Pediatrics

Caroline Bonham, MD, and Avi Kriechman, MD, join Psychcast host Lorenzo Norris, MD, via phone to discuss enhancing resilience in rural communities. Overall U.S. life expectancy decreased from 78.7 years to 78.6 years from 2016 to 2017. Researchers from the Centers for Disease Control and Prevention noted that, along with drug overdose deaths, suicide also drove the decrease in average lifespan over that time period. Addressing suicide in rural communities presents unique challenges.

Dr. Bonham is vice chair of community behavioral health in the department of psychiatry and behavioral sciences at the University of New Mexico, Albuquerque. Dr. Kriechman is a child, adolescent and family psychiatrist at the university, where he serves as principal investigator on ASPYR – Alliance-building for Suicide Prevention & Youth Resilience.

You can hear more on resilience and suicide from the MDedge Psychcast in these past episodes:

•  
•  
•  
• Find the MDedge Psychcast where ever you listen:

Amazon

Apple Podcasts

Google Podcasts

Spotify


 

Caroline Bonham, MD, and Avi Kriechman, MD, join Psychcast host Lorenzo Norris, MD, via phone to discuss enhancing resilience in rural communities. Overall U.S. life expectancy decreased from 78.7 years to 78.6 years from 2016 to 2017. Researchers from the Centers for Disease Control and Prevention noted that, along with drug overdose deaths, suicide also drove the decrease in average lifespan over that time period. Addressing suicide in rural communities presents unique challenges.

Dr. Bonham is vice chair of community behavioral health in the department of psychiatry and behavioral sciences at the University of New Mexico, Albuquerque. Dr. Kriechman is a child, adolescent and family psychiatrist at the university, where he serves as principal investigator on ASPYR – Alliance-building for Suicide Prevention & Youth Resilience.

You can hear more on resilience and suicide from the MDedge Psychcast in these past episodes:

•  
•  
•  
• Find the MDedge Psychcast where ever you listen:

Amazon

Apple Podcasts

Google Podcasts

Spotify


 

Caroline Bonham, MD, and Avi Kriechman, MD, join Psychcast host Lorenzo Norris, MD, via phone to discuss enhancing resilience in rural communities. Overall U.S. life expectancy decreased from 78.7 years to 78.6 years from 2016 to 2017. Researchers from the Centers for Disease Control and Prevention noted that, along with drug overdose deaths, suicide also drove the decrease in average lifespan over that time period. Addressing suicide in rural communities presents unique challenges.

Dr. Bonham is vice chair of community behavioral health in the department of psychiatry and behavioral sciences at the University of New Mexico, Albuquerque. Dr. Kriechman is a child, adolescent and family psychiatrist at the university, where he serves as principal investigator on ASPYR – Alliance-building for Suicide Prevention & Youth Resilience.

You can hear more on resilience and suicide from the MDedge Psychcast in these past episodes:

•  
•  
•  
• Find the MDedge Psychcast where ever you listen:

Amazon

Apple Podcasts

Google Podcasts

Spotify


 

Young women who delay starting contraception when they start sexual activity are at increased risk of unwanted pregnancy, according to data from a cross-sectional study of more than 26,000 women in the United States.

Jupiterimages/thinkstock

Unintended pregnancy in the United States is associated with delayed prenatal care, premature birth, and low birth weight and remains more common among African American and Hispanic women than among white women, and it also is more common among low-income women than among high income women, wrote Mara E. Murray Horwitz, MD, of Harvard Pilgrim Health Care Institute in Boston and her colleagues.

“Reducing unintended pregnancy and the associated socioeconomic disparities is a national public health priority,” they wrote.

In a study published in Pediatrics, the researchers reviewed data from four cycles of the National Survey of Family Growth between 2002 and 2015. They examined self-reported responses from 26,359 women aged 15-44 years with sexual debuts during 1970-2014, including the dates of sexual debut, initiation of contraceptives, and rates of unwanted pregnancy. Timely contraceptive initiation was defined as use within a month of starting sexual activity.

Overall, one in five women reported delayed initiation of contraception. This delay was significantly associated with an increased unwanted pregnancy risk within 3 months of starting sexual activity, compared with timely use of contraception (adjusted risk ratio, 3.7). The average age of sexual debut was 17 years.

When the researchers examined subgroups, they found that one in four respondents who were African American, Hispanic, or low income reported delayed contraceptive initiation.

No association with unwanted pregnancy was found between effective versus less effective contraception methods. Timely contraceptive use increased during the study period from less than 10% in the 1970s to more than 25% in the 2000s, but condoms accounted for most of this increase. Use of other methods including long-acting reversible and short-acting hormonal options was low, especially among African American, Hispanic, and low-income women, Dr. Murray Horwitz and her colleagues noted.

The study was limited by several factors including the use of self-reports, lack of data on the exact start of contraceptive initiation, and the lack of association between contraceptive method and unwanted pregnancy, the researchers noted. However, the findings suggest that clinicians can help by intervening with young patients and educating them about early adoption of pregnancy prevention strategies.

The study was funded by the National Institutes of Health; Dr. Murray Horwitz was supported by an award from the NIH and Harvard Pilgrim Health Care Institute. Another researcher received support from Harvard Pilgrim Health Care Institute to provide mentorship for the study. The remaining researcher had no relevant financial disclosures.

SOURCE: Murray Horwitz M et al. Pediatrics. 2019;143(2):e20182463.

Young women who delay starting contraception when they start sexual activity are at increased risk of unwanted pregnancy, according to data from a cross-sectional study of more than 26,000 women in the United States.

Jupiterimages/thinkstock

Unintended pregnancy in the United States is associated with delayed prenatal care, premature birth, and low birth weight and remains more common among African American and Hispanic women than among white women, and it also is more common among low-income women than among high income women, wrote Mara E. Murray Horwitz, MD, of Harvard Pilgrim Health Care Institute in Boston and her colleagues.

“Reducing unintended pregnancy and the associated socioeconomic disparities is a national public health priority,” they wrote.

In a study published in Pediatrics, the researchers reviewed data from four cycles of the National Survey of Family Growth between 2002 and 2015. They examined self-reported responses from 26,359 women aged 15-44 years with sexual debuts during 1970-2014, including the dates of sexual debut, initiation of contraceptives, and rates of unwanted pregnancy. Timely contraceptive initiation was defined as use within a month of starting sexual activity.

Overall, one in five women reported delayed initiation of contraception. This delay was significantly associated with an increased unwanted pregnancy risk within 3 months of starting sexual activity, compared with timely use of contraception (adjusted risk ratio, 3.7). The average age of sexual debut was 17 years.

When the researchers examined subgroups, they found that one in four respondents who were African American, Hispanic, or low income reported delayed contraceptive initiation.

No association with unwanted pregnancy was found between effective versus less effective contraception methods. Timely contraceptive use increased during the study period from less than 10% in the 1970s to more than 25% in the 2000s, but condoms accounted for most of this increase. Use of other methods including long-acting reversible and short-acting hormonal options was low, especially among African American, Hispanic, and low-income women, Dr. Murray Horwitz and her colleagues noted.

The study was limited by several factors including the use of self-reports, lack of data on the exact start of contraceptive initiation, and the lack of association between contraceptive method and unwanted pregnancy, the researchers noted. However, the findings suggest that clinicians can help by intervening with young patients and educating them about early adoption of pregnancy prevention strategies.

The study was funded by the National Institutes of Health; Dr. Murray Horwitz was supported by an award from the NIH and Harvard Pilgrim Health Care Institute. Another researcher received support from Harvard Pilgrim Health Care Institute to provide mentorship for the study. The remaining researcher had no relevant financial disclosures.

SOURCE: Murray Horwitz M et al. Pediatrics. 2019;143(2):e20182463.

Young women who delay starting contraception when they start sexual activity are at increased risk of unwanted pregnancy, according to data from a cross-sectional study of more than 26,000 women in the United States.

Jupiterimages/thinkstock

Unintended pregnancy in the United States is associated with delayed prenatal care, premature birth, and low birth weight and remains more common among African American and Hispanic women than among white women, and it also is more common among low-income women than among high income women, wrote Mara E. Murray Horwitz, MD, of Harvard Pilgrim Health Care Institute in Boston and her colleagues.

“Reducing unintended pregnancy and the associated socioeconomic disparities is a national public health priority,” they wrote.

In a study published in Pediatrics, the researchers reviewed data from four cycles of the National Survey of Family Growth between 2002 and 2015. They examined self-reported responses from 26,359 women aged 15-44 years with sexual debuts during 1970-2014, including the dates of sexual debut, initiation of contraceptives, and rates of unwanted pregnancy. Timely contraceptive initiation was defined as use within a month of starting sexual activity.

Overall, one in five women reported delayed initiation of contraception. This delay was significantly associated with an increased unwanted pregnancy risk within 3 months of starting sexual activity, compared with timely use of contraception (adjusted risk ratio, 3.7). The average age of sexual debut was 17 years.

When the researchers examined subgroups, they found that one in four respondents who were African American, Hispanic, or low income reported delayed contraceptive initiation.

No association with unwanted pregnancy was found between effective versus less effective contraception methods. Timely contraceptive use increased during the study period from less than 10% in the 1970s to more than 25% in the 2000s, but condoms accounted for most of this increase. Use of other methods including long-acting reversible and short-acting hormonal options was low, especially among African American, Hispanic, and low-income women, Dr. Murray Horwitz and her colleagues noted.

The study was limited by several factors including the use of self-reports, lack of data on the exact start of contraceptive initiation, and the lack of association between contraceptive method and unwanted pregnancy, the researchers noted. However, the findings suggest that clinicians can help by intervening with young patients and educating them about early adoption of pregnancy prevention strategies.

The study was funded by the National Institutes of Health; Dr. Murray Horwitz was supported by an award from the NIH and Harvard Pilgrim Health Care Institute. Another researcher received support from Harvard Pilgrim Health Care Institute to provide mentorship for the study. The remaining researcher had no relevant financial disclosures.

SOURCE: Murray Horwitz M et al. Pediatrics. 2019;143(2):e20182463.

The patient was diagnosed with lichen spinulosus (LS) based on the physical appearance of the lesions (hyperkeratotic spiny papules forming plaques), the lack of pruritus, and negative personal history of atopic dermatitis.

Lichen spinulosus is an underreported entity, first described in 1908 by Adamson as superficial circumscribed chronic dermatitis in children and adolescents. The median age of presentation is age 16 years. There are several reports of possible associations with systemic infections such as HIV, fungi, and syphilis, as well as chronic diseases such as Crohn’s disease, Hodgkin disease, seborrhea, and secondary to certain medications such as omeprazole. There are no prior reports of infliximab being associated with LS, but it has been reported to cause other lichenoid reactions such as lichen planus and lichen planopilaris.

Clinically the lesions are characterized by asymptomatic, small (1 cm), skin color, hyperkeratotic, follicular papules that coalesce into plaques. The lesions usually occur on the extensor surfaces of the arms, neck, torso, and buttocks. Mild pruritus can occur in some patients.

The lesions in keratosis pilaris can be very similar to lichen spinulosus, but usually they don’t coalesce into plaques and are commonly present on the extensor surfaces of the arms, thighs, and cheeks. Histopathology of both conditions is very similar.

Another condition to consider includes papular eczema. The lesions in papular eczema tend to be pruritic and are not as circumscribed as LS lesions. Papular eczema responds well to the use of topical corticosteroids, while LS lesions usually do not. Lichen nitidus (LN) is characterized by monomorphic, skin color, 1-mm, flat-topped papules. Lesions tend to occur in crops rather than circumscribed papules forming plaques. LN most commonly presents on the extensor surface of the arms, trunk, dorsal hands, and genitalia. Koebner phenomenon is usually seen. Although uncommon in children, a more generalized type of follicular mucinosis can present very similar to lichen spinulosus. A recent study found LS-like lesions with associated hypopigmentation and hair loss should be suspicious for folliculotropic mycosis fungoides.

Keratolytics such as lactic acid, urea, and salicylic acid can help improve LS, although they do not cure it. Other reported treatments include the use of topical adapalene, tacalcitol cream, and tretinoin gel with hydroactive adhesive.

Dr. Matiz is a pediatric dermatologist at Southern California Permanente Medical Group, San Diego. Email her at pdnews@mdedge.com.

The patient was diagnosed with lichen spinulosus (LS) based on the physical appearance of the lesions (hyperkeratotic spiny papules forming plaques), the lack of pruritus, and negative personal history of atopic dermatitis.

Lichen spinulosus is an underreported entity, first described in 1908 by Adamson as superficial circumscribed chronic dermatitis in children and adolescents. The median age of presentation is age 16 years. There are several reports of possible associations with systemic infections such as HIV, fungi, and syphilis, as well as chronic diseases such as Crohn’s disease, Hodgkin disease, seborrhea, and secondary to certain medications such as omeprazole. There are no prior reports of infliximab being associated with LS, but it has been reported to cause other lichenoid reactions such as lichen planus and lichen planopilaris.

Clinically the lesions are characterized by asymptomatic, small (1 cm), skin color, hyperkeratotic, follicular papules that coalesce into plaques. The lesions usually occur on the extensor surfaces of the arms, neck, torso, and buttocks. Mild pruritus can occur in some patients.

The lesions in keratosis pilaris can be very similar to lichen spinulosus, but usually they don’t coalesce into plaques and are commonly present on the extensor surfaces of the arms, thighs, and cheeks. Histopathology of both conditions is very similar.

Another condition to consider includes papular eczema. The lesions in papular eczema tend to be pruritic and are not as circumscribed as LS lesions. Papular eczema responds well to the use of topical corticosteroids, while LS lesions usually do not. Lichen nitidus (LN) is characterized by monomorphic, skin color, 1-mm, flat-topped papules. Lesions tend to occur in crops rather than circumscribed papules forming plaques. LN most commonly presents on the extensor surface of the arms, trunk, dorsal hands, and genitalia. Koebner phenomenon is usually seen. Although uncommon in children, a more generalized type of follicular mucinosis can present very similar to lichen spinulosus. A recent study found LS-like lesions with associated hypopigmentation and hair loss should be suspicious for folliculotropic mycosis fungoides.

Keratolytics such as lactic acid, urea, and salicylic acid can help improve LS, although they do not cure it. Other reported treatments include the use of topical adapalene, tacalcitol cream, and tretinoin gel with hydroactive adhesive.

Dr. Matiz is a pediatric dermatologist at Southern California Permanente Medical Group, San Diego. Email her at pdnews@mdedge.com.

The patient was diagnosed with lichen spinulosus (LS) based on the physical appearance of the lesions (hyperkeratotic spiny papules forming plaques), the lack of pruritus, and negative personal history of atopic dermatitis.

Lichen spinulosus is an underreported entity, first described in 1908 by Adamson as superficial circumscribed chronic dermatitis in children and adolescents. The median age of presentation is age 16 years. There are several reports of possible associations with systemic infections such as HIV, fungi, and syphilis, as well as chronic diseases such as Crohn’s disease, Hodgkin disease, seborrhea, and secondary to certain medications such as omeprazole. There are no prior reports of infliximab being associated with LS, but it has been reported to cause other lichenoid reactions such as lichen planus and lichen planopilaris.

Clinically the lesions are characterized by asymptomatic, small (1 cm), skin color, hyperkeratotic, follicular papules that coalesce into plaques. The lesions usually occur on the extensor surfaces of the arms, neck, torso, and buttocks. Mild pruritus can occur in some patients.

The lesions in keratosis pilaris can be very similar to lichen spinulosus, but usually they don’t coalesce into plaques and are commonly present on the extensor surfaces of the arms, thighs, and cheeks. Histopathology of both conditions is very similar.

Another condition to consider includes papular eczema. The lesions in papular eczema tend to be pruritic and are not as circumscribed as LS lesions. Papular eczema responds well to the use of topical corticosteroids, while LS lesions usually do not. Lichen nitidus (LN) is characterized by monomorphic, skin color, 1-mm, flat-topped papules. Lesions tend to occur in crops rather than circumscribed papules forming plaques. LN most commonly presents on the extensor surface of the arms, trunk, dorsal hands, and genitalia. Koebner phenomenon is usually seen. Although uncommon in children, a more generalized type of follicular mucinosis can present very similar to lichen spinulosus. A recent study found LS-like lesions with associated hypopigmentation and hair loss should be suspicious for folliculotropic mycosis fungoides.

Keratolytics such as lactic acid, urea, and salicylic acid can help improve LS, although they do not cure it. Other reported treatments include the use of topical adapalene, tacalcitol cream, and tretinoin gel with hydroactive adhesive.

Dr. Matiz is a pediatric dermatologist at Southern California Permanente Medical Group, San Diego. Email her at pdnews@mdedge.com.

The Food and Drug Administration has approved the expanded use of Adacel (Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis (Tdap) Vaccine Adsorbed) to include repeat vaccinations 8 years or more after the first vaccination in people aged 10-64 years.

Wikimedia Commons/FitzColinGerald/Creative Commons License

The expanded indication was based on results of a randomized, controlled trial, published in the Journal of the Pediatric Infectious Diseases Society, in which more than 1,300 adults aged 18-64 years received either Adacel or a Td (tetanus-diphtheria) vaccine 8-12 years after receiving a previous dose of Adacel.

Over the course of the study, no significant difference in adverse event incidence was observed between groups. Injection-site reaction was the most common adverse event during the study, occurring in 87.7% of those who received Adacel and 88.0% of those who received the Td vaccine. Other common adverse events associated with Adacel include headache, body ache or muscle weakness, tiredness, muscle aches, and general discomfort.

“While strong vaccination programs are in place for young adolescents, a single Tdap immunization does not offer lifetime protection against pertussis due to waning immunity. The licensure of Adacel as the first Tdap vaccine in the U.S. for repeat vaccination is an important step for eligible patients and offers flexibility for health care providers to help manage their immunization schedules,” said David P. Greenberg, MD, regional medical head North America at Sanofi Pasteur, in the press release.

Find the full press release on the Sanofi website.

lfranki@mdedge.com

The Food and Drug Administration has approved the expanded use of Adacel (Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis (Tdap) Vaccine Adsorbed) to include repeat vaccinations 8 years or more after the first vaccination in people aged 10-64 years.

Wikimedia Commons/FitzColinGerald/Creative Commons License

The expanded indication was based on results of a randomized, controlled trial, published in the Journal of the Pediatric Infectious Diseases Society, in which more than 1,300 adults aged 18-64 years received either Adacel or a Td (tetanus-diphtheria) vaccine 8-12 years after receiving a previous dose of Adacel.

Over the course of the study, no significant difference in adverse event incidence was observed between groups. Injection-site reaction was the most common adverse event during the study, occurring in 87.7% of those who received Adacel and 88.0% of those who received the Td vaccine. Other common adverse events associated with Adacel include headache, body ache or muscle weakness, tiredness, muscle aches, and general discomfort.

“While strong vaccination programs are in place for young adolescents, a single Tdap immunization does not offer lifetime protection against pertussis due to waning immunity. The licensure of Adacel as the first Tdap vaccine in the U.S. for repeat vaccination is an important step for eligible patients and offers flexibility for health care providers to help manage their immunization schedules,” said David P. Greenberg, MD, regional medical head North America at Sanofi Pasteur, in the press release.

Find the full press release on the Sanofi website.

lfranki@mdedge.com

The Food and Drug Administration has approved the expanded use of Adacel (Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis (Tdap) Vaccine Adsorbed) to include repeat vaccinations 8 years or more after the first vaccination in people aged 10-64 years.

Wikimedia Commons/FitzColinGerald/Creative Commons License

The expanded indication was based on results of a randomized, controlled trial, published in the Journal of the Pediatric Infectious Diseases Society, in which more than 1,300 adults aged 18-64 years received either Adacel or a Td (tetanus-diphtheria) vaccine 8-12 years after receiving a previous dose of Adacel.

Over the course of the study, no significant difference in adverse event incidence was observed between groups. Injection-site reaction was the most common adverse event during the study, occurring in 87.7% of those who received Adacel and 88.0% of those who received the Td vaccine. Other common adverse events associated with Adacel include headache, body ache or muscle weakness, tiredness, muscle aches, and general discomfort.

“While strong vaccination programs are in place for young adolescents, a single Tdap immunization does not offer lifetime protection against pertussis due to waning immunity. The licensure of Adacel as the first Tdap vaccine in the U.S. for repeat vaccination is an important step for eligible patients and offers flexibility for health care providers to help manage their immunization schedules,” said David P. Greenberg, MD, regional medical head North America at Sanofi Pasteur, in the press release.

Find the full press release on the Sanofi website.

lfranki@mdedge.com

Less clinical attention has been paid to caffeine lately as the medical community works to overcome the negative effects of substances such as opiates and cannabis. Quietly, however, caffeine continues to be widely consumed among children and adolescents, and its use often flies under the radar for pediatricians who have so many other topics to address. To help clinicians decide whether more focus on caffeine use is needed, a review was published in the Journal of the American Academy of Child & Adolescent Psychiatry (2019;58[1]:36-45). A synopsis of this paper which summarizes 90 individual studies on caffeine use in children and adolescents is provided here.

MonthiraYodtiwong/Thinkstock

Caffeine usage in children and adolescents

Caffeine continues to be one of the most commonly used substances in youth, with about 75% of older children and adolescents consuming it regularly, often at an average dose of about 25 mg/day for children aged 6-11 years and 50 mg/day for adolescents. Because most people have trouble quickly converting commonly used products into milligrams of caffeine, the following guide can be useful:

• Soda (12 oz). About 40 mg caffeine.
• Coffee (8 oz). About 100 mg caffeine.
• Tea (8 oz). About 48 mg caffeine.
• Energy drinks (12 oz). About 150 mg caffeine plus, with 5-Hour Energy being around 215 mg caffeine, according to a Consumer Reports study.

It is important to pay attention to the serving size, as the actual volume consumed of products like coffee or soft drinks often are much higher.

With regards to caffeine trends over time, a surprising observation is that total caffeine consumption among youth over the past decade or so looks relatively flat and may even be decreasing. This trend has occurred despite the aggressive marketing to youth of many energy drinks that contain high amounts of caffeine. In many ways, the pattern of caffeine use fits with what we know about substance use in general in adolescents, with rates dropping for many commonly used substances – with the exception of cannabis.
 

Effects of caffeine

As many know, caffeine is a stimulant and is known to increase arousal, alertness, and amount of motor behavior. While many youth drink caffeine in an effort to improve cognitive performance, the evidence that it does so directly is modest. There are some studies that show improvements on some cognitive tests when children take moderate doses of caffeine, but these effects tend to be most pronounced for kids who are more naive to caffeine at baseline. Of course, caffeine also can temporarily reduce feelings of fatigue and sleepiness.

Anecdotally, many youth and parents will report that caffeine is a way to “self-medicate” various symptoms of ADHD. While many will report some benefit, there is a surprising lack of rigorous data about the effects of caffeine for youth who meet criteria for ADHD, according to this review.

There also are some well-known negative effects of caffeine use. One of the most important ones is that caffeine can interfere with sleep onset, thereby inducing a cycle that reinforces more caffeine use in the day in an effort to compensate for poor sleep at night. A less obvious negative effect that has been documented is that caffeine added to sweetened beverages can increase consumption of similar sugary foods, even if they don’t have caffeine.

A number of adverse effects have been observed when youth consume caffeine at excessive doses, which tend to be around a threshold of 400 mg/day for teens and about 100 mg/day for younger children. These can include both behavioral and nonbehavioral changes such as agitation or irritability, anxiety, heart arrhythmias, and hypertension. Concern over high caffeine intake also was raised in relation to a number of cases of sudden death, although these events fortunately are rare. The review mentions that one factor that could increase the risk of a serious medical event related to caffeine use is the presence of an underlying cardiac problem which may go undetected until a negative outcome occurs. In thinking about these risks associated with “excessive” caffeine consumption, it can be important to go back to the guides and see just how easily an adolescent can get to a level of 400 mg or more. A couple large cups of coffee per day or two to three specific “energy-boosting” products can be all that it takes.

There also are a few large longitudinal studies that have shown a significant association between increased caffeine consumption and future problems with anger, aggression, risky sexual behavior, and substance use. Energy drinks, which can deliver a lot of caffeine quickly, were singled out as particularly problematic in some of these studies, although these naturalistic studies are unable to determine causation, and it also is possible that teens who are already prone towards behavioral problems tend to consume more caffeine. However, the review also mentions animal studies that have demonstrated that caffeine may prime the brain to use other substances like amphetamines or cocaine. Finally, another concern raised about energy drinks in particular is that they also often contain other substances which may have similar physiological effects but are relatively untested when it comes to safety.
 

Conclusions

This review, like the current position of the Food and Drug Administration, considers caffeine as generally safe at low doses because there does not appear to be much evidence that low or moderate use in youth leads to significant problems. The conclusion changes, however, with higher levels of consumption, as more frequent and more serious risks are encountered. The article recommends that both parents and doctors be more vigilant in monitoring the amount of caffeine that a child consumes as well as the timing of that use during the day. Some quick calculations can be done to give adolescents and their parents an estimate of their caffeine use in milligrams. And while caffeine may not rise to the level of public health concern as substances like opiates or alcohol, there is evidence that it can cause some real problems in children and teens, especially in higher amounts, and thus shouldn’t be given a total pass by parents and doctors alike.

Dr. Rettew is a child and adolescent psychiatrist and associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. Email him at pdnews@mdedge.com. Follow him on Twitter @PediPsych. Looking for more mental health training? Attend the 13th annual Child Psychiatry in Primary Care conference in Burlington, Vt., May 3, 2019 (http://www.med.uvm.edu/cme/conferences).

Less clinical attention has been paid to caffeine lately as the medical community works to overcome the negative effects of substances such as opiates and cannabis. Quietly, however, caffeine continues to be widely consumed among children and adolescents, and its use often flies under the radar for pediatricians who have so many other topics to address. To help clinicians decide whether more focus on caffeine use is needed, a review was published in the Journal of the American Academy of Child & Adolescent Psychiatry (2019;58[1]:36-45). A synopsis of this paper which summarizes 90 individual studies on caffeine use in children and adolescents is provided here.

MonthiraYodtiwong/Thinkstock

Caffeine usage in children and adolescents

Caffeine continues to be one of the most commonly used substances in youth, with about 75% of older children and adolescents consuming it regularly, often at an average dose of about 25 mg/day for children aged 6-11 years and 50 mg/day for adolescents. Because most people have trouble quickly converting commonly used products into milligrams of caffeine, the following guide can be useful:

• Soda (12 oz). About 40 mg caffeine.
• Coffee (8 oz). About 100 mg caffeine.
• Tea (8 oz). About 48 mg caffeine.
• Energy drinks (12 oz). About 150 mg caffeine plus, with 5-Hour Energy being around 215 mg caffeine, according to a Consumer Reports study.

It is important to pay attention to the serving size, as the actual volume consumed of products like coffee or soft drinks often are much higher.

With regards to caffeine trends over time, a surprising observation is that total caffeine consumption among youth over the past decade or so looks relatively flat and may even be decreasing. This trend has occurred despite the aggressive marketing to youth of many energy drinks that contain high amounts of caffeine. In many ways, the pattern of caffeine use fits with what we know about substance use in general in adolescents, with rates dropping for many commonly used substances – with the exception of cannabis.
 

Effects of caffeine

As many know, caffeine is a stimulant and is known to increase arousal, alertness, and amount of motor behavior. While many youth drink caffeine in an effort to improve cognitive performance, the evidence that it does so directly is modest. There are some studies that show improvements on some cognitive tests when children take moderate doses of caffeine, but these effects tend to be most pronounced for kids who are more naive to caffeine at baseline. Of course, caffeine also can temporarily reduce feelings of fatigue and sleepiness.

Anecdotally, many youth and parents will report that caffeine is a way to “self-medicate” various symptoms of ADHD. While many will report some benefit, there is a surprising lack of rigorous data about the effects of caffeine for youth who meet criteria for ADHD, according to this review.

There also are some well-known negative effects of caffeine use. One of the most important ones is that caffeine can interfere with sleep onset, thereby inducing a cycle that reinforces more caffeine use in the day in an effort to compensate for poor sleep at night. A less obvious negative effect that has been documented is that caffeine added to sweetened beverages can increase consumption of similar sugary foods, even if they don’t have caffeine.

A number of adverse effects have been observed when youth consume caffeine at excessive doses, which tend to be around a threshold of 400 mg/day for teens and about 100 mg/day for younger children. These can include both behavioral and nonbehavioral changes such as agitation or irritability, anxiety, heart arrhythmias, and hypertension. Concern over high caffeine intake also was raised in relation to a number of cases of sudden death, although these events fortunately are rare. The review mentions that one factor that could increase the risk of a serious medical event related to caffeine use is the presence of an underlying cardiac problem which may go undetected until a negative outcome occurs. In thinking about these risks associated with “excessive” caffeine consumption, it can be important to go back to the guides and see just how easily an adolescent can get to a level of 400 mg or more. A couple large cups of coffee per day or two to three specific “energy-boosting” products can be all that it takes.

There also are a few large longitudinal studies that have shown a significant association between increased caffeine consumption and future problems with anger, aggression, risky sexual behavior, and substance use. Energy drinks, which can deliver a lot of caffeine quickly, were singled out as particularly problematic in some of these studies, although these naturalistic studies are unable to determine causation, and it also is possible that teens who are already prone towards behavioral problems tend to consume more caffeine. However, the review also mentions animal studies that have demonstrated that caffeine may prime the brain to use other substances like amphetamines or cocaine. Finally, another concern raised about energy drinks in particular is that they also often contain other substances which may have similar physiological effects but are relatively untested when it comes to safety.
 

Conclusions

This review, like the current position of the Food and Drug Administration, considers caffeine as generally safe at low doses because there does not appear to be much evidence that low or moderate use in youth leads to significant problems. The conclusion changes, however, with higher levels of consumption, as more frequent and more serious risks are encountered. The article recommends that both parents and doctors be more vigilant in monitoring the amount of caffeine that a child consumes as well as the timing of that use during the day. Some quick calculations can be done to give adolescents and their parents an estimate of their caffeine use in milligrams. And while caffeine may not rise to the level of public health concern as substances like opiates or alcohol, there is evidence that it can cause some real problems in children and teens, especially in higher amounts, and thus shouldn’t be given a total pass by parents and doctors alike.

Dr. Rettew is a child and adolescent psychiatrist and associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. Email him at pdnews@mdedge.com. Follow him on Twitter @PediPsych. Looking for more mental health training? Attend the 13th annual Child Psychiatry in Primary Care conference in Burlington, Vt., May 3, 2019 (http://www.med.uvm.edu/cme/conferences).

Less clinical attention has been paid to caffeine lately as the medical community works to overcome the negative effects of substances such as opiates and cannabis. Quietly, however, caffeine continues to be widely consumed among children and adolescents, and its use often flies under the radar for pediatricians who have so many other topics to address. To help clinicians decide whether more focus on caffeine use is needed, a review was published in the Journal of the American Academy of Child & Adolescent Psychiatry (2019;58[1]:36-45). A synopsis of this paper which summarizes 90 individual studies on caffeine use in children and adolescents is provided here.

MonthiraYodtiwong/Thinkstock

Caffeine usage in children and adolescents

Caffeine continues to be one of the most commonly used substances in youth, with about 75% of older children and adolescents consuming it regularly, often at an average dose of about 25 mg/day for children aged 6-11 years and 50 mg/day for adolescents. Because most people have trouble quickly converting commonly used products into milligrams of caffeine, the following guide can be useful:

• Soda (12 oz). About 40 mg caffeine.
• Coffee (8 oz). About 100 mg caffeine.
• Tea (8 oz). About 48 mg caffeine.
• Energy drinks (12 oz). About 150 mg caffeine plus, with 5-Hour Energy being around 215 mg caffeine, according to a Consumer Reports study.

It is important to pay attention to the serving size, as the actual volume consumed of products like coffee or soft drinks often are much higher.

With regards to caffeine trends over time, a surprising observation is that total caffeine consumption among youth over the past decade or so looks relatively flat and may even be decreasing. This trend has occurred despite the aggressive marketing to youth of many energy drinks that contain high amounts of caffeine. In many ways, the pattern of caffeine use fits with what we know about substance use in general in adolescents, with rates dropping for many commonly used substances – with the exception of cannabis.
 

Effects of caffeine

As many know, caffeine is a stimulant and is known to increase arousal, alertness, and amount of motor behavior. While many youth drink caffeine in an effort to improve cognitive performance, the evidence that it does so directly is modest. There are some studies that show improvements on some cognitive tests when children take moderate doses of caffeine, but these effects tend to be most pronounced for kids who are more naive to caffeine at baseline. Of course, caffeine also can temporarily reduce feelings of fatigue and sleepiness.

Anecdotally, many youth and parents will report that caffeine is a way to “self-medicate” various symptoms of ADHD. While many will report some benefit, there is a surprising lack of rigorous data about the effects of caffeine for youth who meet criteria for ADHD, according to this review.

There also are some well-known negative effects of caffeine use. One of the most important ones is that caffeine can interfere with sleep onset, thereby inducing a cycle that reinforces more caffeine use in the day in an effort to compensate for poor sleep at night. A less obvious negative effect that has been documented is that caffeine added to sweetened beverages can increase consumption of similar sugary foods, even if they don’t have caffeine.

A number of adverse effects have been observed when youth consume caffeine at excessive doses, which tend to be around a threshold of 400 mg/day for teens and about 100 mg/day for younger children. These can include both behavioral and nonbehavioral changes such as agitation or irritability, anxiety, heart arrhythmias, and hypertension. Concern over high caffeine intake also was raised in relation to a number of cases of sudden death, although these events fortunately are rare. The review mentions that one factor that could increase the risk of a serious medical event related to caffeine use is the presence of an underlying cardiac problem which may go undetected until a negative outcome occurs. In thinking about these risks associated with “excessive” caffeine consumption, it can be important to go back to the guides and see just how easily an adolescent can get to a level of 400 mg or more. A couple large cups of coffee per day or two to three specific “energy-boosting” products can be all that it takes.

There also are a few large longitudinal studies that have shown a significant association between increased caffeine consumption and future problems with anger, aggression, risky sexual behavior, and substance use. Energy drinks, which can deliver a lot of caffeine quickly, were singled out as particularly problematic in some of these studies, although these naturalistic studies are unable to determine causation, and it also is possible that teens who are already prone towards behavioral problems tend to consume more caffeine. However, the review also mentions animal studies that have demonstrated that caffeine may prime the brain to use other substances like amphetamines or cocaine. Finally, another concern raised about energy drinks in particular is that they also often contain other substances which may have similar physiological effects but are relatively untested when it comes to safety.
 

Conclusions

This review, like the current position of the Food and Drug Administration, considers caffeine as generally safe at low doses because there does not appear to be much evidence that low or moderate use in youth leads to significant problems. The conclusion changes, however, with higher levels of consumption, as more frequent and more serious risks are encountered. The article recommends that both parents and doctors be more vigilant in monitoring the amount of caffeine that a child consumes as well as the timing of that use during the day. Some quick calculations can be done to give adolescents and their parents an estimate of their caffeine use in milligrams. And while caffeine may not rise to the level of public health concern as substances like opiates or alcohol, there is evidence that it can cause some real problems in children and teens, especially in higher amounts, and thus shouldn’t be given a total pass by parents and doctors alike.

Dr. Rettew is a child and adolescent psychiatrist and associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. Email him at pdnews@mdedge.com. Follow him on Twitter @PediPsych. Looking for more mental health training? Attend the 13th annual Child Psychiatry in Primary Care conference in Burlington, Vt., May 3, 2019 (http://www.med.uvm.edu/cme/conferences).

Incidence of late-onset disease for group B streptococcus is higher than early-onset disease for infants under 90 days old in the United States, according to a multistate study of invasive group B streptococcal disease published in JAMA Pediatrics.

Janice Haney Carr/CDC

Using data from the Active Bacterial Core surveillance (ABCs) program, Srinivas Acharya Nanduri, MD, MPH, at the Centers for Disease Control and Prevention, and colleagues performed an analysis of early-onset disease (EOD) and late-onset disease (LOD) cases of group B Streptococcus (GBS) in infants from 10 different states between 2006 and 2015, and whether mothers of infants with EOD received intrapartum antibiotic prophylaxis (IAP). EOD was defined as between 0 and 6 days old, while LOD occurred between 7 days and 89 days old.

They found 1,277 cases of EOD and 1,387 cases of LOD in total, with a decrease in incidence of EOD from 0.37 per 1,000 live births in 2006 to 0.23 per 1,000 live births in 2015 (P less than .001); LOD incidence remained stable at a mean 0.31 per 1,000 live births during the same time period.

In 2015, the national burden for EOD and LOD was estimated at 840 and 1,265 cases, respectively. Mothers of infants with EOD did not have indications for and did not receive IAP in 617 cases (48%) and did not receive IAP despite indications in 278 (22%) cases.

“While the current culture-based screening strategy has been highly successful in reducing EOD burden, our data show that almost half of remaining infants with EOD were born to mothers with no indication for receiving IAP,” Dr. Nanduri and colleagues wrote.

Because there currently is no effective prevention strategy against LOS GBS, the investigators wrote that a maternal vaccine against the most common serotypes “holds promise to prevent a substantial portion of this remaining burden,” and noted several GBS candidate vaccines were in advanced stages of development.

The researchers also looked at GBS serotype data in 1,743 patients from seven different centers. The most commonly found serotype isolates of 887 EOD cases were Ia (242 cases, 27%) and III (242 cases, 27%) overall. Serotype III was most common for LOD cases (481 cases, 56%) and increased in incidence from 0.12 per 1,000 live births to 0.20 per 1,000 live births during the study period (P less than .001), while serotype IV was responsible for 53 cases (6%) of both EOD and LOD.

Dr. Nanduri and associates wrote that over 99% of the serotyped EOD (881 cases) and serotyped LOD (853 cases) cases were caused by serotypes Ia, Ib, II, III, IV, and V. With regard to antimicrobial resistance, there were no cases of beta-lactam resistance, but there was constitutive clindamycin resistance in 359 isolate test results (21%).

The researchers noted that they were limited in the study by 1 year of whole-genome sequencing data, the ABCs capturing only 10% of live birth data in the United States, and conclusions on EOD prevention restricted to data from labor and delivery records.

This study was funded in part by the CDC. Paula S. Vagnone received grants from the CDC, while William S. Schaffner, MD, received grants from the CDC and personal fees from Pfizer, Merck, SutroVax, Shionogi, Dynavax, and Seqirus outside of the study. The other authors reported no relevant disclosures.

SOURCE: Nanduri SA et al. JAMA Pediatr. 2019 Jan 14. doi: 10.1001/jamapediatrics.2018.4826.

Incidence of late-onset disease for group B streptococcus is higher than early-onset disease for infants under 90 days old in the United States, according to a multistate study of invasive group B streptococcal disease published in JAMA Pediatrics.

Janice Haney Carr/CDC

Using data from the Active Bacterial Core surveillance (ABCs) program, Srinivas Acharya Nanduri, MD, MPH, at the Centers for Disease Control and Prevention, and colleagues performed an analysis of early-onset disease (EOD) and late-onset disease (LOD) cases of group B Streptococcus (GBS) in infants from 10 different states between 2006 and 2015, and whether mothers of infants with EOD received intrapartum antibiotic prophylaxis (IAP). EOD was defined as between 0 and 6 days old, while LOD occurred between 7 days and 89 days old.

They found 1,277 cases of EOD and 1,387 cases of LOD in total, with a decrease in incidence of EOD from 0.37 per 1,000 live births in 2006 to 0.23 per 1,000 live births in 2015 (P less than .001); LOD incidence remained stable at a mean 0.31 per 1,000 live births during the same time period.

In 2015, the national burden for EOD and LOD was estimated at 840 and 1,265 cases, respectively. Mothers of infants with EOD did not have indications for and did not receive IAP in 617 cases (48%) and did not receive IAP despite indications in 278 (22%) cases.

“While the current culture-based screening strategy has been highly successful in reducing EOD burden, our data show that almost half of remaining infants with EOD were born to mothers with no indication for receiving IAP,” Dr. Nanduri and colleagues wrote.

Because there currently is no effective prevention strategy against LOS GBS, the investigators wrote that a maternal vaccine against the most common serotypes “holds promise to prevent a substantial portion of this remaining burden,” and noted several GBS candidate vaccines were in advanced stages of development.

The researchers also looked at GBS serotype data in 1,743 patients from seven different centers. The most commonly found serotype isolates of 887 EOD cases were Ia (242 cases, 27%) and III (242 cases, 27%) overall. Serotype III was most common for LOD cases (481 cases, 56%) and increased in incidence from 0.12 per 1,000 live births to 0.20 per 1,000 live births during the study period (P less than .001), while serotype IV was responsible for 53 cases (6%) of both EOD and LOD.

Dr. Nanduri and associates wrote that over 99% of the serotyped EOD (881 cases) and serotyped LOD (853 cases) cases were caused by serotypes Ia, Ib, II, III, IV, and V. With regard to antimicrobial resistance, there were no cases of beta-lactam resistance, but there was constitutive clindamycin resistance in 359 isolate test results (21%).

The researchers noted that they were limited in the study by 1 year of whole-genome sequencing data, the ABCs capturing only 10% of live birth data in the United States, and conclusions on EOD prevention restricted to data from labor and delivery records.

This study was funded in part by the CDC. Paula S. Vagnone received grants from the CDC, while William S. Schaffner, MD, received grants from the CDC and personal fees from Pfizer, Merck, SutroVax, Shionogi, Dynavax, and Seqirus outside of the study. The other authors reported no relevant disclosures.

SOURCE: Nanduri SA et al. JAMA Pediatr. 2019 Jan 14. doi: 10.1001/jamapediatrics.2018.4826.

Incidence of late-onset disease for group B streptococcus is higher than early-onset disease for infants under 90 days old in the United States, according to a multistate study of invasive group B streptococcal disease published in JAMA Pediatrics.

Janice Haney Carr/CDC

Using data from the Active Bacterial Core surveillance (ABCs) program, Srinivas Acharya Nanduri, MD, MPH, at the Centers for Disease Control and Prevention, and colleagues performed an analysis of early-onset disease (EOD) and late-onset disease (LOD) cases of group B Streptococcus (GBS) in infants from 10 different states between 2006 and 2015, and whether mothers of infants with EOD received intrapartum antibiotic prophylaxis (IAP). EOD was defined as between 0 and 6 days old, while LOD occurred between 7 days and 89 days old.

They found 1,277 cases of EOD and 1,387 cases of LOD in total, with a decrease in incidence of EOD from 0.37 per 1,000 live births in 2006 to 0.23 per 1,000 live births in 2015 (P less than .001); LOD incidence remained stable at a mean 0.31 per 1,000 live births during the same time period.

In 2015, the national burden for EOD and LOD was estimated at 840 and 1,265 cases, respectively. Mothers of infants with EOD did not have indications for and did not receive IAP in 617 cases (48%) and did not receive IAP despite indications in 278 (22%) cases.

“While the current culture-based screening strategy has been highly successful in reducing EOD burden, our data show that almost half of remaining infants with EOD were born to mothers with no indication for receiving IAP,” Dr. Nanduri and colleagues wrote.

Because there currently is no effective prevention strategy against LOS GBS, the investigators wrote that a maternal vaccine against the most common serotypes “holds promise to prevent a substantial portion of this remaining burden,” and noted several GBS candidate vaccines were in advanced stages of development.

The researchers also looked at GBS serotype data in 1,743 patients from seven different centers. The most commonly found serotype isolates of 887 EOD cases were Ia (242 cases, 27%) and III (242 cases, 27%) overall. Serotype III was most common for LOD cases (481 cases, 56%) and increased in incidence from 0.12 per 1,000 live births to 0.20 per 1,000 live births during the study period (P less than .001), while serotype IV was responsible for 53 cases (6%) of both EOD and LOD.

Dr. Nanduri and associates wrote that over 99% of the serotyped EOD (881 cases) and serotyped LOD (853 cases) cases were caused by serotypes Ia, Ib, II, III, IV, and V. With regard to antimicrobial resistance, there were no cases of beta-lactam resistance, but there was constitutive clindamycin resistance in 359 isolate test results (21%).

The researchers noted that they were limited in the study by 1 year of whole-genome sequencing data, the ABCs capturing only 10% of live birth data in the United States, and conclusions on EOD prevention restricted to data from labor and delivery records.

This study was funded in part by the CDC. Paula S. Vagnone received grants from the CDC, while William S. Schaffner, MD, received grants from the CDC and personal fees from Pfizer, Merck, SutroVax, Shionogi, Dynavax, and Seqirus outside of the study. The other authors reported no relevant disclosures.

SOURCE: Nanduri SA et al. JAMA Pediatr. 2019 Jan 14. doi: 10.1001/jamapediatrics.2018.4826.

I suspect, like me, you have never put much stock in astrology. It just doesn’t feel like a good fit with our science-based training. But recent evidence suggests that maybe we should be paying more attention to the whether our patient is a Taurus or a Leo when we are hunting for a diagnosis.

patchareeporn_s/Getty Images

Three researchers from Harvard’s Schools of Medicine and Public Health have followed several hundred thousand children born between 2007 and 2009 until 2016 (“Attention deficit–hyperactivity disorder and month of school enrollment,” N Engl J Med. 2018;379:2122-30). Their data revealed that, in states with a Sept. 1 school entry cutoff, children born in August had rates of diagnosis and treatment of ADHD that were 34% higher than those born in other months.

Their findings could mean that astrology deserves a lot more credibility than we have been giving it. More likely it suggests that those of us committed to the health and education of children deserve a booby prize for objectivity. In a New York Times Op-Ed piece, the study’s investigators point out that their data show that the relative immaturity of the youngest children in a class too often is interpreted as a symptom of ADHD (“The Link Between August Birthdays and ADHD,” 2018 Nov 28. Jena AB et al.).

For many of us who practiced pediatrics before the ADHD phenomenon erupted, this new study substantiates our suspicion that the condition is currently being both overdiagnosed and overtreated. The data leave unanswered the question of whom or what is to blame for starting the epidemic. However, the study does suggest that physicians and educators deserve some culpability by failing to maintain their objectivity when interpreting childhood behavior.

I clearly can recall the first time I spoke to a group of teachers about the articles I had been reading that suggested a beneficial effect of treating “hyperactive” children with stimulant medication. The teachers uniformly were incredulous and repulsed by the counterintuitive notion of medicating children whom they saw as difficult, but not out of the broad range of age and developmental maturity they could expect to see in their classrooms.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@mdedge.com.

I suspect, like me, you have never put much stock in astrology. It just doesn’t feel like a good fit with our science-based training. But recent evidence suggests that maybe we should be paying more attention to the whether our patient is a Taurus or a Leo when we are hunting for a diagnosis.

patchareeporn_s/Getty Images

Three researchers from Harvard’s Schools of Medicine and Public Health have followed several hundred thousand children born between 2007 and 2009 until 2016 (“Attention deficit–hyperactivity disorder and month of school enrollment,” N Engl J Med. 2018;379:2122-30). Their data revealed that, in states with a Sept. 1 school entry cutoff, children born in August had rates of diagnosis and treatment of ADHD that were 34% higher than those born in other months.

Their findings could mean that astrology deserves a lot more credibility than we have been giving it. More likely it suggests that those of us committed to the health and education of children deserve a booby prize for objectivity. In a New York Times Op-Ed piece, the study’s investigators point out that their data show that the relative immaturity of the youngest children in a class too often is interpreted as a symptom of ADHD (“The Link Between August Birthdays and ADHD,” 2018 Nov 28. Jena AB et al.).

For many of us who practiced pediatrics before the ADHD phenomenon erupted, this new study substantiates our suspicion that the condition is currently being both overdiagnosed and overtreated. The data leave unanswered the question of whom or what is to blame for starting the epidemic. However, the study does suggest that physicians and educators deserve some culpability by failing to maintain their objectivity when interpreting childhood behavior.

I clearly can recall the first time I spoke to a group of teachers about the articles I had been reading that suggested a beneficial effect of treating “hyperactive” children with stimulant medication. The teachers uniformly were incredulous and repulsed by the counterintuitive notion of medicating children whom they saw as difficult, but not out of the broad range of age and developmental maturity they could expect to see in their classrooms.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@mdedge.com.

I suspect, like me, you have never put much stock in astrology. It just doesn’t feel like a good fit with our science-based training. But recent evidence suggests that maybe we should be paying more attention to the whether our patient is a Taurus or a Leo when we are hunting for a diagnosis.

patchareeporn_s/Getty Images

Three researchers from Harvard’s Schools of Medicine and Public Health have followed several hundred thousand children born between 2007 and 2009 until 2016 (“Attention deficit–hyperactivity disorder and month of school enrollment,” N Engl J Med. 2018;379:2122-30). Their data revealed that, in states with a Sept. 1 school entry cutoff, children born in August had rates of diagnosis and treatment of ADHD that were 34% higher than those born in other months.

Their findings could mean that astrology deserves a lot more credibility than we have been giving it. More likely it suggests that those of us committed to the health and education of children deserve a booby prize for objectivity. In a New York Times Op-Ed piece, the study’s investigators point out that their data show that the relative immaturity of the youngest children in a class too often is interpreted as a symptom of ADHD (“The Link Between August Birthdays and ADHD,” 2018 Nov 28. Jena AB et al.).

For many of us who practiced pediatrics before the ADHD phenomenon erupted, this new study substantiates our suspicion that the condition is currently being both overdiagnosed and overtreated. The data leave unanswered the question of whom or what is to blame for starting the epidemic. However, the study does suggest that physicians and educators deserve some culpability by failing to maintain their objectivity when interpreting childhood behavior.

I clearly can recall the first time I spoke to a group of teachers about the articles I had been reading that suggested a beneficial effect of treating “hyperactive” children with stimulant medication. The teachers uniformly were incredulous and repulsed by the counterintuitive notion of medicating children whom they saw as difficult, but not out of the broad range of age and developmental maturity they could expect to see in their classrooms.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@mdedge.com.

We are in the middle of flu season, and many of our patients are coughing. Is it the flu or might the child have a secondary bacterial pneumonia? Let’s start with the history for a tip off. The course of flu and respiratory viral infections in general involves a typical pattern of timing for fever and cough.

DavidWhalen/Thinkstock

A late-developing fever or fever that subsides then recurs should raise concern. A prolonged cough or cough that subsides then recurs also should raise concern. The respiratory rate and chest retractions are key physical findings that can aid in distinguishing children with bacterial pneumonia. Rales and decreased breath sounds in lung segments are best heard with deep breaths.

What diagnostic laboratory and imaging tests should be used

Fortunately, rapid tests to detect influenza are available, and many providers have added those to their laboratory evaluation. A complete blood count and differential may be helpful. If a pulse oximeter is available, checking oxygen saturation might be helpful. The American Academy of Pediatrics community pneumonia guideline states that routine chest radiographs are not necessary for the confirmation of suspected community-acquired pneumonia (CAP) in patients well enough to be treated in the outpatient setting (Clin Inf Dis. 2011 Oct;53[7]:e25–e76). Blood cultures should not be performed routinely in nontoxic, fully immunized children with CAP managed in the outpatient setting.

What antibiotic should be used

Antimicrobial therapy is not routinely required for preschool-aged children with cough, even cough caused by CAP, because viral pathogens are responsible for the great majority of clinical disease. If the diagnosis of CAP is made, the AAP endorses amoxicillin as first-line therapy for previously healthy, appropriately immunized infants and preschool children with mild to moderate CAP suspected to be of bacterial origin. For previously healthy, appropriately immunized school-aged children and adolescents with mild to moderate CAP, amoxicillin is recommended for treatment of Streptococcus pneumoniae, the most prominent invasive bacterial pathogen.

However, the treatment paradigm is complicated because Mycoplasma pneumoniae also should be considered in management decisions. Children with signs and symptoms suspicious for M. pneumoniae should be tested to help guide antibiotic selection. This may be a simple bedside cold agglutinin test. The highest incidence of Mycoplasma pneumonia is in 5- to 20-year-olds (51% in 5- to 9-year-olds, 74% in 9- to 15-year-olds, and 3%-18% in adults with pneumonia), but 9% of CAP occurs in patients younger than 5 years old. The clinical features of Mycoplasma pneumonia resemble influenza: The patient has gradual onset of headache, malaise, fever, sore throat, and cough. Mycoplasma pneumonia has a similar incidence of productive cough, rales, and diarrhea as pneumococcal CAP, but with more frequent upper respiratory symptoms and a normal leukocyte count. Mycoplasma bronchopneumonia occurs 30 times more frequently than Mycoplasma lobar pneumonia. The radiologic features of Mycoplasma is typical of a bronchopneumonia, usually involving a single lobe, subsegmental atelectasis, peribronchial thickening, and streaky interstitial densities. While Mycoplasma pneumonia is usually self-limited, the duration of illness is shortened by oral treatment with doxycycline, erythromycin, clarithromycin, or azithromycin.
 

What is the appropriate duration of antimicrobial therapy

Recommendations by the AAP for CAP note that treatment courses of 10 days have been best studied, although shorter courses may be just as effective, particularly for mild disease managed on an outpatient basis.

When should children be hospitalized

Dr. Pichichero is a specialist in pediatric infectious diseases and director of the Research Institute at Rochester (N.Y.) General Hospital. He had no conflicts to declare. Email him at pdnews@mdedge.com.

We are in the middle of flu season, and many of our patients are coughing. Is it the flu or might the child have a secondary bacterial pneumonia? Let’s start with the history for a tip off. The course of flu and respiratory viral infections in general involves a typical pattern of timing for fever and cough.

DavidWhalen/Thinkstock

A late-developing fever or fever that subsides then recurs should raise concern. A prolonged cough or cough that subsides then recurs also should raise concern. The respiratory rate and chest retractions are key physical findings that can aid in distinguishing children with bacterial pneumonia. Rales and decreased breath sounds in lung segments are best heard with deep breaths.

What diagnostic laboratory and imaging tests should be used

Fortunately, rapid tests to detect influenza are available, and many providers have added those to their laboratory evaluation. A complete blood count and differential may be helpful. If a pulse oximeter is available, checking oxygen saturation might be helpful. The American Academy of Pediatrics community pneumonia guideline states that routine chest radiographs are not necessary for the confirmation of suspected community-acquired pneumonia (CAP) in patients well enough to be treated in the outpatient setting (Clin Inf Dis. 2011 Oct;53[7]:e25–e76). Blood cultures should not be performed routinely in nontoxic, fully immunized children with CAP managed in the outpatient setting.

What antibiotic should be used

Antimicrobial therapy is not routinely required for preschool-aged children with cough, even cough caused by CAP, because viral pathogens are responsible for the great majority of clinical disease. If the diagnosis of CAP is made, the AAP endorses amoxicillin as first-line therapy for previously healthy, appropriately immunized infants and preschool children with mild to moderate CAP suspected to be of bacterial origin. For previously healthy, appropriately immunized school-aged children and adolescents with mild to moderate CAP, amoxicillin is recommended for treatment of Streptococcus pneumoniae, the most prominent invasive bacterial pathogen.

However, the treatment paradigm is complicated because Mycoplasma pneumoniae also should be considered in management decisions. Children with signs and symptoms suspicious for M. pneumoniae should be tested to help guide antibiotic selection. This may be a simple bedside cold agglutinin test. The highest incidence of Mycoplasma pneumonia is in 5- to 20-year-olds (51% in 5- to 9-year-olds, 74% in 9- to 15-year-olds, and 3%-18% in adults with pneumonia), but 9% of CAP occurs in patients younger than 5 years old. The clinical features of Mycoplasma pneumonia resemble influenza: The patient has gradual onset of headache, malaise, fever, sore throat, and cough. Mycoplasma pneumonia has a similar incidence of productive cough, rales, and diarrhea as pneumococcal CAP, but with more frequent upper respiratory symptoms and a normal leukocyte count. Mycoplasma bronchopneumonia occurs 30 times more frequently than Mycoplasma lobar pneumonia. The radiologic features of Mycoplasma is typical of a bronchopneumonia, usually involving a single lobe, subsegmental atelectasis, peribronchial thickening, and streaky interstitial densities. While Mycoplasma pneumonia is usually self-limited, the duration of illness is shortened by oral treatment with doxycycline, erythromycin, clarithromycin, or azithromycin.
 

What is the appropriate duration of antimicrobial therapy

Recommendations by the AAP for CAP note that treatment courses of 10 days have been best studied, although shorter courses may be just as effective, particularly for mild disease managed on an outpatient basis.

When should children be hospitalized

Dr. Pichichero is a specialist in pediatric infectious diseases and director of the Research Institute at Rochester (N.Y.) General Hospital. He had no conflicts to declare. Email him at pdnews@mdedge.com.

We are in the middle of flu season, and many of our patients are coughing. Is it the flu or might the child have a secondary bacterial pneumonia? Let’s start with the history for a tip off. The course of flu and respiratory viral infections in general involves a typical pattern of timing for fever and cough.

DavidWhalen/Thinkstock

A late-developing fever or fever that subsides then recurs should raise concern. A prolonged cough or cough that subsides then recurs also should raise concern. The respiratory rate and chest retractions are key physical findings that can aid in distinguishing children with bacterial pneumonia. Rales and decreased breath sounds in lung segments are best heard with deep breaths.

What diagnostic laboratory and imaging tests should be used

Fortunately, rapid tests to detect influenza are available, and many providers have added those to their laboratory evaluation. A complete blood count and differential may be helpful. If a pulse oximeter is available, checking oxygen saturation might be helpful. The American Academy of Pediatrics community pneumonia guideline states that routine chest radiographs are not necessary for the confirmation of suspected community-acquired pneumonia (CAP) in patients well enough to be treated in the outpatient setting (Clin Inf Dis. 2011 Oct;53[7]:e25–e76). Blood cultures should not be performed routinely in nontoxic, fully immunized children with CAP managed in the outpatient setting.

What antibiotic should be used

Antimicrobial therapy is not routinely required for preschool-aged children with cough, even cough caused by CAP, because viral pathogens are responsible for the great majority of clinical disease. If the diagnosis of CAP is made, the AAP endorses amoxicillin as first-line therapy for previously healthy, appropriately immunized infants and preschool children with mild to moderate CAP suspected to be of bacterial origin. For previously healthy, appropriately immunized school-aged children and adolescents with mild to moderate CAP, amoxicillin is recommended for treatment of Streptococcus pneumoniae, the most prominent invasive bacterial pathogen.

However, the treatment paradigm is complicated because Mycoplasma pneumoniae also should be considered in management decisions. Children with signs and symptoms suspicious for M. pneumoniae should be tested to help guide antibiotic selection. This may be a simple bedside cold agglutinin test. The highest incidence of Mycoplasma pneumonia is in 5- to 20-year-olds (51% in 5- to 9-year-olds, 74% in 9- to 15-year-olds, and 3%-18% in adults with pneumonia), but 9% of CAP occurs in patients younger than 5 years old. The clinical features of Mycoplasma pneumonia resemble influenza: The patient has gradual onset of headache, malaise, fever, sore throat, and cough. Mycoplasma pneumonia has a similar incidence of productive cough, rales, and diarrhea as pneumococcal CAP, but with more frequent upper respiratory symptoms and a normal leukocyte count. Mycoplasma bronchopneumonia occurs 30 times more frequently than Mycoplasma lobar pneumonia. The radiologic features of Mycoplasma is typical of a bronchopneumonia, usually involving a single lobe, subsegmental atelectasis, peribronchial thickening, and streaky interstitial densities. While Mycoplasma pneumonia is usually self-limited, the duration of illness is shortened by oral treatment with doxycycline, erythromycin, clarithromycin, or azithromycin.
 

What is the appropriate duration of antimicrobial therapy

Recommendations by the AAP for CAP note that treatment courses of 10 days have been best studied, although shorter courses may be just as effective, particularly for mild disease managed on an outpatient basis.

When should children be hospitalized

Dr. Pichichero is a specialist in pediatric infectious diseases and director of the Research Institute at Rochester (N.Y.) General Hospital. He had no conflicts to declare. Email him at pdnews@mdedge.com.

“Parenthood in the United States has become much more demanding than it used to be.” It is hard to argue with this opening sentence in Clair Cain Miller’s op-ed piece titled “The Relentlessness of Modern Parenting,” published in the Dec. 25, 2018, electronic edition of the New York Times. But just in case you don’t agree with her premise, she lays out her case with evidence that parents in this country are investing more time, attention, and money into raising their children than was the norm several decades ago. She goes on to describe how this “intensive parenting” is taking its toll on parents on both sides of our nation’s widening economic divide. I’m sure you have seen it in your office in the tired faces and stooped shoulders of your patients’ parents. You may even be struggling yourself to find the time and energy to be the parent you believe your children need and deserve.

ftwitty/Getty Images

While there is debate on whether “parent” is inherently a verb or a noun (“Parent is a Noun, Not a Verb,” Cliff Price, the Australian Family Association; “Parent is a Verb – and we All do it,” Zaeli Kane, mother.ly), it is clear that “parenting” used as a verb has become one of the hot topics in pediatrics over the last quarter century and with it an epidemic of parental anxiety. What are the driving forces behind this shift in attitude? How has a relatively relaxed nature-will-take-its-course philosophy become an anxiety-provoking, stress-inducing phenomenon that will inevitably result in a disturbed and disappointed adult without a parent’s relentless attention to creating a nurturing and optimally stimulating environment?

Of course, parents have always worried about the health of their children and hope that they will be successful, regardless of how one defines success. But this natural parental concern seems to have gotten out of hand.

Is it because North Americans are having fewer children? Is it because in smaller families children become adults with little or no practical experience with hands-on child rearing? Are parents reacting to the predictions that the next generation may not be able to earn enough to match their parents’ lifestyle?

How much blame should fall on those of us who market ourselves as child health experts? Have we failed to put the research supporting the importance of early life experiences in the proper perspective? Are our recommendations creating unrealistic goals for parents? The American Academy of Pediatrics advice on breastfeeding duration and room sharing come to mind immediately. How realistic is it for parents to coview the majority of television shows their children are watching?

On one hand, we are beginning to realize that free play is important, but for years pediatricians have been one of the loudest voices supporting playground and toy safety. These two initiatives can certainly coexist, but I fear that at times we have begun to sound a bit like that annoying parent who is constantly warning his or her child, “Don’t do that, you’ll hurt yourself?”

Have we become the worry merchants? As a marketing strategy it seems to be working well. If we generate enough advice that supports an intensive parenting style, we can fill our waiting rooms with families struggling to meet the expectations we have been promoting.

A child can thrive without intensive parenting as long as he feels loved and he has been provided an environment with sensible limits to keep him safe. It is our job to help parents create that child-friendly discipline structure and then encourage them to step back.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@mdedge.com.

“Parenthood in the United States has become much more demanding than it used to be.” It is hard to argue with this opening sentence in Clair Cain Miller’s op-ed piece titled “The Relentlessness of Modern Parenting,” published in the Dec. 25, 2018, electronic edition of the New York Times. But just in case you don’t agree with her premise, she lays out her case with evidence that parents in this country are investing more time, attention, and money into raising their children than was the norm several decades ago. She goes on to describe how this “intensive parenting” is taking its toll on parents on both sides of our nation’s widening economic divide. I’m sure you have seen it in your office in the tired faces and stooped shoulders of your patients’ parents. You may even be struggling yourself to find the time and energy to be the parent you believe your children need and deserve.

ftwitty/Getty Images

While there is debate on whether “parent” is inherently a verb or a noun (“Parent is a Noun, Not a Verb,” Cliff Price, the Australian Family Association; “Parent is a Verb – and we All do it,” Zaeli Kane, mother.ly), it is clear that “parenting” used as a verb has become one of the hot topics in pediatrics over the last quarter century and with it an epidemic of parental anxiety. What are the driving forces behind this shift in attitude? How has a relatively relaxed nature-will-take-its-course philosophy become an anxiety-provoking, stress-inducing phenomenon that will inevitably result in a disturbed and disappointed adult without a parent’s relentless attention to creating a nurturing and optimally stimulating environment?

Of course, parents have always worried about the health of their children and hope that they will be successful, regardless of how one defines success. But this natural parental concern seems to have gotten out of hand.

Is it because North Americans are having fewer children? Is it because in smaller families children become adults with little or no practical experience with hands-on child rearing? Are parents reacting to the predictions that the next generation may not be able to earn enough to match their parents’ lifestyle?

How much blame should fall on those of us who market ourselves as child health experts? Have we failed to put the research supporting the importance of early life experiences in the proper perspective? Are our recommendations creating unrealistic goals for parents? The American Academy of Pediatrics advice on breastfeeding duration and room sharing come to mind immediately. How realistic is it for parents to coview the majority of television shows their children are watching?

On one hand, we are beginning to realize that free play is important, but for years pediatricians have been one of the loudest voices supporting playground and toy safety. These two initiatives can certainly coexist, but I fear that at times we have begun to sound a bit like that annoying parent who is constantly warning his or her child, “Don’t do that, you’ll hurt yourself?”

Have we become the worry merchants? As a marketing strategy it seems to be working well. If we generate enough advice that supports an intensive parenting style, we can fill our waiting rooms with families struggling to meet the expectations we have been promoting.

A child can thrive without intensive parenting as long as he feels loved and he has been provided an environment with sensible limits to keep him safe. It is our job to help parents create that child-friendly discipline structure and then encourage them to step back.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@mdedge.com.

“Parenthood in the United States has become much more demanding than it used to be.” It is hard to argue with this opening sentence in Clair Cain Miller’s op-ed piece titled “The Relentlessness of Modern Parenting,” published in the Dec. 25, 2018, electronic edition of the New York Times. But just in case you don’t agree with her premise, she lays out her case with evidence that parents in this country are investing more time, attention, and money into raising their children than was the norm several decades ago. She goes on to describe how this “intensive parenting” is taking its toll on parents on both sides of our nation’s widening economic divide. I’m sure you have seen it in your office in the tired faces and stooped shoulders of your patients’ parents. You may even be struggling yourself to find the time and energy to be the parent you believe your children need and deserve.

ftwitty/Getty Images

While there is debate on whether “parent” is inherently a verb or a noun (“Parent is a Noun, Not a Verb,” Cliff Price, the Australian Family Association; “Parent is a Verb – and we All do it,” Zaeli Kane, mother.ly), it is clear that “parenting” used as a verb has become one of the hot topics in pediatrics over the last quarter century and with it an epidemic of parental anxiety. What are the driving forces behind this shift in attitude? How has a relatively relaxed nature-will-take-its-course philosophy become an anxiety-provoking, stress-inducing phenomenon that will inevitably result in a disturbed and disappointed adult without a parent’s relentless attention to creating a nurturing and optimally stimulating environment?

Of course, parents have always worried about the health of their children and hope that they will be successful, regardless of how one defines success. But this natural parental concern seems to have gotten out of hand.

Is it because North Americans are having fewer children? Is it because in smaller families children become adults with little or no practical experience with hands-on child rearing? Are parents reacting to the predictions that the next generation may not be able to earn enough to match their parents’ lifestyle?

How much blame should fall on those of us who market ourselves as child health experts? Have we failed to put the research supporting the importance of early life experiences in the proper perspective? Are our recommendations creating unrealistic goals for parents? The American Academy of Pediatrics advice on breastfeeding duration and room sharing come to mind immediately. How realistic is it for parents to coview the majority of television shows their children are watching?

On one hand, we are beginning to realize that free play is important, but for years pediatricians have been one of the loudest voices supporting playground and toy safety. These two initiatives can certainly coexist, but I fear that at times we have begun to sound a bit like that annoying parent who is constantly warning his or her child, “Don’t do that, you’ll hurt yourself?”

Have we become the worry merchants? As a marketing strategy it seems to be working well. If we generate enough advice that supports an intensive parenting style, we can fill our waiting rooms with families struggling to meet the expectations we have been promoting.

A child can thrive without intensive parenting as long as he feels loved and he has been provided an environment with sensible limits to keep him safe. It is our job to help parents create that child-friendly discipline structure and then encourage them to step back.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@mdedge.com.