaches in children are common. The first stop for these children will be to your office -- to understand the history of the headaches, the severity and nature of the headaches, family history, and to examine the child for common causes of headaches in childhood. But some of these children will be examined by you, that examination will be normal, and no obvious cause of the headaches will be found. It may be appropriate to refer these children for an ophthalmic examination with a pediatric ophthalmologist.
There are certain types of alarming headaches where it probably is not appropriate to refer them for a routine pediatric eye examination, and the child may need to go directly to an emergency room or to a pediatric neurologist. These would be:
  • Severe headaches;
  • Headaches that are increasing in severity and frequency;
  • Headaches that are interfering with normal activities;
  • Headaches that are associated with nausea and vomiting; and
  • Headaches that occur during the night and awaken the child or occur early in the morning.
But for other types of headaches, if the general examination is normal and there is no obvious cause from the history, it would be appropriate for a pediatric ophthalmologist to examine these patients for certain eye abnormalities that may be associated with headaches.
What would we be looking for when these children come to pediatric ophthalmology? First, we will look at their vision and refraction to see whether there may be an uncorrected refractive error causing poor vision and requiring glasses, which may be the cause of the headaches and is easily treated.
Second, we will be looking at their eye alignment and assessing for the presence of strabismus. There are certain forms of strabismus, particularly convergence insufficiency, that may cause eye strain with reading and headaches and are treatable by an ophthalmologist.
Next, we will look at the slit-lamp examination under high-powered magnification to look for uveitis, ocular inflammation, glaucoma, and other causes of referred pain that may come from the eye but be felt by the child as headache.
We will be looking at the dilated fundus examination to see the optic nerve and retina to look for such problems as papilledema, diabetic retinopathy, hypertension, and other changes in the eye that may be related to the cause of the headaches.
Don't be surprised when many of these examinations come back normal. We expect many of these kids to have benign types of childhood headaches that do not cause eye problems. That should be reassuring to you and to the parents. Don't be surprised if the ophthalmologist feels that other studies may be indicated, including sinus imaging or other imaging studies, and suggests referral to a neurologist for certain types of headaches.

Two Major Concerns in Autism

From Medscape Psychiatry

Bret Stetka, MD; Fred Volkmar, MD
Posted: 07/10/2012

Autism Up 78%: Reality or Increased Diagnosis?

Medscape: Hello Dr. Volkmar. A new CDC report  shows a 78% increase in ASD prevalence since 2002. How do you explain these findings? Do the data represent an actual increase, or rather increased diagnosis?
Dr. Volkmar: A long story made short: There are a number of possible factors that could account for an apparent increase that might or might not be real. Of course, one possibility is that to some extent there might be a real increase. However, while that can't be ruled out, it is probably a less likely possibility.
There is more public awareness of autism. There's more attention. There's often a pressure on the part of parents for an autism spectrum label. Often there's a slippery slope equating autism with autism spectrum and there's often a push for getting the label for school services -- sometimes quite appropriately and sometimes less so. This is a problem that sometimes has been referred to as diagnostic substitution in the literature: having multiple possible labels and picking the one that will get you the most services. All of those things factor into it. And there is some reason to think that there could, at least in theory, be some potential for the actual increase based on genetic studies. Usually in terms of seeing such a fast increase, you would think this is going to be more about method than reality. But again, it's hard to know.
In terms of the CDC paper, we would have a better handle on all this had they broken it down by diagnostic categories. The great beauty of the report is that it involved multiple sites around the country. The downside is there's not quite enough diagnostic detail -- how many of the diagnoses were spectrum and how many classical autism? I think also there's a general problem in epidemiologic studies; that is, not seeing the child and looking at records vs seeing the child. All of these issues must be factored into the findings. Eric Fombonne has discussed these issues in some detail.
Medscape: Could the CDC study have overestimated prevalence owing to study design?
Dr. Volkmar: Yes, it's possible. To get the best data, children would have actually been seen and evaluated recently. Or at least a subsample of the children would've been seen to compare results of direct assessment with record review.
Medscape: You mentioned that there are genetic data supporting an actual increase in autism prevalence. Could you elaborate?
Dr. Volkmar: Data suggest that there's a potential for subtle changes in sperm as men get older. To make a long story very short, when women are born they have their full complement of eggs. They're not going to develop any more during their life. Men, on the other hand, are constantly regenerating sperm once spermatogenesis begins. And as men get older, there's an increase in the rate of small mutations. There's some suggestion from studies both here in the United States at the Simmons Foundation and also in Iceland and other locations that older fathers might account for some degree of a true increase in rates of autism.
Medscape: Where do the data stand on potential environmental influences in autism and ASDs?
Dr. Volkmar: The interesting thing about environmental studies is that they've been much less productive than we expected. However, there a number of interesting studies here. For example, there were a group of children who grew up in the horribly depriving orphanages in Romania, when Romania was a communist country.[7] These were just dreadful institutions and the children looked very autistic. The interesting thing is they were followed over time as researchers thought, "Oh, we might have an environmental model of autism related to severe deprivation." As those children were placed in more supportive family environments, they got better. I'm not saying they became perfectly normal, but it was a very different kind of course.
There was an eminent child psychiatrist named Stella Chess who wrote about children with congenital rubella, a congenital infection that often leaves babies blind and deaf. She wrote about them having what looks like possible autism. The interesting thing again with those children is that over time they looked less so, and of course children with very severe problems like blindness and deafness associated with congenital rubella are difficult to assess. And so we've learned to be a little careful about this because it's a slippery slope. Sadly, it's a little like the joke about asking Mrs. Lincoln how the play was. Because there's so much else going on, this is just not adding very much. And the trouble is that the issues of diagnoses are actually, especially in classical autism, most complicated at the bottom and top of the IQ range. The middle range is less complicated.
In the very impaired child with mental retardation, what's now called intellectual deficiency, there are many autistic-like behaviors, such as motor mannerisms and unusual movements. Often those children don't have social difficulties that are more profound than their intellectual disability. That's one of the great complexities with dealing with all this.
And, of course, there was a lot of interest in the last few years about that work suggesting that perhaps the measles-mumps-rubella vaccination had some role in autism.[8] That paper has been withdrawn, as I understand it, from The Lancet. It is surprising that more hasn't panned out about the environmental causes.
One area that has some potential relevance is whether very premature infants are more likely to have autism or ASDs. There is a small body of work on this but it is growing. In some ways it is interesting in that it may parallel some of the older work on animal models of autism using lesion studies. That is, there may be some potential for linking damage in some areas of the brain to behaviors and developmental features similar to those seen in autism. On balance, however, while there has been some research on environmental factors in autism, there is much less evidence here as compared with genetics.
Medscape: Do most experts believe there probably is, at least in some cases, an environmental component to autism?
Dr. Volkmar: Well, there's certainly some potential here. Even if you look among identical twins, the concordance for autism is not perfect, although it is very high. But again even here, keep in mind that identical twins in utero may be exposed to different things. So there is certainly a potential role for environmental factors, but the data for now are lacking.

And Finally, The DSM-5 Controversy

Medscape: Let's touch on the topic that seems to be on everyone's minds these days: the DSM. Can you summarize what's being proposed in the way of autism and ASDs for inclusion in DSM-5 vs the current DSM-IV criteria?
Dr. Volkmar: Well, first of all, there's no question that periodically things need to be redone, and that's just the nature of business. DSM-IV has been around since 1994. It has been remarkably productive, and research has advanced. On the other hand, there are some things that clearly do need to be thought through and changed. One might argue at the very high level that perhaps the way to do this is not to have to change the entire book every time you redo it but to redo sections on a periodic basis. Updates could be published in loose-leaf hardcopies and online.
As far as autism goes, there are some aspects of what's being proposed that are very interesting and innovative, particularly those looking at dimensions of function/dysfunction. The question of moving from this funny term "pervasive developmental disorder" -- which was coined back in 1980 -- to "autism spectrum disorder" is being discussed, which is in some ways in keeping with how people are using the term. So there are aspects to the proposal that are not bad. And also we have a number of very good diagnostic instruments now that have been in the past key to the categorical DSM and International Classification of Diseases (ICD) criteria. And I would point out that one of the other great advantages of the DSM-IV system is that DSM-IV and its international counterpart, ICD-10, essentially are effectively the same. So that means whether you're doing work in Switzerland, Swaziland, or New Haven, you're pretty much working with the same system.
DSM-IV retained what had historically been described since about 1978 -- that is, the grouping of autism features into 3 areas: social disability, communication disability, and unusual behaviors. The proposals in the DSM-5 are to combine social and communication into one criterion set and have another set that has to do with sensitivity to the environment. One of the potential disadvantages of this is that at the end of the day this really needs to be a research-based question and proposal -- it's not a question of opinion, it should be a question of what the data showed.
They're proposing moving to a classification called "autism spectrum disorder," which on the face of it implies a broader view. And that, in fact, was my first worry upon hearing about this -- that it would broaden criteria and potentially dilute services. Paradoxically, my worry is now the opposite. There are multiple studies that have looked or are looking into this at the moment,but in reviewing the data we collected as part of DSM-IV, we are worried that the more cognitively able -- people with IQs of 70 and above -- would actually be somewhat more likely to lose a diagnosis of ASD. This could greatly complicate their lives in terms of getting services and also complicate things for those of us who do research, in terms of following children over 10, or 15, or 20 years who suddenly are no longer supposedly on the spectrum. In going back to matching the new proposed criteria with those we used in DSM-IV, we discovered that even the more highly able people with classical autism lost that label and may be at risk for losing services. Many of the children who previously would have been said to have what are called atypical pervasive developmental disorder and pervasive developmental disorder not otherwise specified also lost their label and thus likely their eligibility for services, as did a majority of the children with Asperger syndrome.
Medscape: Some American Psychiatric Association representatives have reported that the new criteria will not dramatically alter diagnosis rates. Can you comment on this?
Dr. Volkmar: Yes, I've heard people argue this several ways. One group of people says, "Look, it's not going to change anything," which would be interesting. That would be fine except if it's not going to change anything, why mess with it?
Other people say we'll lose people who have been cured. Now the idea of being "cured" is a tricky business -- my worry is that because we're doing a better job of identifying children early and intervening earlier, children are as a group doing better. In April we had a daylong conference for high school students, their parents, and teachers about sending children with ASDs to college. Now that's not a problem I would have had to cope with very much 20 years ago. That's a new phenomenon and it's because they're doing better. Now, are those kids "cured?"
I did see some unpublished data from someone who was basically claiming this. Those data had to do with kids who are in college with good IQ scores. But the part of the data that she didn't make such a point of addressing -- but which I asked about -- was their real-world skills, which turned out to be an order of magnitude down from where their IQ is. And yes, these kids are very bright, but they may not be able to cope with the world. They may not be able to be out there and be independent, to drive, to balance a check book. I have one young man who does math equations in his head, who’s got an IQ of about 140, who literally can't go into McDonalds and get a cheeseburger. It's just too much for him. You could argue he's cured. But I would argue that, well, that's ridiculous. If you mean by cured he's got a high IQ, then yes, but the problem is he's quite disabled.
And so I worry a little bit that when we talk about this "cured" business, we're minimizing the service needs of our more able children. They're doing better and better, which is fantastic, but the problem is how can we best support them? And many of them get depressed and anxious as they get older because they're out on their own and their resources no longer exist in the usual ways. I worry a little bit that we're going to abandon them. And I worry that school districts could potentially institute occasional evaluations using the new criteria and basically say, "This kid no longer qualifies; no reason to give service."
Medscape: By how much could the prevalence of autism decrease according to your data?
Dr. Volkmar: Among the more cognitively able children (those with IQs above 70) our data suggest it could be as high as 40%; this would be less of an issue in individuals with lower intellectual levels.
Medscape: It's almost paradoxical because usually psychiatrists come under fire for overdiagnosing.
Dr. Volkmar: Yes. And that's certainly the issue for some of the other proposals like the new substance abuse criteria, which could greatly increase rates. But again, if you're somebody who's an epidemiologist, or even somebody like me, who works in a very specific area, you have to step back and say to yourself, "does it make sense that something's going to change radically in either direction overnight?" It makes sense to make changes as change is needed, but the idea of turning the whole book upside down at this point seems to me a little nutty.
Medscape: How would you approach updating the DSM ASD criteria?
Dr. Volkmar: I think at this point there are going to be conflicting data. And I think before we have a radical change, which is going to complicate not only the lives of researchers but especially the lives of parents and children, we should really take a step back and say, "okay, let's really think through what is needed here." And I worry a little bit that the way the process has gone, we have lost of sight of the patients and clinicians who are trying to use this in community and practice settings. I hope I'm wrong about this but fear I'm not.
Medscape: In terms of potentially cutting people out of access to care, what specific treatments are you most concerned about?
Dr. Volkmar: There are good data supporting a number of therapies. And this goes back to a report from the National Research Council back in 2001 called Educating Children with Autism. There are very good data that say that structured and behavioral interventions do work for many children -- though not necessarily for everybody -- and that the earlier we intervene, the better. We understand more and more about how treatment is working. We understand more and more about how having a social disability like autism can result in an idiosyncratic way of learning about the world. I'm not saying right or wrong, just idiosyncratic and not shared with the majority of people. You don't share with others what is and isn't relevant to learn about, so by the time you get to first grade you're in deep trouble. And now we're getting to these children earlier and earlier with a number of evidence-based treatments that really help these kids. It's not like there's necessarily a single right and wrong one, but there are many good, evidence-based treatments that really help with development and normative learning. There's behavioral therapy, special education, communication therapy, technology-based treatments -- there are a ton of options, which is great. So as I said, the problem is that as kids are getting better, I worry that we're going to essentially disqualify some of the kids who most need services and who've done the best and should continue working to do even better. That seems extremely unfortunate.

Paracetamol Prescription by Age or by Weight?

From Archives of Disease in Childhood

Warren Lenney
Posted: 03/23/2012; Arch Dis Child. 2012;97(3):277-278. © 2012 BMJ 

Abstract and Introduction


Paracetamol is the most frequently used medicine worldwide. It is usually bought as an over-the-counter medication for use in all ages but is particularly favoured for treatment in infants and children by parents, pharmacists, doctors and nurses. It has an excellent safety profile when used within the recommended dose range and is the first line pharmaceutical treatment in common clinical situations such as elevated temperature in childhood caused by intercurrent infection, and irritability in infancy and childhood following immunisation. It is also used for the relief of pain, for example following mild injury, and for toothache and simple headache. Given that much usage is undertaken by parents and carers without discussion or contact with the medical profession, it is important that prescribing and administration information is clear and simple.
The dosages recommended in the British National Formulary for Children (BNFC) are divided into different age groups and are within the licensed dose recommendations as indicated in the summary of product characteristics agreed with the Medicines and Healthcare products Regulatory Agency (MHRA).
It has been suggested that due to wide variations in children's weight for a given age range, paracetamol may be mis-prescribed if the dosage is based purely on the child's age.  Eyers et al in New Zealand have very recently compared age-based prescribing of paracetamol as used in the BNFC with internationally recommended weight-based guidelines. 
The authors conclude that children underweight or overweight for their age are at risk of inappropriate paracetamol administration based on the BNFC age-based dosing instructions. To illustrate their point, the authors suggest that a 3-month-old child could have their paracetamol dose chosen either from the 1–3-month or the 3–12-month age range. Therefore, the upper dose could be determined by using the maximum dose in the 3–12-month range (120 mg), and assuming the child's weight was below the 10th centile in the 1–3-month range, an inappropriately high dose could be administered. Similarly, to determine the lower dose the authors used the minimum dose in the 1–3-month age group (30 mg), and assuming the child was on or above the 90th centile in the 3–12-month age group, an inappropriately low dose could be given. Such assumptions would naturally produce upper and lower dose values widely different from each other but leave no scope for pragmatism and administration using common sense on an individual basis.
Does the above matter? Are some children at clinical risk? Are there recorded problems based on the recommended oral paracetamol dosages as appear in the 2011–2012 BNFC? The dosage of every medicine needs very careful scrutiny and it behoves us all to closely consider both safety and efficacy. The dosages of paracetamol in the BNFC are fully in line with the licensed recommendations. Although the total oral dose is important, so too are pharmacokinetic issues such as absorption, metabolism and excretion. In young infants gastric emptying is slow and erratic. Do parents administer paracetamol to infants and children before, during or after feeds and what effect does this have on blood levels and efficacy? Do children with a lower body weight for age respond differently to the same dosage of paracetamol as heavier children of the same age? What data are available to answer these questions? What is the relationship between paracetamol blood levels, its efficacy and its safety? Are the dosages of paracetamol required to treat fever the same as those needed to relieve moderate pain?
We do not have the answers to many of these questions as few studies have been undertaken in children. Paracetamol blood levels of 4–18 mg/l in children have been shown to be efficacious in treating fever, but response is better the higher the fever. 
Also, the clinical benefits for a specific paracetamol blood level are much greater when the level is falling rather than rising. The clinical response to paracetamol, therefore, is related not only to the paracetamol blood level but also to the time lag, known as the effect compartment. Thus, there is a considerable confusion about the exact dose required for a given body weight and the relationship of paracetamol blood levels to clinical efficacy. One suggestion to explain the effect compartment is that time is required for paracetamol to pass from the blood compartment into the cerebrospinal fluid (CSF) compartment. It is the CSF level which more closely equates with clinical response to fever as the mechanism directly involves the hypothalamus. With regard to safety, the BNFC is unaware of any reported toxicity incident involving paracetamol used in children within the licensed dose range.
The BNFC is published annually in July. In July 2011, the MHRA published new guideline dosing tables for paracetamol usage in children, developed because of the wide age bands used previously. These tables will appear on products entering the market by the end of 2011. In the meantime, the MHRA states that parents and carers should continue to follow the advice currently on packaging. The old and the new guidelines remain age range-based for simplicity and clarity (see Table 1). However, the age bands are narrower than previously and as the MHRA Director of Vigilance and Risk Management of Medicines stated, "The change is not because of safety concerns but to ensure children get the optimal dose of paracetamol for their age".
As the BNF for adults is updated every 6 months, the most recent edition, BNF 62 published in September 2011, includes the new MHRA recommendations with the narrower age bands. The next BNFC publication in July 2012 will be similarly updated.

    Water safety for young children

    Drowning is the second most common cause of death for children under 5 years of age. Children can drown in as little as 2.5 cm (1 inch) of water.
    Many of these tragedies happen in backyard pools, and almost always in pools without 4-side pool fencing and self-closing, self-latching safety gates.

    Take the following essential precautions to help protect your children:

    • Babies who cannot sit without support and are too young to wear a portable flotation device (PFD) should be held by an adult at all times.
    • Toddlers should always be within arm’s reach of an adult when they are in or around water. This includes pools, bathtubs, and beaches, and other water sources.
    • Swimming lessons are a great opportunity for families to participate in fun activities that contribute to a healthy lifestyle. But on their own, they will not protect or prevent a child from drowning.
    • All children should be supervised by an adult when they are in or around water and should never be left alone in a pool or bathtub, even for a moment.
    • The Lifesaving Society recommends a supervision ratio of at least 1 adult for every 2 young children, and 1 adult for every baby.

    Should I use a life jacket or a personal flotation device (PFD) for my child?

    Life jackets are different from PFDs. A life jacket can turn the person over from face-down to face-up. A PFD will keep a person floating, but not necessarily face-up. It is lighter and less bulky than a lifejacket. PFDs also keep people warmer in the water because the foam in the vest is spread more evenly around the body.
    You can use either a lifejacket or a PFD for your child, as long as it is designed for children.
    In Canada, approved life jackets and PFDs are not available for infants who weigh less than 9 kg (20 lb). There is no safety standard for smaller infants.
    • PFDs or life jackets should be worn by all infants who weigh at least 9 kg (20 lb) and by toddlers who are swimming or playing near or in the water.
    • Check the label to be sure that your child’s PFD or life jacket meets current national safety standards. It should be approved by at least one of the following: Transport Canada, Canadian Coast Guard or Fisheries and Oceans Canada.
    • It should be the right size for your child’s weight. Make sure it stays buckled up. Keep all safety straps fastened, including the crotch strap.
    • Remember that water wings, bathing suits with flotation devices in them, inflatable wings and other swim toys ARE NOT safety devices.

    What should we do if we have a swimming pool at home?

    • Swimming pools—whether in- or above-ground—should be fenced on four sides. That meansNOT having direct access to a pool from a deck, patio or back door (the house doesn’t count as a “side”). The fence should be climbing-resistant and at least 1.2 m (4 ft.) high. Any gate to the pool area should be self-closing and self-latching.
    • Make sure that hot tubs and spas not contained within the fenced pool area have a locking hard cover or are located in an area that can be closed and locked.
    • Empty toddler and other portable backyard pools after use (at least once daily if you are using them every day). By not having standing water, you also help reduce the risk of West Nile Virus.
    • Parents and pool owners should learn how to swim and how to rescue a drowning victim. They should also maintain certification in first aid and cardiopulmonary resuscitation (CPR). Pool owners should have an emergency action plan, rescue equipment, and a telephone on the deck or poolside.
    • Slide or play equipment should be designed specifically for pool use.

    What are some other water safety tips?

    • Use diapers designed for use in water. They don’t get as heavy as regular diapers and are less likely to cause your child to lose his balance in a wading pool.
    • Empty buckets and pails, ice chests with melted ice, or bathtubs as soon as you are done with them. Do not keep a container filled with water (such as a rain barrel) around your home.
    • When your children are playing under a sprinkler, watch for pools of water collecting on the ground. They can be slippery. Move the sprinkler often, or take a break until the water has drained. Use sprinklers on grassy surfaces only, and make sure the play area is free of toys or other obstacles.
    • A backyard water slide should be used with caution. Set it up on a soft, grassy slope, free of bumps, and well away from trees or shrubs. Teach children to slide in a sitting position.
    • Keep children away from ponds and streams at any time of year, unless you are with them.

    When can my child take swimming lessons?

    There is not a lot of research about the exact age when young children are ready to learn how to swim. Several studies show that children do not have the skills to swim on their own until they are 4 years old, even if they start lessons at a younger age.
    If your child is younger than 4 years old, look for swimming programs that focus on building water confidence and that teach parents about water safety. This is a great way to have fun and be active with your children.
    Teach your children these important pool rules and follow them at all times:
    • No swimming without an adult.
    • No running or pushing.
    • No food or drinks.
    • No riding toys.

    Physical Activity in Adolescence Staves Off Depression in Adulthood

    From Medscape Education Clinical Briefs

    News Author: Fran Lowry
    CME Author: Penny Murata, MD
    CME Released: 07/03/2012


    Physical exercise appears to improve executive functions in patients with depression, according to Kubesch and colleagues in the September 2003 issue of the Journal of Clinical Psychiatry. However, it is not clear whether physical exercise prevents affective disorders. In the May 28, 2010, issue of BMC Medicine, Rothon and colleagues reported that a change in physical activity was not associated with depressive symptoms in adolescents at 2-year follow-up.
    This prospective cohort study by Åberg and colleagues assesses whether cardiovascular fitness at age 18 years in a male population is associated with a future risk for affective disorders and whether muscle strength plays a role.


    Good physical fitness at age 18 years is associated with a reduced risk for serious depression later in life, a new study shows.
    "Lower cardiovascular fitness, independent of muscle strength, at age 18 years was associated with increased risk of serious depression in adulthood, even 31 to 40 years later, although no such association could be shown for bipolar disorder," lead author Maria A. Åberg, MD, PhD, Sahlgrenska Academy, University of Gothenburg, in Sweden, toldMedscape Medical News.
    "These results strengthen the theory of a cardiovascular contribution to the etiology of depression," she added.
    The results, which are from a study that included more than 1 million Swedish men, was published online June 14 in the British Journal of Psychiatry.
    Preventing Depression?
    Dr. Åberg and her team have been studying brain plasticity in animal models for many years; the results from those studies, as well as intervention studies, suggest that physical exercise may improve cognition and mood in persons with an already established depression.
    "A proposed mechanism is that physical exercise could reverse the reduced neuronal plasticity that is observed in both depression and bipolar disorders. Previous human studies have shown that a sedentary lifestyle increases the risk of depression, but most of these have been based on interviews with adults and the results have been inconclusive, and we felt that there was a real need for a large study with long follow-up times and objective measures of physical performance," Dr. Åberg explained.
    The researchers carried out a prospective cohort study of all Swedish men born between 1950 and 1987 with no history of mental illness who were enlisted for mandatory military service at the age of 18 years.
    When enlisting, all 1,117,292 men were given extensive physical and psychological examinations, including tests of their cardiovascular and muscle fitness.
    The men were followed between 1969 and 2008. The researchers used data from the Swedish National Hospital Discharge Register to see how many had received inpatient treatment for depression.
    The study showed that the men who performed poorly on the cardiovascular fitness tests at age 18 years were at greater risk of being hospitalized with depression in later life.
    After controlling for factors that included body mass index, conscription test center, and familial factors, the hazard ratio (HR) associated with lower cardiovascular fitness at age 18 for serious depression in adulthood was 1.96 (95% confidence interval [CI], 1.71 - 2.23).
    There was no such association found for bipolar disorder (HR, 1.11; 95% CI, 0.84 - 1.47).
    "Doctors can tell their teenage patients and their parents that the brain needs two types of training, both cognitive challenges and physical exercise," Dr. Åberg said.
    She added that she hoped politicians and school administrators would give sport a higher status and also more resources. "Moreover, targeting specific high-risk groups for developing depression with cardiovascular training early in life is of high importance."
    Incremental Step Forward
    Alan J. Gelenberg, MD, Shively/Tan Professor and chair, Department of Psychiatry, Penn State University, Hershey, Pennsylvania, called this an "exciting" study when commenting on it for Medscape Medical News.
    "When I saw this study, I shared it with a couple of the researchers in my own department, because it's a very nice incremental step forward," he said.
    "In terms of linking exercise, physical fitness, and mood disorders, it is a puzzle that we don't have the full picture. This is another piece, and given the fact that the study deals with more than a million human beings, it does give us some ability to dissect apart important variables," Dr. Gelenberg said.
    "Now we are having an epidemic of lack of fitness, obesity, diabetes, and cardiovascular problems, but we are learning in my field that these problems are not just restricted to the heart and the endocrine and vascular system; it also seems to have effects on brain health," he said.
    Dr. Åberg and Dr. Gelenberg have disclosed no relevant financial relationships.
    Br J Psych. Published online June 14, 2012. Abstract


    • Lower cardiovascular fitness in 18-year-old men is linked with an increased risk for serious depression in adulthood (HR, 1.96) but not bipolar disorder.
    • The link between lower cardiovascular fitness in 18-year-old men and the risk for serious depression in adulthood is independent of muscle strength.