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New research in otitis media means new controversies
SAN FRANCISCO – As researchers have learned more about otitis media in the past decade, the guidelines have shifted accordingly for one of the most common conditions of childhood.
Yet some controversies remain, and the condition remains a challenge to properly identify, David Conrad, MD, of the University of California, San Francisco, said at the annual meeting of the American Academy of Pediatrics.
Pediatricians already know it’s the most common reason young children come into their offices and the most common reason they prescribe antibiotics. But they may know less about recognizing complications and long-term effects.
Complications and treatment
Ossicular erosion or tympanic membrane perforation are two complications; the latter’s rate is 5%-29% for untreated acute otitis media. It typically closes within hours to days, however, with a 95% closure rate within 4 weeks.
“The ear drum is pretty forgiving, pretty resilient, really,” Dr. Conrad said. The perforation occurs when pressure builds up and takes the path of least resistance through the drum, but that release of pressure also typically relieves the pain.
“Mastoiditis is one of the most feared complications, obviously,” Dr. Conrad noted, and it’s a clinical diagnosis that’s important to distinguish from mastoid effusion.
“Any child who has acute otitis media, and the middle ear fills up with fluid, which is under pressure, it will then migrate up the mastoid cavity; so, if you have an ear infection, you will have mastoid fluid – but that doesn’t necessarily mean you have mastoiditis,” he explained. “Mastoiditis is a very aggressive inflammatory process that destroys bone in the mastoid cavity. It’s often due to strep, and it’s usually a pyogenic organism that’s particularly virulent.”
Pus will then leak out from the mastoid cavity and form an abscess. If there is bone destruction, that is mastoiditis, which is treated with an ear tube or sometimes a mastoidectomy, in which a drill drains all the pus and other tissue.
Speech development and other controversies
Aside from the child’s pain, parental anxiety, and the other potential complications, researchers have learned more recently about speech delay with otitis media. The average child with recurrent otitis media or with otitis media with effusion will experience decreased hearing for about 3 or 4 months, which can affect speech, educational, and cognitive outcomes.
“If that process repeats itself, they could lose out on an entire year of not hearing well. It’s like walking around with an ear plug in,” Dr. Conrad said. It’s about a 25-35 dB hearing loss, he said, which can lead to trouble with speech discrimination, particularly with background noise, and can interfere with relationships with family, peers, and other adults.
Emerging data suggest educational difficulties, such as problems with reading comprehension, could result, and research is pivoting to look at potential cognitive development concerns, Dr. Conrad said.
“It has been noted that earlier onset of otitis media has a greater impact on educational and attention outcomes,” he said. Central auditory processing drives the development of the auditory cortex, and if that is impaired during a critical window of opportunity while synapses are forming, it could also have effects on speech.
“Otitis media and speech development is an area of controversy,” Dr. Conrad explained. Otitis media has been found to impact auditory processing skills, speech discrimination, auditory pattern recognition, and auditory temporal processing, “but there’s little evidence to support long-term language impairment,” he said.
But that’s being challenged now. Research in rats and cats in particular, however, has shown changes in the auditory cortex from ear infections.
“Most of the data are from animal models, and I think that will morph into more studies into educational outcomes in children who had a lot of ear infections when they were younger,” Dr. Conrad predicted.
Other areas of controversy relate to whether the use of the pneumococcal conjugate vaccine (PCV13), which has reduced ear infections, may have led to the rise of infections from Haemophilus influenzae and Moraxella catarrhalis, and what the duration of therapy should be for antibiotics.
If not doing watchful waiting, first-line treatment is amoxicillin or amoxicillin-clavulanate unless the child has a penicillin allergy, in which case cefdinir, cefuroxime, or cefpodoxime can be prescribed. After 48-72 hours of failed therapy, amoxicillin-clavulanate can be considered, or clindamycin or ceftriaxone, “obviously a popular option if the child has had multiple ear infections in the past month or so,” he said.
“If the child is older, we don’t treat as long,” Dr. Conrad noted. Current guidelines recommend a 10-day course if the infection resulted from strep, a 7-day or 10-day course in children aged 2-5 years, and a 5-7 day course for children older than 6 years.
Dr. Conrad reported no disclosures.
SAN FRANCISCO – As researchers have learned more about otitis media in the past decade, the guidelines have shifted accordingly for one of the most common conditions of childhood.
Yet some controversies remain, and the condition remains a challenge to properly identify, David Conrad, MD, of the University of California, San Francisco, said at the annual meeting of the American Academy of Pediatrics.
Pediatricians already know it’s the most common reason young children come into their offices and the most common reason they prescribe antibiotics. But they may know less about recognizing complications and long-term effects.
Complications and treatment
Ossicular erosion or tympanic membrane perforation are two complications; the latter’s rate is 5%-29% for untreated acute otitis media. It typically closes within hours to days, however, with a 95% closure rate within 4 weeks.
“The ear drum is pretty forgiving, pretty resilient, really,” Dr. Conrad said. The perforation occurs when pressure builds up and takes the path of least resistance through the drum, but that release of pressure also typically relieves the pain.
“Mastoiditis is one of the most feared complications, obviously,” Dr. Conrad noted, and it’s a clinical diagnosis that’s important to distinguish from mastoid effusion.
“Any child who has acute otitis media, and the middle ear fills up with fluid, which is under pressure, it will then migrate up the mastoid cavity; so, if you have an ear infection, you will have mastoid fluid – but that doesn’t necessarily mean you have mastoiditis,” he explained. “Mastoiditis is a very aggressive inflammatory process that destroys bone in the mastoid cavity. It’s often due to strep, and it’s usually a pyogenic organism that’s particularly virulent.”
Pus will then leak out from the mastoid cavity and form an abscess. If there is bone destruction, that is mastoiditis, which is treated with an ear tube or sometimes a mastoidectomy, in which a drill drains all the pus and other tissue.
Speech development and other controversies
Aside from the child’s pain, parental anxiety, and the other potential complications, researchers have learned more recently about speech delay with otitis media. The average child with recurrent otitis media or with otitis media with effusion will experience decreased hearing for about 3 or 4 months, which can affect speech, educational, and cognitive outcomes.
“If that process repeats itself, they could lose out on an entire year of not hearing well. It’s like walking around with an ear plug in,” Dr. Conrad said. It’s about a 25-35 dB hearing loss, he said, which can lead to trouble with speech discrimination, particularly with background noise, and can interfere with relationships with family, peers, and other adults.
Emerging data suggest educational difficulties, such as problems with reading comprehension, could result, and research is pivoting to look at potential cognitive development concerns, Dr. Conrad said.
“It has been noted that earlier onset of otitis media has a greater impact on educational and attention outcomes,” he said. Central auditory processing drives the development of the auditory cortex, and if that is impaired during a critical window of opportunity while synapses are forming, it could also have effects on speech.
“Otitis media and speech development is an area of controversy,” Dr. Conrad explained. Otitis media has been found to impact auditory processing skills, speech discrimination, auditory pattern recognition, and auditory temporal processing, “but there’s little evidence to support long-term language impairment,” he said.
But that’s being challenged now. Research in rats and cats in particular, however, has shown changes in the auditory cortex from ear infections.
“Most of the data are from animal models, and I think that will morph into more studies into educational outcomes in children who had a lot of ear infections when they were younger,” Dr. Conrad predicted.
Other areas of controversy relate to whether the use of the pneumococcal conjugate vaccine (PCV13), which has reduced ear infections, may have led to the rise of infections from Haemophilus influenzae and Moraxella catarrhalis, and what the duration of therapy should be for antibiotics.
If not doing watchful waiting, first-line treatment is amoxicillin or amoxicillin-clavulanate unless the child has a penicillin allergy, in which case cefdinir, cefuroxime, or cefpodoxime can be prescribed. After 48-72 hours of failed therapy, amoxicillin-clavulanate can be considered, or clindamycin or ceftriaxone, “obviously a popular option if the child has had multiple ear infections in the past month or so,” he said.
“If the child is older, we don’t treat as long,” Dr. Conrad noted. Current guidelines recommend a 10-day course if the infection resulted from strep, a 7-day or 10-day course in children aged 2-5 years, and a 5-7 day course for children older than 6 years.
Dr. Conrad reported no disclosures.
SAN FRANCISCO – As researchers have learned more about otitis media in the past decade, the guidelines have shifted accordingly for one of the most common conditions of childhood.
Yet some controversies remain, and the condition remains a challenge to properly identify, David Conrad, MD, of the University of California, San Francisco, said at the annual meeting of the American Academy of Pediatrics.
Pediatricians already know it’s the most common reason young children come into their offices and the most common reason they prescribe antibiotics. But they may know less about recognizing complications and long-term effects.
Complications and treatment
Ossicular erosion or tympanic membrane perforation are two complications; the latter’s rate is 5%-29% for untreated acute otitis media. It typically closes within hours to days, however, with a 95% closure rate within 4 weeks.
“The ear drum is pretty forgiving, pretty resilient, really,” Dr. Conrad said. The perforation occurs when pressure builds up and takes the path of least resistance through the drum, but that release of pressure also typically relieves the pain.
“Mastoiditis is one of the most feared complications, obviously,” Dr. Conrad noted, and it’s a clinical diagnosis that’s important to distinguish from mastoid effusion.
“Any child who has acute otitis media, and the middle ear fills up with fluid, which is under pressure, it will then migrate up the mastoid cavity; so, if you have an ear infection, you will have mastoid fluid – but that doesn’t necessarily mean you have mastoiditis,” he explained. “Mastoiditis is a very aggressive inflammatory process that destroys bone in the mastoid cavity. It’s often due to strep, and it’s usually a pyogenic organism that’s particularly virulent.”
Pus will then leak out from the mastoid cavity and form an abscess. If there is bone destruction, that is mastoiditis, which is treated with an ear tube or sometimes a mastoidectomy, in which a drill drains all the pus and other tissue.
Speech development and other controversies
Aside from the child’s pain, parental anxiety, and the other potential complications, researchers have learned more recently about speech delay with otitis media. The average child with recurrent otitis media or with otitis media with effusion will experience decreased hearing for about 3 or 4 months, which can affect speech, educational, and cognitive outcomes.
“If that process repeats itself, they could lose out on an entire year of not hearing well. It’s like walking around with an ear plug in,” Dr. Conrad said. It’s about a 25-35 dB hearing loss, he said, which can lead to trouble with speech discrimination, particularly with background noise, and can interfere with relationships with family, peers, and other adults.
Emerging data suggest educational difficulties, such as problems with reading comprehension, could result, and research is pivoting to look at potential cognitive development concerns, Dr. Conrad said.
“It has been noted that earlier onset of otitis media has a greater impact on educational and attention outcomes,” he said. Central auditory processing drives the development of the auditory cortex, and if that is impaired during a critical window of opportunity while synapses are forming, it could also have effects on speech.
“Otitis media and speech development is an area of controversy,” Dr. Conrad explained. Otitis media has been found to impact auditory processing skills, speech discrimination, auditory pattern recognition, and auditory temporal processing, “but there’s little evidence to support long-term language impairment,” he said.
But that’s being challenged now. Research in rats and cats in particular, however, has shown changes in the auditory cortex from ear infections.
“Most of the data are from animal models, and I think that will morph into more studies into educational outcomes in children who had a lot of ear infections when they were younger,” Dr. Conrad predicted.
Other areas of controversy relate to whether the use of the pneumococcal conjugate vaccine (PCV13), which has reduced ear infections, may have led to the rise of infections from Haemophilus influenzae and Moraxella catarrhalis, and what the duration of therapy should be for antibiotics.
If not doing watchful waiting, first-line treatment is amoxicillin or amoxicillin-clavulanate unless the child has a penicillin allergy, in which case cefdinir, cefuroxime, or cefpodoxime can be prescribed. After 48-72 hours of failed therapy, amoxicillin-clavulanate can be considered, or clindamycin or ceftriaxone, “obviously a popular option if the child has had multiple ear infections in the past month or so,” he said.
“If the child is older, we don’t treat as long,” Dr. Conrad noted. Current guidelines recommend a 10-day course if the infection resulted from strep, a 7-day or 10-day course in children aged 2-5 years, and a 5-7 day course for children older than 6 years.
Dr. Conrad reported no disclosures.
Research yields 5 key points about vaccine hesitancy
ATLANTA – While there is no question about the need to address pockets of increasing vaccine refusals, determining how to address it requires a better understanding of the forces underlying vaccine hesitancy.
This area of research is still young, but Glen Nowak, PhD, a visiting communication scientist at the National Vaccine Program Office and director of the Grady College Center for Health & Risk Communication at the University of Georgia in Athens, drew on multiple recent studies and an in-progress review of vaccine hesitancy and confidence literature to distill five key findings from recent research into vaccine hesitancy. He presented that summary at a conference sponsored by the Centers for Disease Control and Prevention.
The first insight: There is a lot of interest in understanding vaccine hesitancy and confidence. But the rub is that many inconsistencies and uncertainties exist, because efforts remain in the early stages of research.
Dr. Nowak referenced the November 2014 report of the World Health Organization’s Strategic Advisory Group of Experts (SAGE) on Immunization to define vaccine hesitancy as the “delay in acceptance or refusal of vaccines despite availability of vaccine services.” But that hesitancy is complex and context specific, varying across time, place, and type of vaccine, the report found.
Those who are hesitant about vaccines are not a homogeneous group, Dr. Nowak said. Their degree of indecision ranges from refusing all vaccines, refusing some and accepting others, or delaying some but not others, to full acceptance of all vaccines despite hesitancy. Their attitudes also vary about vaccination overall and about specific vaccines.
“Vaccines hesitancy is influenced by several factors: complacency, convenience, and confidence,” Dr. Nowak said.
“Generally speaking, the end goal of all of our efforts is vaccine coverage, and before that is vaccine acceptance,” he said. “Before acceptance is hesitancy, and confidence is considered the precursor to hesitancy.” But no clear definition or measure of “vaccine confidence” exists yet.
Dr. Nowak next highlighted the second key finding: that research has identified an association between vaccine hesitancy or vaccine-related hesitancy and vaccine acceptance.
A 2016 study found that scores from the Attitudes about Childhood Vaccines Survey predicted under-immunization in children at 19 months of age, and three studies from 2008 through 2012 found a greater likelihood to delay or refuse vaccines among parents who had vaccine-related doubts.
Focus groups have found that parents who express hesitation or a lack of trust in vaccines also tend to mention using “alternative schedules,” including delaying vaccines or only vaccinating their children with select vaccines instead of all the recommended immunizations.
The third key finding Dr. Nowak discussed returned to the idea of “vaccine confidence,” which has aroused more interest in research but which requires refinement before it can become a truly helpful concept. Studies have already found links between confidence and parents vaccinating their children, but the field lacks standard measures.
“There are all different definitions that are out there, but they have not been measured,” Dr. Nowak said.
For example, the 2015 National Vaccine Advisory Committee report defined vaccine confidence as parents’ or health care providers’ trust in three areas: the immunizations recommended by the CDC’s Advisory Committee on Immunization Practices, the providers who administer the vaccines, and the processes that lead to vaccine licensure and vaccine recommendations.
But other definitions might include having faith that a person will benefit from a vaccine or that they won’t experience harm, or lacking any concerns about potential adverse outcomes.
The fourth key finding of recent research delivered positive news, Dr. Nowak noted: “Vaccines do relatively well compared to other health-related products that parents of young children have to make decisions about, such as antibiotics, over-the-counter medicines and vitamins.”
For example, in one study, the mean score (scale 1-10) of parents’ confidence that their child will not have a bad or serious adverse reaction to a recommended vaccine was 6.6, the same as the confidence level for antibiotics and only slightly below the scores of 6.8 for OTC medications and 7.3 for vitamins. Vaccines and antibiotics tied for the highest score for parents’ confidence in their effectiveness: 7.1, compared with 6.3 for OTC medications and 5.8 for vitamins. And of all four products, parents had the highest faith in vaccines as benefiting their children’s health.
But it was the final finding Dr. Nowak discussed that can present some of the greatest challenges to addressing vaccine hesitancy: Parents’ direct and indirect experiences play a significant role in their confidence about vaccines.
One study found that nearly a quarter of parents reported knowing someone who had a “bad reaction” to a vaccine (aside from soreness, fever, redness, or swelling), compared with 16.7% reporting that someone they knew had a bad reaction to an OTC medication. About one-third of parents reported the same for antibiotics.
Similarly, the measles outbreak at Disneyland in 2015 increased parents’ confidence in the safety and effectiveness of the CDC-recommended childhood vaccination schedule, and in the belief that their child’s health would benefit from receiving all the recommended vaccines.
Dr. Nowak reported no disclosures.
ATLANTA – While there is no question about the need to address pockets of increasing vaccine refusals, determining how to address it requires a better understanding of the forces underlying vaccine hesitancy.
This area of research is still young, but Glen Nowak, PhD, a visiting communication scientist at the National Vaccine Program Office and director of the Grady College Center for Health & Risk Communication at the University of Georgia in Athens, drew on multiple recent studies and an in-progress review of vaccine hesitancy and confidence literature to distill five key findings from recent research into vaccine hesitancy. He presented that summary at a conference sponsored by the Centers for Disease Control and Prevention.
The first insight: There is a lot of interest in understanding vaccine hesitancy and confidence. But the rub is that many inconsistencies and uncertainties exist, because efforts remain in the early stages of research.
Dr. Nowak referenced the November 2014 report of the World Health Organization’s Strategic Advisory Group of Experts (SAGE) on Immunization to define vaccine hesitancy as the “delay in acceptance or refusal of vaccines despite availability of vaccine services.” But that hesitancy is complex and context specific, varying across time, place, and type of vaccine, the report found.
Those who are hesitant about vaccines are not a homogeneous group, Dr. Nowak said. Their degree of indecision ranges from refusing all vaccines, refusing some and accepting others, or delaying some but not others, to full acceptance of all vaccines despite hesitancy. Their attitudes also vary about vaccination overall and about specific vaccines.
“Vaccines hesitancy is influenced by several factors: complacency, convenience, and confidence,” Dr. Nowak said.
“Generally speaking, the end goal of all of our efforts is vaccine coverage, and before that is vaccine acceptance,” he said. “Before acceptance is hesitancy, and confidence is considered the precursor to hesitancy.” But no clear definition or measure of “vaccine confidence” exists yet.
Dr. Nowak next highlighted the second key finding: that research has identified an association between vaccine hesitancy or vaccine-related hesitancy and vaccine acceptance.
A 2016 study found that scores from the Attitudes about Childhood Vaccines Survey predicted under-immunization in children at 19 months of age, and three studies from 2008 through 2012 found a greater likelihood to delay or refuse vaccines among parents who had vaccine-related doubts.
Focus groups have found that parents who express hesitation or a lack of trust in vaccines also tend to mention using “alternative schedules,” including delaying vaccines or only vaccinating their children with select vaccines instead of all the recommended immunizations.
The third key finding Dr. Nowak discussed returned to the idea of “vaccine confidence,” which has aroused more interest in research but which requires refinement before it can become a truly helpful concept. Studies have already found links between confidence and parents vaccinating their children, but the field lacks standard measures.
“There are all different definitions that are out there, but they have not been measured,” Dr. Nowak said.
For example, the 2015 National Vaccine Advisory Committee report defined vaccine confidence as parents’ or health care providers’ trust in three areas: the immunizations recommended by the CDC’s Advisory Committee on Immunization Practices, the providers who administer the vaccines, and the processes that lead to vaccine licensure and vaccine recommendations.
But other definitions might include having faith that a person will benefit from a vaccine or that they won’t experience harm, or lacking any concerns about potential adverse outcomes.
The fourth key finding of recent research delivered positive news, Dr. Nowak noted: “Vaccines do relatively well compared to other health-related products that parents of young children have to make decisions about, such as antibiotics, over-the-counter medicines and vitamins.”
For example, in one study, the mean score (scale 1-10) of parents’ confidence that their child will not have a bad or serious adverse reaction to a recommended vaccine was 6.6, the same as the confidence level for antibiotics and only slightly below the scores of 6.8 for OTC medications and 7.3 for vitamins. Vaccines and antibiotics tied for the highest score for parents’ confidence in their effectiveness: 7.1, compared with 6.3 for OTC medications and 5.8 for vitamins. And of all four products, parents had the highest faith in vaccines as benefiting their children’s health.
But it was the final finding Dr. Nowak discussed that can present some of the greatest challenges to addressing vaccine hesitancy: Parents’ direct and indirect experiences play a significant role in their confidence about vaccines.
One study found that nearly a quarter of parents reported knowing someone who had a “bad reaction” to a vaccine (aside from soreness, fever, redness, or swelling), compared with 16.7% reporting that someone they knew had a bad reaction to an OTC medication. About one-third of parents reported the same for antibiotics.
Similarly, the measles outbreak at Disneyland in 2015 increased parents’ confidence in the safety and effectiveness of the CDC-recommended childhood vaccination schedule, and in the belief that their child’s health would benefit from receiving all the recommended vaccines.
Dr. Nowak reported no disclosures.
ATLANTA – While there is no question about the need to address pockets of increasing vaccine refusals, determining how to address it requires a better understanding of the forces underlying vaccine hesitancy.
This area of research is still young, but Glen Nowak, PhD, a visiting communication scientist at the National Vaccine Program Office and director of the Grady College Center for Health & Risk Communication at the University of Georgia in Athens, drew on multiple recent studies and an in-progress review of vaccine hesitancy and confidence literature to distill five key findings from recent research into vaccine hesitancy. He presented that summary at a conference sponsored by the Centers for Disease Control and Prevention.
The first insight: There is a lot of interest in understanding vaccine hesitancy and confidence. But the rub is that many inconsistencies and uncertainties exist, because efforts remain in the early stages of research.
Dr. Nowak referenced the November 2014 report of the World Health Organization’s Strategic Advisory Group of Experts (SAGE) on Immunization to define vaccine hesitancy as the “delay in acceptance or refusal of vaccines despite availability of vaccine services.” But that hesitancy is complex and context specific, varying across time, place, and type of vaccine, the report found.
Those who are hesitant about vaccines are not a homogeneous group, Dr. Nowak said. Their degree of indecision ranges from refusing all vaccines, refusing some and accepting others, or delaying some but not others, to full acceptance of all vaccines despite hesitancy. Their attitudes also vary about vaccination overall and about specific vaccines.
“Vaccines hesitancy is influenced by several factors: complacency, convenience, and confidence,” Dr. Nowak said.
“Generally speaking, the end goal of all of our efforts is vaccine coverage, and before that is vaccine acceptance,” he said. “Before acceptance is hesitancy, and confidence is considered the precursor to hesitancy.” But no clear definition or measure of “vaccine confidence” exists yet.
Dr. Nowak next highlighted the second key finding: that research has identified an association between vaccine hesitancy or vaccine-related hesitancy and vaccine acceptance.
A 2016 study found that scores from the Attitudes about Childhood Vaccines Survey predicted under-immunization in children at 19 months of age, and three studies from 2008 through 2012 found a greater likelihood to delay or refuse vaccines among parents who had vaccine-related doubts.
Focus groups have found that parents who express hesitation or a lack of trust in vaccines also tend to mention using “alternative schedules,” including delaying vaccines or only vaccinating their children with select vaccines instead of all the recommended immunizations.
The third key finding Dr. Nowak discussed returned to the idea of “vaccine confidence,” which has aroused more interest in research but which requires refinement before it can become a truly helpful concept. Studies have already found links between confidence and parents vaccinating their children, but the field lacks standard measures.
“There are all different definitions that are out there, but they have not been measured,” Dr. Nowak said.
For example, the 2015 National Vaccine Advisory Committee report defined vaccine confidence as parents’ or health care providers’ trust in three areas: the immunizations recommended by the CDC’s Advisory Committee on Immunization Practices, the providers who administer the vaccines, and the processes that lead to vaccine licensure and vaccine recommendations.
But other definitions might include having faith that a person will benefit from a vaccine or that they won’t experience harm, or lacking any concerns about potential adverse outcomes.
The fourth key finding of recent research delivered positive news, Dr. Nowak noted: “Vaccines do relatively well compared to other health-related products that parents of young children have to make decisions about, such as antibiotics, over-the-counter medicines and vitamins.”
For example, in one study, the mean score (scale 1-10) of parents’ confidence that their child will not have a bad or serious adverse reaction to a recommended vaccine was 6.6, the same as the confidence level for antibiotics and only slightly below the scores of 6.8 for OTC medications and 7.3 for vitamins. Vaccines and antibiotics tied for the highest score for parents’ confidence in their effectiveness: 7.1, compared with 6.3 for OTC medications and 5.8 for vitamins. And of all four products, parents had the highest faith in vaccines as benefiting their children’s health.
But it was the final finding Dr. Nowak discussed that can present some of the greatest challenges to addressing vaccine hesitancy: Parents’ direct and indirect experiences play a significant role in their confidence about vaccines.
One study found that nearly a quarter of parents reported knowing someone who had a “bad reaction” to a vaccine (aside from soreness, fever, redness, or swelling), compared with 16.7% reporting that someone they knew had a bad reaction to an OTC medication. About one-third of parents reported the same for antibiotics.
Similarly, the measles outbreak at Disneyland in 2015 increased parents’ confidence in the safety and effectiveness of the CDC-recommended childhood vaccination schedule, and in the belief that their child’s health would benefit from receiving all the recommended vaccines.
Dr. Nowak reported no disclosures.
Pornography warps children’s concept of sex, sexual identity
SAN FRANCISCO – The pornography industry has taken over children’s sense of self and sexuality and warped their concept of what sex and a sexual identity is, said Gail Dines, PhD.
She challenged pediatricians to shape policy and help parents in wrangling back that control in a presentation at the annual meeting of the American Academy of Pediatrics.
The culprit, Dr. Dines charged, is the multibillion-dollar porn industry that exploded around the year 2000 with the Internet. Then, in 2011, the business model shifted to free pornography to hook young boys in their adolescence and hopefully maintain them as customers after age 18 when they could get their own credit cards.
The average age of a boy’s first encounter with pornography is age 11, explained Dr. Dines, a professor of sociology and women’s studies at Wheelock College in Chestnut Hill, Mass.
Instead of a father’s Playboy featuring a naked woman in a cornfield, as many male pediatricians in the room might have been introduced to pornography or sexuality, today’s youth are introduced via the brutalization and dehumanization of women, she said. Such experiences traumatize the children viewing them, who become confused about who they are if they are masturbating to images and video of sexual violence, and then they enter a cycle of retraumatization that engenders shame while bringing children back to those sites again and again.
“Hence, in the business model of free porn, you are building in trauma, which is building in addiction,” Dr. Dines said. The effects of this exposure and addiction, based on decades of research, include limited capacity for intimacy, a greater likelihood of using coercive tactics for sex, decreased empathy for rape victims, increased depression and anxiety, and, most recently, rates of erectile dysfunction in males aged 15-27 that mirror the rates in those aged 27-35.
“We have never brought up boys with access to hard core pornography 24-7,” Dr. Dines said. The best way to tackle hard-core pornography is a public health model that educates parents and pediatricians who can band together to raise awareness. Her organization, Culture Reframed, is attempting to do precisely that.
Dr. Dines founded the nonprofit Culture Reframed, which attempts to counter the effects of the pornography industry and media sexuality. Her presentation used no external funding.
SAN FRANCISCO – The pornography industry has taken over children’s sense of self and sexuality and warped their concept of what sex and a sexual identity is, said Gail Dines, PhD.
She challenged pediatricians to shape policy and help parents in wrangling back that control in a presentation at the annual meeting of the American Academy of Pediatrics.
The culprit, Dr. Dines charged, is the multibillion-dollar porn industry that exploded around the year 2000 with the Internet. Then, in 2011, the business model shifted to free pornography to hook young boys in their adolescence and hopefully maintain them as customers after age 18 when they could get their own credit cards.
The average age of a boy’s first encounter with pornography is age 11, explained Dr. Dines, a professor of sociology and women’s studies at Wheelock College in Chestnut Hill, Mass.
Instead of a father’s Playboy featuring a naked woman in a cornfield, as many male pediatricians in the room might have been introduced to pornography or sexuality, today’s youth are introduced via the brutalization and dehumanization of women, she said. Such experiences traumatize the children viewing them, who become confused about who they are if they are masturbating to images and video of sexual violence, and then they enter a cycle of retraumatization that engenders shame while bringing children back to those sites again and again.
“Hence, in the business model of free porn, you are building in trauma, which is building in addiction,” Dr. Dines said. The effects of this exposure and addiction, based on decades of research, include limited capacity for intimacy, a greater likelihood of using coercive tactics for sex, decreased empathy for rape victims, increased depression and anxiety, and, most recently, rates of erectile dysfunction in males aged 15-27 that mirror the rates in those aged 27-35.
“We have never brought up boys with access to hard core pornography 24-7,” Dr. Dines said. The best way to tackle hard-core pornography is a public health model that educates parents and pediatricians who can band together to raise awareness. Her organization, Culture Reframed, is attempting to do precisely that.
Dr. Dines founded the nonprofit Culture Reframed, which attempts to counter the effects of the pornography industry and media sexuality. Her presentation used no external funding.
SAN FRANCISCO – The pornography industry has taken over children’s sense of self and sexuality and warped their concept of what sex and a sexual identity is, said Gail Dines, PhD.
She challenged pediatricians to shape policy and help parents in wrangling back that control in a presentation at the annual meeting of the American Academy of Pediatrics.
The culprit, Dr. Dines charged, is the multibillion-dollar porn industry that exploded around the year 2000 with the Internet. Then, in 2011, the business model shifted to free pornography to hook young boys in their adolescence and hopefully maintain them as customers after age 18 when they could get their own credit cards.
The average age of a boy’s first encounter with pornography is age 11, explained Dr. Dines, a professor of sociology and women’s studies at Wheelock College in Chestnut Hill, Mass.
Instead of a father’s Playboy featuring a naked woman in a cornfield, as many male pediatricians in the room might have been introduced to pornography or sexuality, today’s youth are introduced via the brutalization and dehumanization of women, she said. Such experiences traumatize the children viewing them, who become confused about who they are if they are masturbating to images and video of sexual violence, and then they enter a cycle of retraumatization that engenders shame while bringing children back to those sites again and again.
“Hence, in the business model of free porn, you are building in trauma, which is building in addiction,” Dr. Dines said. The effects of this exposure and addiction, based on decades of research, include limited capacity for intimacy, a greater likelihood of using coercive tactics for sex, decreased empathy for rape victims, increased depression and anxiety, and, most recently, rates of erectile dysfunction in males aged 15-27 that mirror the rates in those aged 27-35.
“We have never brought up boys with access to hard core pornography 24-7,” Dr. Dines said. The best way to tackle hard-core pornography is a public health model that educates parents and pediatricians who can band together to raise awareness. Her organization, Culture Reframed, is attempting to do precisely that.
Dr. Dines founded the nonprofit Culture Reframed, which attempts to counter the effects of the pornography industry and media sexuality. Her presentation used no external funding.
EXPERT ANALYSIS FROM AAP 16
Mental health integration into pediatric primary care offers multiple benefits
SAN FRANCISCO – Integrating pediatric mental health care into your primary care office can be an effective way to ensure your patients get the care they really need – and it’s easier than you think.
That’s the message Jay Rabinowitz, MD, MPH, a clinical professor of pediatrics at the University of Colorado at Denver, Aurora, delivered to a packed room at the annual meeting of the American Academy of Pediatrics.
He noted that depression and anxiety are among the top five conditions driving overall health costs in the United States, and a 1999 Surgeon General’s Report found that one in five children have a diagnosable mental disorder – but only a fifth to a quarter of these children receive treatment. The rub is that treatment is highly successful; it’s just difficult to access for many families, so making it a part of a child’s medical home just makes sense, Dr. Rabinowitz said.
To drive home his point, he described a case of a depressed adolescent with cutting and suicidal ideation, and the steps he would need to take without integration: find out their insurance, get a list of covered mental health professionals, refer to someone he may or may not heard of, and then rarely receive follow-up reports, much less confirmation the patient had gone to the appointment. With integrated care, parents can make appointments on their way out, he can read the psychologist’s report immediately after the visit, and he can drop in to say hello during the child’s mental health appointment.
“Sometimes there’s a question abut a medication or something, and sometimes it’s an inopportune moment if the child is sad or crying, but generally it seems to be pretty popular,” he said.
Taking steps toward integration
If providers are interesting in exploring the possibility of integration, they need to consider and decide on several issues before taking any concrete steps, Dr. Rabinowitz said. One is the type of arrangement that would work best for your practice: hiring on mental health professionals as employees of the practice, hiring independent contractors, coordinating a space share agreement or creating an out-of-office agreement.
“In our practice, psychologists are employees of the practice, but there are other arrangements,” he said, and some may depend on what is easiest based on state law or billing procedures.
The next question is what kind of provider(s) you would hire. His office has child psychologists with a PhD and postdoctorate fellowships working with children, but other possibilities include social workers, licensed counselors, psychiatric nurse practitioners, or psychiatrists.
Another consideration is what diagnoses your office will handle because it’s not possible to see everything. His practice sees patients in-house for attention deficit/hyperactivity disorder (ADHD), depression, anxiety, drug counseling, and behavioral and adjustment disorders. They choose to refer out educational testing, autism, difficult divorce cases, and complex cases that require more than 20 sessions. They refer out divorce cases because they frequently require specialized knowledge and a lot of court time and phone calls. Aside from ADHD evaluations, his office does not see the staff’s children.
Providers also should consider options for adapting their physical space to accommodate integration. His practice converted an exam room into a consultation room, making it homier with a throw rug, soft chairs, a painted wall, and office decor.
Establishing effective protocols with integration
The next step after providers decide to integrate is to determine the office protocols that govern what forms get used, who can schedule appointments and how long they last, billing, and similar procedures.
“You need to have certain protocols, and some of these things you don’t think about it until you start doing it,” Dr. Rabinowitz said. Should mental health appointments be 50 minutes, for example, or 20 to 25 minutes? His office has gradually shrunk these appointments from 50 to 30 minutes, but they give psychologists an hour of time each day for follow-up phone calls.
Forms to consider developing include a disclosure form, notice of privacy practices, late cancel/no show policy, financial policy, and a summary of parent concerns. His office’s charting includes an extensive intake form with medical, treatment, family, and social history, an intake summary, and a progress note.
It’s with reimbursement, of course, that providers will need to do the most research, particularly with regard to their state’s laws and in looking for grants to provide funding – which is more available than many realize.
“Money is often out there if you look for it,” Dr. Rabinowitz said.” Mental health is an area where no one is really against it: You get together the NRA (National Rifle Association) and the anti-gun movement, and they are both for it.”
Planning for reimbursement challenges
Reimbursement barriers can include lack of payment if mental health codes are used instead of pediatrics ones (depending on the practice arrangement), lack of “incident to” payments, same day billing of physical and mental health appointments, reimbursement for screening, and lack of payment for non–face-to-face services. Although a concierge or fee-for-service option solves many of these, it excludes Medicaid patients and is an economic barrier for many families.
Mental health networks offer a different route, but they can involve poor reimbursement and an additional layer of administration, which makes financial integration more viable as long as providers investigate their options.
“It’s going to be a regional variation, and you need to look at state rules and regulations,” Dr. Rabinowitz said, explaining that his office then sought insurance contracts to include mental health care reimbursement through their office and then sought the same from Medicaid.
“We weren’t about to see Medicaid patients for fear of an audit unless we got written permission, but we got that,” he said. His office simply asked for it and received in writing a letter starting as follows: “Under Department policy, they (our psychologists) may submit E&M claims to Medicaid under a supervising physician’s billing ID. It is not mandatory they be credentialed into a BHO (Behavioral Healthcare Options) network…”
He also noted that his state allows inclusion of psychologists on medical malpractice insurance policies, which is far less expensive for mental health professionals, compared with medical doctors.
Ultimately, the result of mental health integration into primary care practices is greater satisfaction among patients and pediatricians as well as potentially better health outcomes, Dr. Rabinowitz said. An in-house patient satisfaction survey his office conducted found that 91% of parents felt it was convenient for their child to receive mental health services at the same location as medical care, and 90% were satisfied with their care. Only 9% cited barriers to their child seeing a psychologist at their office, and 89% found the services beneficial for their child. Similarly, providers find integration more convenient, easier for follow-up, less stressful, and more efficient while improving communication, confidence, and follow-up.
Dr. Rabinowitz reported no disclosures. No external funding was used for the presentation.
SAN FRANCISCO – Integrating pediatric mental health care into your primary care office can be an effective way to ensure your patients get the care they really need – and it’s easier than you think.
That’s the message Jay Rabinowitz, MD, MPH, a clinical professor of pediatrics at the University of Colorado at Denver, Aurora, delivered to a packed room at the annual meeting of the American Academy of Pediatrics.
He noted that depression and anxiety are among the top five conditions driving overall health costs in the United States, and a 1999 Surgeon General’s Report found that one in five children have a diagnosable mental disorder – but only a fifth to a quarter of these children receive treatment. The rub is that treatment is highly successful; it’s just difficult to access for many families, so making it a part of a child’s medical home just makes sense, Dr. Rabinowitz said.
To drive home his point, he described a case of a depressed adolescent with cutting and suicidal ideation, and the steps he would need to take without integration: find out their insurance, get a list of covered mental health professionals, refer to someone he may or may not heard of, and then rarely receive follow-up reports, much less confirmation the patient had gone to the appointment. With integrated care, parents can make appointments on their way out, he can read the psychologist’s report immediately after the visit, and he can drop in to say hello during the child’s mental health appointment.
“Sometimes there’s a question abut a medication or something, and sometimes it’s an inopportune moment if the child is sad or crying, but generally it seems to be pretty popular,” he said.
Taking steps toward integration
If providers are interesting in exploring the possibility of integration, they need to consider and decide on several issues before taking any concrete steps, Dr. Rabinowitz said. One is the type of arrangement that would work best for your practice: hiring on mental health professionals as employees of the practice, hiring independent contractors, coordinating a space share agreement or creating an out-of-office agreement.
“In our practice, psychologists are employees of the practice, but there are other arrangements,” he said, and some may depend on what is easiest based on state law or billing procedures.
The next question is what kind of provider(s) you would hire. His office has child psychologists with a PhD and postdoctorate fellowships working with children, but other possibilities include social workers, licensed counselors, psychiatric nurse practitioners, or psychiatrists.
Another consideration is what diagnoses your office will handle because it’s not possible to see everything. His practice sees patients in-house for attention deficit/hyperactivity disorder (ADHD), depression, anxiety, drug counseling, and behavioral and adjustment disorders. They choose to refer out educational testing, autism, difficult divorce cases, and complex cases that require more than 20 sessions. They refer out divorce cases because they frequently require specialized knowledge and a lot of court time and phone calls. Aside from ADHD evaluations, his office does not see the staff’s children.
Providers also should consider options for adapting their physical space to accommodate integration. His practice converted an exam room into a consultation room, making it homier with a throw rug, soft chairs, a painted wall, and office decor.
Establishing effective protocols with integration
The next step after providers decide to integrate is to determine the office protocols that govern what forms get used, who can schedule appointments and how long they last, billing, and similar procedures.
“You need to have certain protocols, and some of these things you don’t think about it until you start doing it,” Dr. Rabinowitz said. Should mental health appointments be 50 minutes, for example, or 20 to 25 minutes? His office has gradually shrunk these appointments from 50 to 30 minutes, but they give psychologists an hour of time each day for follow-up phone calls.
Forms to consider developing include a disclosure form, notice of privacy practices, late cancel/no show policy, financial policy, and a summary of parent concerns. His office’s charting includes an extensive intake form with medical, treatment, family, and social history, an intake summary, and a progress note.
It’s with reimbursement, of course, that providers will need to do the most research, particularly with regard to their state’s laws and in looking for grants to provide funding – which is more available than many realize.
“Money is often out there if you look for it,” Dr. Rabinowitz said.” Mental health is an area where no one is really against it: You get together the NRA (National Rifle Association) and the anti-gun movement, and they are both for it.”
Planning for reimbursement challenges
Reimbursement barriers can include lack of payment if mental health codes are used instead of pediatrics ones (depending on the practice arrangement), lack of “incident to” payments, same day billing of physical and mental health appointments, reimbursement for screening, and lack of payment for non–face-to-face services. Although a concierge or fee-for-service option solves many of these, it excludes Medicaid patients and is an economic barrier for many families.
Mental health networks offer a different route, but they can involve poor reimbursement and an additional layer of administration, which makes financial integration more viable as long as providers investigate their options.
“It’s going to be a regional variation, and you need to look at state rules and regulations,” Dr. Rabinowitz said, explaining that his office then sought insurance contracts to include mental health care reimbursement through their office and then sought the same from Medicaid.
“We weren’t about to see Medicaid patients for fear of an audit unless we got written permission, but we got that,” he said. His office simply asked for it and received in writing a letter starting as follows: “Under Department policy, they (our psychologists) may submit E&M claims to Medicaid under a supervising physician’s billing ID. It is not mandatory they be credentialed into a BHO (Behavioral Healthcare Options) network…”
He also noted that his state allows inclusion of psychologists on medical malpractice insurance policies, which is far less expensive for mental health professionals, compared with medical doctors.
Ultimately, the result of mental health integration into primary care practices is greater satisfaction among patients and pediatricians as well as potentially better health outcomes, Dr. Rabinowitz said. An in-house patient satisfaction survey his office conducted found that 91% of parents felt it was convenient for their child to receive mental health services at the same location as medical care, and 90% were satisfied with their care. Only 9% cited barriers to their child seeing a psychologist at their office, and 89% found the services beneficial for their child. Similarly, providers find integration more convenient, easier for follow-up, less stressful, and more efficient while improving communication, confidence, and follow-up.
Dr. Rabinowitz reported no disclosures. No external funding was used for the presentation.
SAN FRANCISCO – Integrating pediatric mental health care into your primary care office can be an effective way to ensure your patients get the care they really need – and it’s easier than you think.
That’s the message Jay Rabinowitz, MD, MPH, a clinical professor of pediatrics at the University of Colorado at Denver, Aurora, delivered to a packed room at the annual meeting of the American Academy of Pediatrics.
He noted that depression and anxiety are among the top five conditions driving overall health costs in the United States, and a 1999 Surgeon General’s Report found that one in five children have a diagnosable mental disorder – but only a fifth to a quarter of these children receive treatment. The rub is that treatment is highly successful; it’s just difficult to access for many families, so making it a part of a child’s medical home just makes sense, Dr. Rabinowitz said.
To drive home his point, he described a case of a depressed adolescent with cutting and suicidal ideation, and the steps he would need to take without integration: find out their insurance, get a list of covered mental health professionals, refer to someone he may or may not heard of, and then rarely receive follow-up reports, much less confirmation the patient had gone to the appointment. With integrated care, parents can make appointments on their way out, he can read the psychologist’s report immediately after the visit, and he can drop in to say hello during the child’s mental health appointment.
“Sometimes there’s a question abut a medication or something, and sometimes it’s an inopportune moment if the child is sad or crying, but generally it seems to be pretty popular,” he said.
Taking steps toward integration
If providers are interesting in exploring the possibility of integration, they need to consider and decide on several issues before taking any concrete steps, Dr. Rabinowitz said. One is the type of arrangement that would work best for your practice: hiring on mental health professionals as employees of the practice, hiring independent contractors, coordinating a space share agreement or creating an out-of-office agreement.
“In our practice, psychologists are employees of the practice, but there are other arrangements,” he said, and some may depend on what is easiest based on state law or billing procedures.
The next question is what kind of provider(s) you would hire. His office has child psychologists with a PhD and postdoctorate fellowships working with children, but other possibilities include social workers, licensed counselors, psychiatric nurse practitioners, or psychiatrists.
Another consideration is what diagnoses your office will handle because it’s not possible to see everything. His practice sees patients in-house for attention deficit/hyperactivity disorder (ADHD), depression, anxiety, drug counseling, and behavioral and adjustment disorders. They choose to refer out educational testing, autism, difficult divorce cases, and complex cases that require more than 20 sessions. They refer out divorce cases because they frequently require specialized knowledge and a lot of court time and phone calls. Aside from ADHD evaluations, his office does not see the staff’s children.
Providers also should consider options for adapting their physical space to accommodate integration. His practice converted an exam room into a consultation room, making it homier with a throw rug, soft chairs, a painted wall, and office decor.
Establishing effective protocols with integration
The next step after providers decide to integrate is to determine the office protocols that govern what forms get used, who can schedule appointments and how long they last, billing, and similar procedures.
“You need to have certain protocols, and some of these things you don’t think about it until you start doing it,” Dr. Rabinowitz said. Should mental health appointments be 50 minutes, for example, or 20 to 25 minutes? His office has gradually shrunk these appointments from 50 to 30 minutes, but they give psychologists an hour of time each day for follow-up phone calls.
Forms to consider developing include a disclosure form, notice of privacy practices, late cancel/no show policy, financial policy, and a summary of parent concerns. His office’s charting includes an extensive intake form with medical, treatment, family, and social history, an intake summary, and a progress note.
It’s with reimbursement, of course, that providers will need to do the most research, particularly with regard to their state’s laws and in looking for grants to provide funding – which is more available than many realize.
“Money is often out there if you look for it,” Dr. Rabinowitz said.” Mental health is an area where no one is really against it: You get together the NRA (National Rifle Association) and the anti-gun movement, and they are both for it.”
Planning for reimbursement challenges
Reimbursement barriers can include lack of payment if mental health codes are used instead of pediatrics ones (depending on the practice arrangement), lack of “incident to” payments, same day billing of physical and mental health appointments, reimbursement for screening, and lack of payment for non–face-to-face services. Although a concierge or fee-for-service option solves many of these, it excludes Medicaid patients and is an economic barrier for many families.
Mental health networks offer a different route, but they can involve poor reimbursement and an additional layer of administration, which makes financial integration more viable as long as providers investigate their options.
“It’s going to be a regional variation, and you need to look at state rules and regulations,” Dr. Rabinowitz said, explaining that his office then sought insurance contracts to include mental health care reimbursement through their office and then sought the same from Medicaid.
“We weren’t about to see Medicaid patients for fear of an audit unless we got written permission, but we got that,” he said. His office simply asked for it and received in writing a letter starting as follows: “Under Department policy, they (our psychologists) may submit E&M claims to Medicaid under a supervising physician’s billing ID. It is not mandatory they be credentialed into a BHO (Behavioral Healthcare Options) network…”
He also noted that his state allows inclusion of psychologists on medical malpractice insurance policies, which is far less expensive for mental health professionals, compared with medical doctors.
Ultimately, the result of mental health integration into primary care practices is greater satisfaction among patients and pediatricians as well as potentially better health outcomes, Dr. Rabinowitz said. An in-house patient satisfaction survey his office conducted found that 91% of parents felt it was convenient for their child to receive mental health services at the same location as medical care, and 90% were satisfied with their care. Only 9% cited barriers to their child seeing a psychologist at their office, and 89% found the services beneficial for their child. Similarly, providers find integration more convenient, easier for follow-up, less stressful, and more efficient while improving communication, confidence, and follow-up.
Dr. Rabinowitz reported no disclosures. No external funding was used for the presentation.
EXPERT ANALYSIS FROM AAP 16
New screen time guidelines address rapid changes in media environment
SAN FRANCISCO – A new set of policy statements on children’s media use from the American Academy of Pediatrics brings the recommendations into the 21st century.
The new guidance, released at the annual meeting of the AAP, synthesizes the most current evidence on mobile devices, interactivity, educational technology, sleep, obesity, cognitive development, and other aspects of the pervasive digital environment children now grow up in.
“I think our policy statement reflects the changes in the media landscape because not all media use is the same,” Megan A. Moreno, MD, lead author of the policy statement, “Media Use in School-Aged Children and Adolescents,” said during a press conference (Pediatrics. 2016, Oct. doi: 10.1542/peds.2016-2592).
The new statement both lowers the overall age at which parents can feel comfortable introducing their children to media and decreases the amount of screen time exposure per day. One key component of the new guidelines includes the unveiling of a new tool parents can use to create a Family Media Plan. The tool, available at https://www.healthychildren.org/English/media/Pages/default.aspx, enables parents to create a plan for each child in the household and reflects the individuality of each child’s use and age-appropriate guidelines.
After parents enter children’s names, the plan provides an editable template for each child that lays out screen-free zones, screen-free times, device curfews, recreational screen-time choices, alternative activities during non-screen time, media manners, digital citizenship, personal safety, sleep, and exercise.
Previous policy statements from the AAP relied primarily on research about television, a passive screen experience. In an age where many children and teens have interactive screens in their pockets and visit grandparents via video conferencing, however, the AAP Council on Communications and Media has likewise broadened its definition of media and noted the problems with applying research about television to other totally different types of screens.
“When we’re using media to connect, this is not what we’re traditionally calling screen time. These are tools,” Jenny S. Radesky, MD, lead author of the policy statement “Media and Young Minds,” said at the press conference (Pediatrics. 2016 Oct. doi: 10.1542/peds.2016-2592). She referred to the fact that many families who are spread across great distances, such as parents deployed overseas or grandparents in another state, use Skype, FaceTime, Google Hangouts, and similar programs to communicate and remain connected.
“We’re making sure our relationships are staying strong and not something to be discouraged with infants and toddlers, even though infants and toddlers will need their parent’s help to understand what they’re seeing on the screen,” said Dr. Radesky, a developmental-behavioral pediatrician at C.S. Mott Children’s Hospital at the University of Michigan in Ann Arbor.
The policy statement further notes that some emerging evidence has suggested children aged 2 and older can learn words from live video chatting with a responsive adult or by using an interactive touch screen that scaffolds learning.
An earlier introduction to screens
Among the most significant changes to the recommendations for children up to 5 years old is an allowance for introducing media before age 2, the previous policy’s age recommendation.
“If you want to introduce media, 18 months is the age when kids are cognitively ready to start, but we’re not saying parents need to introduce media then,” Dr. Radesky said, adding that more research is needed regarding devices such as tablets before it’s possible to know whether apps can be beneficial in toddlers that young. “There’s not enough evidence to know if interactivity helps or not right now,” she said.
The “Media and Young Minds” policy statement notes that children under age 2 years develop their cognitive, language, motor, and social-emotional skills through hands-on exploration and social interaction with trusted adults.
“Apps can’t do the things that parents’ minds can do or children’s minds can do on their own,” Dr. Radesky said. The policy notes that digital books, or eBooks, can be beneficial when used like a traditional physical book, but interactive elements to these eBooks could be distracting and decrease children’s comprehension.
When parents do choose to introduce media to their children, it’s “crucial that media be a shared experience” between the caregiving adult and the child, she said. “Think of media as a teaching tool, a way to connect and to create, not just to consume,” Dr. Radesky said.
What can preschoolers learn?
Although some laboratory research shows toddlers as young as 15 months can learn new words from touch screens, they have difficulty transferring that knowledge to the three-dimensional world. For children aged 3-5 years, however, both well-designed television programming and high-quality learning apps from Public Broadcasting Service (PBS) and the Sesame Workshop have shown benefits. In addition to early literacy, math, and personal and social development skills learned from shows such as Sesame Street, preschoolers have learned literacy skills from those programs’ apps.
But those apps are unfortunately in the minority.
“Most apps parents find under the ‘educational’ category in app stores have no such evidence of efficacy, target only rote academic skills, are not based on established curricula, and use little or no input from developmental specialists and educators,” the “Media and Young Minds” policy states. “The higher-order thinking skills and executive functions essential for school success, such as task persistence, impulse control, emotion regulation, and creative, flexible thinking, are best taught through unstructured and social (not digital) play, as well as responsive parent-child interactions.” 
Risks and recommendations for preschoolers
Heavy media use among preschoolers, meanwhile, carries risks of increased weight – primarily as a result of food advertising and eating while watching TV – as well as reduced sleep and cognitive, language, and social/emotional delays.
“Content is crucial,” the “Media and Young Minds” policy notes. “Experimental evidence shows that switching from violent content to educational/prosocial content results in significant improvement in behavioral symptoms, particularly for low-income boys.”
The key points of the new statement therefore include the following recommendations:
• Limit media use to 1 hour a day in children ages 2 years and older.
• Do not use screens during mealtimes and for 1 hour before bedtime.
• Start discussing family and child media use with parents early in children’s lives.
• Educate parents about early brain development and help families develop a Family Media Use Plan.
• Discourage screen use besides video-chatting in children under 18 months old.
• Encourage caregiving adults to use screen media with children aged 18-24 months, who should not use it on their own.
• Encourage parents to rely on high-quality programming products such as PBS Kids, Sesame Workshop, and Common Sense Media.
• Help parents with challenges such as setting limits, finding alternatives to screen time, and calming children without using media.
• Avoid using screens or media to calm children except during rare extenuating circumstances, such as painful medical procedures and airplane flights.
• Encourage parents to avoid fast-paced programs, apps with distracting content, any media with violent content, and any background television, which can stunt children’s early language development.
Understanding older youth’s media use
As children move into school age and adolescence, the opportunities and utilities for media use expand – and so do the risks. Children and teens can benefit from media through gaining social support, learning about healthy behaviors, and discovering new ideas and knowledge, but youth remain at risk for obesity, sleep problems, cyberbullying, compromised privacy, and exposure to inaccurate, inappropriate or unsafe content, the “Media Use in School-Aged Children and Adolescents” policy statement reports.
Despite the wide range of media types available, TV remains the most commonly used media type among school-aged children and teens and is watched an average of 2 hours a day. Still, 91% of boys have access to a video game console, and 84% report playing games online or on a mobile phone. Further, three-quarters of teens own a smartphone and 76% use at least one social media site, with more than 70% maintaining a “social media portfolio” across several platforms.
Such social media use can provide teens with helpful support networks, particularly for those with ongoing illnesses or disabilities or those needing community support as lesbian, gay, bisexual, transgender, questioning, or intersex individuals. Social media can also promote wellness and healthy behaviors such as eating well and not smoking.
Risks for school-aged children and adolescents using media
Yet social media also can open the door to cyberbullying, leading to short-term and long-term social, academic, and health problems. It carries the risk of exploitation of youth or their images, or predation from pornographers and pedophiles. Children and teens must be made aware that the “Internet is forever” and should be taught to consider privacy and confidentiality concerns in their use of social and other media.
Another concern is teens’ “sexting,” in which they share sexually explicit messages and/or partly or fully nude photos. Exposures to unhealthy behaviors, such as substance abuse, sexual behaviors, self-injury, or disordered eating are likewise among the risks of social media, as they are with television and cinema.
In fact, TV/movie content showing alcohol use, smoking, and sexual activity is linked to earlier experimentation among children and adolescents. In addition, each extra hour of television watching is associated with increase in body mass index, as is having a TV set in the bedroom. Enjoying entertainment media while doing school work is linked to poor learning and academics.
Excessive media use may lead to problematic Internet use and Internet gaming disorder as described in the DSM-5, occurring among 4%-8.5% of children and adolescents.
“Symptoms can include a preoccupation with the activity, decreased interest in offline or ‘real life’ relationships, unsuccessful attempts to decrease use and withdrawal symptoms,” the “Media Use in School-Aged Children and Adolescents” policy statement notes.
Recommendations for older children
The policy statement advises pediatricians to help families and schools promote understanding of media’s risks and benefits, including awareness of tools to screen for sexting, cyberbullying, problematic Internet use, and Internet gaming disorder. Pediatricians should advocate for training in media literacy in the community and encourage parents to follow the media, sleep, and physical activity guidelines included in the Family Media Plan.
The research was supported by the American Academy of Pediatrics. The authors reported no disclosures.
SAN FRANCISCO – A new set of policy statements on children’s media use from the American Academy of Pediatrics brings the recommendations into the 21st century.
The new guidance, released at the annual meeting of the AAP, synthesizes the most current evidence on mobile devices, interactivity, educational technology, sleep, obesity, cognitive development, and other aspects of the pervasive digital environment children now grow up in.
“I think our policy statement reflects the changes in the media landscape because not all media use is the same,” Megan A. Moreno, MD, lead author of the policy statement, “Media Use in School-Aged Children and Adolescents,” said during a press conference (Pediatrics. 2016, Oct. doi: 10.1542/peds.2016-2592).
The new statement both lowers the overall age at which parents can feel comfortable introducing their children to media and decreases the amount of screen time exposure per day. One key component of the new guidelines includes the unveiling of a new tool parents can use to create a Family Media Plan. The tool, available at https://www.healthychildren.org/English/media/Pages/default.aspx, enables parents to create a plan for each child in the household and reflects the individuality of each child’s use and age-appropriate guidelines.
After parents enter children’s names, the plan provides an editable template for each child that lays out screen-free zones, screen-free times, device curfews, recreational screen-time choices, alternative activities during non-screen time, media manners, digital citizenship, personal safety, sleep, and exercise.
Previous policy statements from the AAP relied primarily on research about television, a passive screen experience. In an age where many children and teens have interactive screens in their pockets and visit grandparents via video conferencing, however, the AAP Council on Communications and Media has likewise broadened its definition of media and noted the problems with applying research about television to other totally different types of screens.
“When we’re using media to connect, this is not what we’re traditionally calling screen time. These are tools,” Jenny S. Radesky, MD, lead author of the policy statement “Media and Young Minds,” said at the press conference (Pediatrics. 2016 Oct. doi: 10.1542/peds.2016-2592). She referred to the fact that many families who are spread across great distances, such as parents deployed overseas or grandparents in another state, use Skype, FaceTime, Google Hangouts, and similar programs to communicate and remain connected.
“We’re making sure our relationships are staying strong and not something to be discouraged with infants and toddlers, even though infants and toddlers will need their parent’s help to understand what they’re seeing on the screen,” said Dr. Radesky, a developmental-behavioral pediatrician at C.S. Mott Children’s Hospital at the University of Michigan in Ann Arbor.
The policy statement further notes that some emerging evidence has suggested children aged 2 and older can learn words from live video chatting with a responsive adult or by using an interactive touch screen that scaffolds learning.
An earlier introduction to screens
Among the most significant changes to the recommendations for children up to 5 years old is an allowance for introducing media before age 2, the previous policy’s age recommendation.
“If you want to introduce media, 18 months is the age when kids are cognitively ready to start, but we’re not saying parents need to introduce media then,” Dr. Radesky said, adding that more research is needed regarding devices such as tablets before it’s possible to know whether apps can be beneficial in toddlers that young. “There’s not enough evidence to know if interactivity helps or not right now,” she said.
The “Media and Young Minds” policy statement notes that children under age 2 years develop their cognitive, language, motor, and social-emotional skills through hands-on exploration and social interaction with trusted adults.
“Apps can’t do the things that parents’ minds can do or children’s minds can do on their own,” Dr. Radesky said. The policy notes that digital books, or eBooks, can be beneficial when used like a traditional physical book, but interactive elements to these eBooks could be distracting and decrease children’s comprehension.
When parents do choose to introduce media to their children, it’s “crucial that media be a shared experience” between the caregiving adult and the child, she said. “Think of media as a teaching tool, a way to connect and to create, not just to consume,” Dr. Radesky said.
What can preschoolers learn?
Although some laboratory research shows toddlers as young as 15 months can learn new words from touch screens, they have difficulty transferring that knowledge to the three-dimensional world. For children aged 3-5 years, however, both well-designed television programming and high-quality learning apps from Public Broadcasting Service (PBS) and the Sesame Workshop have shown benefits. In addition to early literacy, math, and personal and social development skills learned from shows such as Sesame Street, preschoolers have learned literacy skills from those programs’ apps.
But those apps are unfortunately in the minority.
“Most apps parents find under the ‘educational’ category in app stores have no such evidence of efficacy, target only rote academic skills, are not based on established curricula, and use little or no input from developmental specialists and educators,” the “Media and Young Minds” policy states. “The higher-order thinking skills and executive functions essential for school success, such as task persistence, impulse control, emotion regulation, and creative, flexible thinking, are best taught through unstructured and social (not digital) play, as well as responsive parent-child interactions.”
Risks and recommendations for preschoolers
Heavy media use among preschoolers, meanwhile, carries risks of increased weight – primarily as a result of food advertising and eating while watching TV – as well as reduced sleep and cognitive, language, and social/emotional delays.
“Content is crucial,” the “Media and Young Minds” policy notes. “Experimental evidence shows that switching from violent content to educational/prosocial content results in significant improvement in behavioral symptoms, particularly for low-income boys.”
The key points of the new statement therefore include the following recommendations:
• Limit media use to 1 hour a day in children ages 2 years and older.
• Do not use screens during mealtimes and for 1 hour before bedtime.
• Start discussing family and child media use with parents early in children’s lives.
• Educate parents about early brain development and help families develop a Family Media Use Plan.
• Discourage screen use besides video-chatting in children under 18 months old.
• Encourage caregiving adults to use screen media with children aged 18-24 months, who should not use it on their own.
• Encourage parents to rely on high-quality programming products such as PBS Kids, Sesame Workshop, and Common Sense Media.
• Help parents with challenges such as setting limits, finding alternatives to screen time, and calming children without using media.
• Avoid using screens or media to calm children except during rare extenuating circumstances, such as painful medical procedures and airplane flights.
• Encourage parents to avoid fast-paced programs, apps with distracting content, any media with violent content, and any background television, which can stunt children’s early language development.
Understanding older youth’s media use
As children move into school age and adolescence, the opportunities and utilities for media use expand – and so do the risks. Children and teens can benefit from media through gaining social support, learning about healthy behaviors, and discovering new ideas and knowledge, but youth remain at risk for obesity, sleep problems, cyberbullying, compromised privacy, and exposure to inaccurate, inappropriate or unsafe content, the “Media Use in School-Aged Children and Adolescents” policy statement reports.
Despite the wide range of media types available, TV remains the most commonly used media type among school-aged children and teens and is watched an average of 2 hours a day. Still, 91% of boys have access to a video game console, and 84% report playing games online or on a mobile phone. Further, three-quarters of teens own a smartphone and 76% use at least one social media site, with more than 70% maintaining a “social media portfolio” across several platforms.
Such social media use can provide teens with helpful support networks, particularly for those with ongoing illnesses or disabilities or those needing community support as lesbian, gay, bisexual, transgender, questioning, or intersex individuals. Social media can also promote wellness and healthy behaviors such as eating well and not smoking.
Risks for school-aged children and adolescents using media
Yet social media also can open the door to cyberbullying, leading to short-term and long-term social, academic, and health problems. It carries the risk of exploitation of youth or their images, or predation from pornographers and pedophiles. Children and teens must be made aware that the “Internet is forever” and should be taught to consider privacy and confidentiality concerns in their use of social and other media.
Another concern is teens’ “sexting,” in which they share sexually explicit messages and/or partly or fully nude photos. Exposures to unhealthy behaviors, such as substance abuse, sexual behaviors, self-injury, or disordered eating are likewise among the risks of social media, as they are with television and cinema.
In fact, TV/movie content showing alcohol use, smoking, and sexual activity is linked to earlier experimentation among children and adolescents. In addition, each extra hour of television watching is associated with increase in body mass index, as is having a TV set in the bedroom. Enjoying entertainment media while doing school work is linked to poor learning and academics.
Excessive media use may lead to problematic Internet use and Internet gaming disorder as described in the DSM-5, occurring among 4%-8.5% of children and adolescents.
“Symptoms can include a preoccupation with the activity, decreased interest in offline or ‘real life’ relationships, unsuccessful attempts to decrease use and withdrawal symptoms,” the “Media Use in School-Aged Children and Adolescents” policy statement notes.
Recommendations for older children
The policy statement advises pediatricians to help families and schools promote understanding of media’s risks and benefits, including awareness of tools to screen for sexting, cyberbullying, problematic Internet use, and Internet gaming disorder. Pediatricians should advocate for training in media literacy in the community and encourage parents to follow the media, sleep, and physical activity guidelines included in the Family Media Plan.
The research was supported by the American Academy of Pediatrics. The authors reported no disclosures.
SAN FRANCISCO – A new set of policy statements on children’s media use from the American Academy of Pediatrics brings the recommendations into the 21st century.
The new guidance, released at the annual meeting of the AAP, synthesizes the most current evidence on mobile devices, interactivity, educational technology, sleep, obesity, cognitive development, and other aspects of the pervasive digital environment children now grow up in.
“I think our policy statement reflects the changes in the media landscape because not all media use is the same,” Megan A. Moreno, MD, lead author of the policy statement, “Media Use in School-Aged Children and Adolescents,” said during a press conference (Pediatrics. 2016, Oct. doi: 10.1542/peds.2016-2592).
The new statement both lowers the overall age at which parents can feel comfortable introducing their children to media and decreases the amount of screen time exposure per day. One key component of the new guidelines includes the unveiling of a new tool parents can use to create a Family Media Plan. The tool, available at https://www.healthychildren.org/English/media/Pages/default.aspx, enables parents to create a plan for each child in the household and reflects the individuality of each child’s use and age-appropriate guidelines.
After parents enter children’s names, the plan provides an editable template for each child that lays out screen-free zones, screen-free times, device curfews, recreational screen-time choices, alternative activities during non-screen time, media manners, digital citizenship, personal safety, sleep, and exercise.
Previous policy statements from the AAP relied primarily on research about television, a passive screen experience. In an age where many children and teens have interactive screens in their pockets and visit grandparents via video conferencing, however, the AAP Council on Communications and Media has likewise broadened its definition of media and noted the problems with applying research about television to other totally different types of screens.
“When we’re using media to connect, this is not what we’re traditionally calling screen time. These are tools,” Jenny S. Radesky, MD, lead author of the policy statement “Media and Young Minds,” said at the press conference (Pediatrics. 2016 Oct. doi: 10.1542/peds.2016-2592). She referred to the fact that many families who are spread across great distances, such as parents deployed overseas or grandparents in another state, use Skype, FaceTime, Google Hangouts, and similar programs to communicate and remain connected.
“We’re making sure our relationships are staying strong and not something to be discouraged with infants and toddlers, even though infants and toddlers will need their parent’s help to understand what they’re seeing on the screen,” said Dr. Radesky, a developmental-behavioral pediatrician at C.S. Mott Children’s Hospital at the University of Michigan in Ann Arbor.
The policy statement further notes that some emerging evidence has suggested children aged 2 and older can learn words from live video chatting with a responsive adult or by using an interactive touch screen that scaffolds learning.
An earlier introduction to screens
Among the most significant changes to the recommendations for children up to 5 years old is an allowance for introducing media before age 2, the previous policy’s age recommendation.
“If you want to introduce media, 18 months is the age when kids are cognitively ready to start, but we’re not saying parents need to introduce media then,” Dr. Radesky said, adding that more research is needed regarding devices such as tablets before it’s possible to know whether apps can be beneficial in toddlers that young. “There’s not enough evidence to know if interactivity helps or not right now,” she said.
The “Media and Young Minds” policy statement notes that children under age 2 years develop their cognitive, language, motor, and social-emotional skills through hands-on exploration and social interaction with trusted adults.
“Apps can’t do the things that parents’ minds can do or children’s minds can do on their own,” Dr. Radesky said. The policy notes that digital books, or eBooks, can be beneficial when used like a traditional physical book, but interactive elements to these eBooks could be distracting and decrease children’s comprehension.
When parents do choose to introduce media to their children, it’s “crucial that media be a shared experience” between the caregiving adult and the child, she said. “Think of media as a teaching tool, a way to connect and to create, not just to consume,” Dr. Radesky said.
What can preschoolers learn?
Although some laboratory research shows toddlers as young as 15 months can learn new words from touch screens, they have difficulty transferring that knowledge to the three-dimensional world. For children aged 3-5 years, however, both well-designed television programming and high-quality learning apps from Public Broadcasting Service (PBS) and the Sesame Workshop have shown benefits. In addition to early literacy, math, and personal and social development skills learned from shows such as Sesame Street, preschoolers have learned literacy skills from those programs’ apps.
But those apps are unfortunately in the minority.
“Most apps parents find under the ‘educational’ category in app stores have no such evidence of efficacy, target only rote academic skills, are not based on established curricula, and use little or no input from developmental specialists and educators,” the “Media and Young Minds” policy states. “The higher-order thinking skills and executive functions essential for school success, such as task persistence, impulse control, emotion regulation, and creative, flexible thinking, are best taught through unstructured and social (not digital) play, as well as responsive parent-child interactions.”
Risks and recommendations for preschoolers
Heavy media use among preschoolers, meanwhile, carries risks of increased weight – primarily as a result of food advertising and eating while watching TV – as well as reduced sleep and cognitive, language, and social/emotional delays.
“Content is crucial,” the “Media and Young Minds” policy notes. “Experimental evidence shows that switching from violent content to educational/prosocial content results in significant improvement in behavioral symptoms, particularly for low-income boys.”
The key points of the new statement therefore include the following recommendations:
• Limit media use to 1 hour a day in children ages 2 years and older.
• Do not use screens during mealtimes and for 1 hour before bedtime.
• Start discussing family and child media use with parents early in children’s lives.
• Educate parents about early brain development and help families develop a Family Media Use Plan.
• Discourage screen use besides video-chatting in children under 18 months old.
• Encourage caregiving adults to use screen media with children aged 18-24 months, who should not use it on their own.
• Encourage parents to rely on high-quality programming products such as PBS Kids, Sesame Workshop, and Common Sense Media.
• Help parents with challenges such as setting limits, finding alternatives to screen time, and calming children without using media.
• Avoid using screens or media to calm children except during rare extenuating circumstances, such as painful medical procedures and airplane flights.
• Encourage parents to avoid fast-paced programs, apps with distracting content, any media with violent content, and any background television, which can stunt children’s early language development.
Understanding older youth’s media use
As children move into school age and adolescence, the opportunities and utilities for media use expand – and so do the risks. Children and teens can benefit from media through gaining social support, learning about healthy behaviors, and discovering new ideas and knowledge, but youth remain at risk for obesity, sleep problems, cyberbullying, compromised privacy, and exposure to inaccurate, inappropriate or unsafe content, the “Media Use in School-Aged Children and Adolescents” policy statement reports.
Despite the wide range of media types available, TV remains the most commonly used media type among school-aged children and teens and is watched an average of 2 hours a day. Still, 91% of boys have access to a video game console, and 84% report playing games online or on a mobile phone. Further, three-quarters of teens own a smartphone and 76% use at least one social media site, with more than 70% maintaining a “social media portfolio” across several platforms.
Such social media use can provide teens with helpful support networks, particularly for those with ongoing illnesses or disabilities or those needing community support as lesbian, gay, bisexual, transgender, questioning, or intersex individuals. Social media can also promote wellness and healthy behaviors such as eating well and not smoking.
Risks for school-aged children and adolescents using media
Yet social media also can open the door to cyberbullying, leading to short-term and long-term social, academic, and health problems. It carries the risk of exploitation of youth or their images, or predation from pornographers and pedophiles. Children and teens must be made aware that the “Internet is forever” and should be taught to consider privacy and confidentiality concerns in their use of social and other media.
Another concern is teens’ “sexting,” in which they share sexually explicit messages and/or partly or fully nude photos. Exposures to unhealthy behaviors, such as substance abuse, sexual behaviors, self-injury, or disordered eating are likewise among the risks of social media, as they are with television and cinema.
In fact, TV/movie content showing alcohol use, smoking, and sexual activity is linked to earlier experimentation among children and adolescents. In addition, each extra hour of television watching is associated with increase in body mass index, as is having a TV set in the bedroom. Enjoying entertainment media while doing school work is linked to poor learning and academics.
Excessive media use may lead to problematic Internet use and Internet gaming disorder as described in the DSM-5, occurring among 4%-8.5% of children and adolescents.
“Symptoms can include a preoccupation with the activity, decreased interest in offline or ‘real life’ relationships, unsuccessful attempts to decrease use and withdrawal symptoms,” the “Media Use in School-Aged Children and Adolescents” policy statement notes.
Recommendations for older children
The policy statement advises pediatricians to help families and schools promote understanding of media’s risks and benefits, including awareness of tools to screen for sexting, cyberbullying, problematic Internet use, and Internet gaming disorder. Pediatricians should advocate for training in media literacy in the community and encourage parents to follow the media, sleep, and physical activity guidelines included in the Family Media Plan.
The research was supported by the American Academy of Pediatrics. The authors reported no disclosures.
Treatment plan addresses circadian rhythm disorders from nighttime screen use
SAN FRANCISCO – Among the most significant concerns associated with youth’s increasing use of screen media is the impact on their sleep, according to two policy statements of the American Academy of Pediatrics on children and media use.
To help pediatricians better understand how media might affect sleep, Sujay Kansagra, MD, a pediatric neurologist at Duke University Medical Center in Durham, N.C., presented an overview of circadian rhythm disorders and how to address them during a program on electronic media at the AAP annual meeting.
Approximately 3 hours before waking, a person experiences a nadir in body temperature that designates “the point at which the light exposure flips from delaying your rhythm to advancing your rhythm,” Dr. Kansagra said. “Five minutes before this point, it delays your phase; 5 minutes after, it advances your phase.”
A significantly advanced or delayed sleep phase can become a circadian rhythm disorder, in which a person gets the normal amount and quality of sleep he or she needs – but not at the right times. “Those with circadian rhythm disorders have failed to entrain to their environmental cues,” such as light, food, and activity levels, he said.
In youth, particularly adolescents, the most common circadian rhythm disorder is delayed sleep-wake phase syndrome, defined in the International Classification of Sleep Disorders – Third Edition (ICSD-3) with four criteria:
• A significant delay in major sleep episode in relation to desired or required sleep time and waking time (often involving a sleep time around 4 a.m.).
• The symptoms are present for more than 3 months.
• When allowed to choose a schedule, the person will exhibit improved sleep quality/duration and maintain delayed phase.
• A sleep log and/or actigraphy demonstrates a delay in timing of the sleep period for at least 7 days.
Because nearly all screen media emit light, use of such media in the evenings may contribute to this disorder. “When you combine light exposure with someone who has that later chronotype, you’re setting yourself up for disaster,” Dr. Kansagra said.
Delayed sleep-wake phase disorder can greatly interfere with school, work, and normal daily activities, and Dr. Kansagra outlined the major steps in preventing and/or treating it, starting with avoiding light exposure at night, whether from the TV, tablets, laptops, or cell phones.
“If they can’t avoid light completely, the brightness is also important,” he said. “We know that the brighter the light, the more likely you are to suppress your brain’s melatonin.” Therefore, reducing the brightness on devices that must be used can mitigate the problem, as can using red- or yellow-tinted light, provided as a “night mode” on some devices, instead of the blue light emitted by the majority of devices.
Next, he recommended that individuals maintain a set bedtime and wake time each day, including on the weekends. Although he acknowledged the challenge this schedule might present, particularly in teenagers, he described how detrimental it can be to stay up late and sleep in late on the weekends. If teens stay up until 11 p.m. throughout the week, then a little later on Friday night, and then up to 2 a.m. on Saturday night, they will likely sleep in until around 11 a.m. on Sunday. But if they need to get up at 6 a.m. for school Monday morning, that’s the equivalent of flying from Hawaii to New York in terms of jet lag effects, he explained.
“They will spend the rest of the school week slowly advancing their clock until the weekend and do it all over again,” Dr. Kansagra said. “They are perpetually jet lagged. No wonder they’re so angry all the time,” he joked. “It’s social jet lag.”
Such social jet lag leads to sleepiness throughout the week, often mistaken for laziness by frustrated parents, he said.
“Sleepiness is not laziness,” he emphasized. “It’s a problem with the quality or quantity of sleep. It’s really important to get parents’ buy in on this because it’s a contentious topic in a lot of families.”
After getting the child or teen on a regular schedule, the next important step in realigning a circadian rhythm and then maintaining it is to expose the person to light early in the morning – but after that temperature nadir that occurs 3 hours before waking. Meanwhile, 2-6 hours before their sleep time, youth trying to adjust their clocks can take a low dose of melatonin, around 0.5-1 mg. But he pointed out a common misconception about how melatonin works.
“Melatonin plays no role in fixing insomnia; melatonin doesn’t make you sleepy,” Dr. Kansagra said. “Melatonin just tells your brain what to do when it’s dark. Melatonin is good for shifting your circadian rhythm.”
But all of these steps can be successful only if the pediatrician and/or parent can convince the child or teen that it’s important to adjust their circadian rhythm. This can include discussions that lead them to realize or conclude that they are unpleasant, angry, or irritable when they don’t get enough sleep. Perhaps they have been told they are rude by a classmate on days they don’t get enough sleep, or perhaps they realize they do not perform as well while playing sports when they don’t have the rest they need. Children who can make those connections can help get the buy in needed to follow all the previous steps.
Some individuals, however, can be particularly resistant to adjusting the circadian rhythm, which calls for a much more dramatic and difficult treatment called chronotherapy. This treatment begins very counterintuitively by flipping the script: The youth should now actually try to stay up later than their bedtime while playing video games, watching TV, using a computer, or engaging in similar activities. Ideally, they should stay up until 6 a.m. and then sleep in as late as they wish.
The next evening, they should stay up even later – until 8 a.m. – and again sleep in as late as they need to. Each successive day, they should go to bed 2 hours later – 10 a.m., 12 p.m., 2 p.m., and so forth – and sleep the adequate amount anyone would need, until they eventually are going to bed at the time they should be, such as 8 p.m. or 10 p.m. Although this is a dramatic treatment, it can be very effective at resetting a person’s clock when other methods have not succeeded, he said.
The key practice-altering elements of Dr. Kansagra’s talk focused on using melatonin as a “clock-shifting” medication instead of a “sleep-inducing one” and dosing children at the appropriate time, 2-6 hours before bed. If nighttime use of light cannot be eliminated, have patients reduce the brightness and duration, and change the color, of the light to lessen its effect on the brain’s melatonin release. Finally, help families understand the concept of “social jet lag” so they grasp the importance of regular sleep times and do not mistake sleepiness for laziness.
Dr. Kansagra reported no relevant financial disclosures or external funding.
SAN FRANCISCO – Among the most significant concerns associated with youth’s increasing use of screen media is the impact on their sleep, according to two policy statements of the American Academy of Pediatrics on children and media use.
To help pediatricians better understand how media might affect sleep, Sujay Kansagra, MD, a pediatric neurologist at Duke University Medical Center in Durham, N.C., presented an overview of circadian rhythm disorders and how to address them during a program on electronic media at the AAP annual meeting.
Approximately 3 hours before waking, a person experiences a nadir in body temperature that designates “the point at which the light exposure flips from delaying your rhythm to advancing your rhythm,” Dr. Kansagra said. “Five minutes before this point, it delays your phase; 5 minutes after, it advances your phase.”
A significantly advanced or delayed sleep phase can become a circadian rhythm disorder, in which a person gets the normal amount and quality of sleep he or she needs – but not at the right times. “Those with circadian rhythm disorders have failed to entrain to their environmental cues,” such as light, food, and activity levels, he said.
In youth, particularly adolescents, the most common circadian rhythm disorder is delayed sleep-wake phase syndrome, defined in the International Classification of Sleep Disorders – Third Edition (ICSD-3) with four criteria:
• A significant delay in major sleep episode in relation to desired or required sleep time and waking time (often involving a sleep time around 4 a.m.).
• The symptoms are present for more than 3 months.
• When allowed to choose a schedule, the person will exhibit improved sleep quality/duration and maintain delayed phase.
• A sleep log and/or actigraphy demonstrates a delay in timing of the sleep period for at least 7 days.
Because nearly all screen media emit light, use of such media in the evenings may contribute to this disorder. “When you combine light exposure with someone who has that later chronotype, you’re setting yourself up for disaster,” Dr. Kansagra said.
Delayed sleep-wake phase disorder can greatly interfere with school, work, and normal daily activities, and Dr. Kansagra outlined the major steps in preventing and/or treating it, starting with avoiding light exposure at night, whether from the TV, tablets, laptops, or cell phones.
“If they can’t avoid light completely, the brightness is also important,” he said. “We know that the brighter the light, the more likely you are to suppress your brain’s melatonin.” Therefore, reducing the brightness on devices that must be used can mitigate the problem, as can using red- or yellow-tinted light, provided as a “night mode” on some devices, instead of the blue light emitted by the majority of devices.
Next, he recommended that individuals maintain a set bedtime and wake time each day, including on the weekends. Although he acknowledged the challenge this schedule might present, particularly in teenagers, he described how detrimental it can be to stay up late and sleep in late on the weekends. If teens stay up until 11 p.m. throughout the week, then a little later on Friday night, and then up to 2 a.m. on Saturday night, they will likely sleep in until around 11 a.m. on Sunday. But if they need to get up at 6 a.m. for school Monday morning, that’s the equivalent of flying from Hawaii to New York in terms of jet lag effects, he explained.
“They will spend the rest of the school week slowly advancing their clock until the weekend and do it all over again,” Dr. Kansagra said. “They are perpetually jet lagged. No wonder they’re so angry all the time,” he joked. “It’s social jet lag.”
Such social jet lag leads to sleepiness throughout the week, often mistaken for laziness by frustrated parents, he said.
“Sleepiness is not laziness,” he emphasized. “It’s a problem with the quality or quantity of sleep. It’s really important to get parents’ buy in on this because it’s a contentious topic in a lot of families.”
After getting the child or teen on a regular schedule, the next important step in realigning a circadian rhythm and then maintaining it is to expose the person to light early in the morning – but after that temperature nadir that occurs 3 hours before waking. Meanwhile, 2-6 hours before their sleep time, youth trying to adjust their clocks can take a low dose of melatonin, around 0.5-1 mg. But he pointed out a common misconception about how melatonin works.
“Melatonin plays no role in fixing insomnia; melatonin doesn’t make you sleepy,” Dr. Kansagra said. “Melatonin just tells your brain what to do when it’s dark. Melatonin is good for shifting your circadian rhythm.”
But all of these steps can be successful only if the pediatrician and/or parent can convince the child or teen that it’s important to adjust their circadian rhythm. This can include discussions that lead them to realize or conclude that they are unpleasant, angry, or irritable when they don’t get enough sleep. Perhaps they have been told they are rude by a classmate on days they don’t get enough sleep, or perhaps they realize they do not perform as well while playing sports when they don’t have the rest they need. Children who can make those connections can help get the buy in needed to follow all the previous steps.
Some individuals, however, can be particularly resistant to adjusting the circadian rhythm, which calls for a much more dramatic and difficult treatment called chronotherapy. This treatment begins very counterintuitively by flipping the script: The youth should now actually try to stay up later than their bedtime while playing video games, watching TV, using a computer, or engaging in similar activities. Ideally, they should stay up until 6 a.m. and then sleep in as late as they wish.
The next evening, they should stay up even later – until 8 a.m. – and again sleep in as late as they need to. Each successive day, they should go to bed 2 hours later – 10 a.m., 12 p.m., 2 p.m., and so forth – and sleep the adequate amount anyone would need, until they eventually are going to bed at the time they should be, such as 8 p.m. or 10 p.m. Although this is a dramatic treatment, it can be very effective at resetting a person’s clock when other methods have not succeeded, he said.
The key practice-altering elements of Dr. Kansagra’s talk focused on using melatonin as a “clock-shifting” medication instead of a “sleep-inducing one” and dosing children at the appropriate time, 2-6 hours before bed. If nighttime use of light cannot be eliminated, have patients reduce the brightness and duration, and change the color, of the light to lessen its effect on the brain’s melatonin release. Finally, help families understand the concept of “social jet lag” so they grasp the importance of regular sleep times and do not mistake sleepiness for laziness.
Dr. Kansagra reported no relevant financial disclosures or external funding.
SAN FRANCISCO – Among the most significant concerns associated with youth’s increasing use of screen media is the impact on their sleep, according to two policy statements of the American Academy of Pediatrics on children and media use.
To help pediatricians better understand how media might affect sleep, Sujay Kansagra, MD, a pediatric neurologist at Duke University Medical Center in Durham, N.C., presented an overview of circadian rhythm disorders and how to address them during a program on electronic media at the AAP annual meeting.
Approximately 3 hours before waking, a person experiences a nadir in body temperature that designates “the point at which the light exposure flips from delaying your rhythm to advancing your rhythm,” Dr. Kansagra said. “Five minutes before this point, it delays your phase; 5 minutes after, it advances your phase.”
A significantly advanced or delayed sleep phase can become a circadian rhythm disorder, in which a person gets the normal amount and quality of sleep he or she needs – but not at the right times. “Those with circadian rhythm disorders have failed to entrain to their environmental cues,” such as light, food, and activity levels, he said.
In youth, particularly adolescents, the most common circadian rhythm disorder is delayed sleep-wake phase syndrome, defined in the International Classification of Sleep Disorders – Third Edition (ICSD-3) with four criteria:
• A significant delay in major sleep episode in relation to desired or required sleep time and waking time (often involving a sleep time around 4 a.m.).
• The symptoms are present for more than 3 months.
• When allowed to choose a schedule, the person will exhibit improved sleep quality/duration and maintain delayed phase.
• A sleep log and/or actigraphy demonstrates a delay in timing of the sleep period for at least 7 days.
Because nearly all screen media emit light, use of such media in the evenings may contribute to this disorder. “When you combine light exposure with someone who has that later chronotype, you’re setting yourself up for disaster,” Dr. Kansagra said.
Delayed sleep-wake phase disorder can greatly interfere with school, work, and normal daily activities, and Dr. Kansagra outlined the major steps in preventing and/or treating it, starting with avoiding light exposure at night, whether from the TV, tablets, laptops, or cell phones.
“If they can’t avoid light completely, the brightness is also important,” he said. “We know that the brighter the light, the more likely you are to suppress your brain’s melatonin.” Therefore, reducing the brightness on devices that must be used can mitigate the problem, as can using red- or yellow-tinted light, provided as a “night mode” on some devices, instead of the blue light emitted by the majority of devices.
Next, he recommended that individuals maintain a set bedtime and wake time each day, including on the weekends. Although he acknowledged the challenge this schedule might present, particularly in teenagers, he described how detrimental it can be to stay up late and sleep in late on the weekends. If teens stay up until 11 p.m. throughout the week, then a little later on Friday night, and then up to 2 a.m. on Saturday night, they will likely sleep in until around 11 a.m. on Sunday. But if they need to get up at 6 a.m. for school Monday morning, that’s the equivalent of flying from Hawaii to New York in terms of jet lag effects, he explained.
“They will spend the rest of the school week slowly advancing their clock until the weekend and do it all over again,” Dr. Kansagra said. “They are perpetually jet lagged. No wonder they’re so angry all the time,” he joked. “It’s social jet lag.”
Such social jet lag leads to sleepiness throughout the week, often mistaken for laziness by frustrated parents, he said.
“Sleepiness is not laziness,” he emphasized. “It’s a problem with the quality or quantity of sleep. It’s really important to get parents’ buy in on this because it’s a contentious topic in a lot of families.”
After getting the child or teen on a regular schedule, the next important step in realigning a circadian rhythm and then maintaining it is to expose the person to light early in the morning – but after that temperature nadir that occurs 3 hours before waking. Meanwhile, 2-6 hours before their sleep time, youth trying to adjust their clocks can take a low dose of melatonin, around 0.5-1 mg. But he pointed out a common misconception about how melatonin works.
“Melatonin plays no role in fixing insomnia; melatonin doesn’t make you sleepy,” Dr. Kansagra said. “Melatonin just tells your brain what to do when it’s dark. Melatonin is good for shifting your circadian rhythm.”
But all of these steps can be successful only if the pediatrician and/or parent can convince the child or teen that it’s important to adjust their circadian rhythm. This can include discussions that lead them to realize or conclude that they are unpleasant, angry, or irritable when they don’t get enough sleep. Perhaps they have been told they are rude by a classmate on days they don’t get enough sleep, or perhaps they realize they do not perform as well while playing sports when they don’t have the rest they need. Children who can make those connections can help get the buy in needed to follow all the previous steps.
Some individuals, however, can be particularly resistant to adjusting the circadian rhythm, which calls for a much more dramatic and difficult treatment called chronotherapy. This treatment begins very counterintuitively by flipping the script: The youth should now actually try to stay up later than their bedtime while playing video games, watching TV, using a computer, or engaging in similar activities. Ideally, they should stay up until 6 a.m. and then sleep in as late as they wish.
The next evening, they should stay up even later – until 8 a.m. – and again sleep in as late as they need to. Each successive day, they should go to bed 2 hours later – 10 a.m., 12 p.m., 2 p.m., and so forth – and sleep the adequate amount anyone would need, until they eventually are going to bed at the time they should be, such as 8 p.m. or 10 p.m. Although this is a dramatic treatment, it can be very effective at resetting a person’s clock when other methods have not succeeded, he said.
The key practice-altering elements of Dr. Kansagra’s talk focused on using melatonin as a “clock-shifting” medication instead of a “sleep-inducing one” and dosing children at the appropriate time, 2-6 hours before bed. If nighttime use of light cannot be eliminated, have patients reduce the brightness and duration, and change the color, of the light to lessen its effect on the brain’s melatonin release. Finally, help families understand the concept of “social jet lag” so they grasp the importance of regular sleep times and do not mistake sleepiness for laziness.
Dr. Kansagra reported no relevant financial disclosures or external funding.
EXPERT ANALYSIS FROM AAP 16
Use of 2D bar coding with vaccines may be the future in pediatric practice
ATLANTA – Since the first bar coded consumer product, a pack of gum, was scanned in June of 1974, the soon widespread use of bar codes changed little until 2D bar codes arrived toward the end of last century. Today, the increasing use of 2D bar code technology with vaccines offers practices the potential for greater accuracy and efficiency with vaccine administration and data entry – if they have the resources to take the plunge.
An overview of 2D bar code use with vaccines, presented at a conference sponsored by the Centers for Disease Control and Prevention, provided a glimpse into both the types of changes practices might see with adoption of the technology and the way some clinics have made the transition.
Ken Gerlach, MPH, of the Immunization Services Division at the CDC in Atlanta, outlined the history of bar code use in immunizations, starting with a November 1999 Institute of Medicine report that identified the contribution of human error to disease and led the Food and Drug Administration to begin requiring linear bar codes on pharmaceutical unit-of-use products to reduce errors.
Then, a meeting organized by the American Academy of Pediatrics in January 2009 with the FDA, CDC, vaccine manufacturers, and other stakeholders led to a bar code rule change by the FDA in August 2011 that allowed alternatives to the traditional linear bar codes on vaccine vials and syringes.
“They essentially indicated to the pharmaceutical companies that it’s okay to add 2D bar codes, and this is essentially the point where things began to take off,” Mr. Gerlach explained. Until then, there had been no 2D bar codes on vaccines, but today the majority of vaccine products have them, as do all Vaccine Information Statements. In addition to the standard information included on traditional bar codes – Global Trade Item Number (GTIN), lot and serial numbers, and the expiration date – 2D bar codes also can include most relevant patient information that would go into the EMR except the injection site and immunization route. But a practice cannot simply jump over to scanning the 2D bar codes without ensuring that its EMR system is configured to accept the scanning.
Mr. Gerlach described a three-part project by the CDC, from 2011 through 2017, that assesses the impact of 2D coding on vaccination data quality and work flow, facilitates the adoption of 2D bar code scanning in health care practices, and then assesses the potential for expanding 2D bar code use in a large health care system. The first part of the project, which ran from 2011 to 2014, involved two vaccine manufacturers and 217 health care practices with more than 1.4 million de-identified vaccination records, 18.1% of which had been 2D bar coded.
Analysis of data quality from that pilot revealed an 8% increase in the correctness of lot numbers and 11% increase for expiration dates, with a time savings of 3.4 seconds per vaccine administration. Among the 116 staff users who completed surveys, 86% agreed that 2D bar coding improves accuracy and completeness, and 60% agreed it was easy to integrate the bar coding into their usual data recording process.
The pilot revealed challenges as well, however: not all individuals units of vaccines were 2D bar coded, users did not always consistently scan the bar codes, and some bar codes were difficult to read, such as one that was brown and wouldn’t scan. Another obstacle was having different lot numbers on the unit of use versus the unit of sale with 10% of the vaccines. Further, because inventory management typically involves unit of sale, it does not always match well with scanning unit of use.
Clinicians’ beliefs and attitudes toward 2D bar coding
As more practices consider adopting the technology, buy-in will important. At the conference, Sharon Humiston, MD, and Jill Hernandez, MPH, of Children’s Mercy Hospital in Kansas City, Mo., shared the findings of an online questionnaire about 2D bar coding and practices’ current systems for vaccine inventory and recording patient immunization information. The researchers distributed the questionnaire link to various AAP sections and committees in listservs and emails. Those eligible to complete the 15-minute survey were primary care personnel who used EMRs but not 2D bar code scanning for vaccines. They also needed to be key decision makers in the process of purchasing technology for the practice, and their practice needed to be enrolled in the Vaccines for Children program.
Among the 77 respondents who met all the inclusion criteria (61% of all who started the survey), 1 in 5 were private practices with one or two physicians, just over a third (36%) were private practices with more than two physicians, and a quarter were multispecialty group practices. Overall, respondents administered an average 116 doses of DTaP and 50 doses of Tdap each month.
Protocols for immunization management varied considerably across the respondents. For recording vaccine information, 49% reported that an administrator pre-entered it into an EMR, but 43% reported that staff manually enter it into an EMR. About 55% of practices entered the information before vaccine administration, and 42% entered it afterward. Although 57% of respondents’ practices upload the vaccination information directly from the EMR to their state’s Immunization Information System (IIS), 30% must enter it both into the EMR and into the state IIS separately, and 11% don’t enter it into a state IIS.
More than half (56%) of the respondents were extremely interested in having a bar code scanner system, and 31% were moderately to strongly interested, rating a 6 to 9 on a scale of 1 to 10. If provided evidence that 2D bar codes reduced errors in vaccine documentation, 56% of respondents said it would greatly increase their interest, and 32% said it would somewhat increase it. Only 23% said their interest would greatly increase if the bar code technology allowed the vaccine information statement to be scanned into EMRs.
Nearly all the respondents agreed that 2D bar code scanning technology would improve efficiency and accuracy of entering vaccine information into medical records and tracking vaccine inventory. Further, 81% believed it would reduce medical malpractice liability, and 85% believed it would reduce risk of harm to patients. However, 23% thought bar code technology would disrupt office work flow, and a quarter believed the technology’s costs would exceeds its benefits.
Despite the strong interest overall, respondents reported a number of barriers to adopting 2D bar code technology. The greatest barrier, reported by more than 70%, was the upfront cost of purchasing software for the EMR interface, followed by the cost of the bar code scanners. Other barriers, reported by 25%-45% of respondents, were the need for staff training, the need to service and maintain electronics for the technology, and the purchase of additional computers for scanner sites. If a bar code system cost less than $5,000, then 80% of the respondents would definitely or probably adopt such a system. Few would adopt it if the system cost $10,000 or more, but 42% probably would if it cost between $5,000 and $9,999. Even this small survey of self-selected volunteers, however, suggested strong interest in using 2D bar code technology for vaccines – although initial costs for a system presented a significant barrier to most practices.
One influenza vaccine clinic’s experience
Interest based on hypothetical questions is one thing. The process of actually implementing a 2D bar code scanning system into a health care center is another. In a separate presentation, Jane Glaser, MSN, RN, executive director of Campbell County Public Health in Gillette, Wyo., reviewed how such a system was implemented for mass influenza vaccination.
Campbell County, in the northeast corner of Wyoming, covers more than 4,800 square miles, has a population base of nearly 50,000 people, and also serves individuals from Montana, South Dakota, and North Dakota. Although the community as a whole works 24/7 in the county because of the oil, mining, and farming industries, the mass flu clinic is open 7 a.m. to 7 p.m., during which it provides an estimated 700 to 1,500 flu vaccines daily. Personnel comprises 13 public health nurses, 5 administrative assistants, and 3-4 community volunteers.
After 20 years of using an IIS, the clinic’s leadership decided to begin using 2D bar code scanners in October 2011 after observing it at a state immunization conference. Their goals in changing systems were to increase clinic flow, decrease registration time, and decrease overtime due to data entry. The new work flow went as follows: Those with Wyoming driver licenses or state ID cards have the linear bar code on their ID scanned in the immunization registry, which automatically populates the patient’s record. Then the staff member enters the vaccine information directly into the IIS registry in real time after the client receives the vaccine.
Ms. Glaser describes a number of improvements that resulted from use of the bar code scanning system, starting with reduced time for clinic registration and improved clinic flow. They also found that using bar code scanning reduced manual entry errors and improved the efficiency of assessing vaccination status and needed vaccines. Entering data in real time at point of care reduced time spent on data entry later on, thereby leading to a decrease in overtime and subsequent cost savings.
For providers and practices interested in learning more about 2D bar coding, the CDC offers a current list of 2D bar coded vaccines, data from the pilot program, training materials, and AAP guidance about 2D bar code use.
None of three presentations noted external funding, and all the researchers reported no financial relationships with companies that profit from bar code scanning technology. Deloitte Consulting, was involved in the three-part project conducted by the CDC.
ATLANTA – Since the first bar coded consumer product, a pack of gum, was scanned in June of 1974, the soon widespread use of bar codes changed little until 2D bar codes arrived toward the end of last century. Today, the increasing use of 2D bar code technology with vaccines offers practices the potential for greater accuracy and efficiency with vaccine administration and data entry – if they have the resources to take the plunge.
An overview of 2D bar code use with vaccines, presented at a conference sponsored by the Centers for Disease Control and Prevention, provided a glimpse into both the types of changes practices might see with adoption of the technology and the way some clinics have made the transition.
Ken Gerlach, MPH, of the Immunization Services Division at the CDC in Atlanta, outlined the history of bar code use in immunizations, starting with a November 1999 Institute of Medicine report that identified the contribution of human error to disease and led the Food and Drug Administration to begin requiring linear bar codes on pharmaceutical unit-of-use products to reduce errors.
Then, a meeting organized by the American Academy of Pediatrics in January 2009 with the FDA, CDC, vaccine manufacturers, and other stakeholders led to a bar code rule change by the FDA in August 2011 that allowed alternatives to the traditional linear bar codes on vaccine vials and syringes.
“They essentially indicated to the pharmaceutical companies that it’s okay to add 2D bar codes, and this is essentially the point where things began to take off,” Mr. Gerlach explained. Until then, there had been no 2D bar codes on vaccines, but today the majority of vaccine products have them, as do all Vaccine Information Statements. In addition to the standard information included on traditional bar codes – Global Trade Item Number (GTIN), lot and serial numbers, and the expiration date – 2D bar codes also can include most relevant patient information that would go into the EMR except the injection site and immunization route. But a practice cannot simply jump over to scanning the 2D bar codes without ensuring that its EMR system is configured to accept the scanning.
Mr. Gerlach described a three-part project by the CDC, from 2011 through 2017, that assesses the impact of 2D coding on vaccination data quality and work flow, facilitates the adoption of 2D bar code scanning in health care practices, and then assesses the potential for expanding 2D bar code use in a large health care system. The first part of the project, which ran from 2011 to 2014, involved two vaccine manufacturers and 217 health care practices with more than 1.4 million de-identified vaccination records, 18.1% of which had been 2D bar coded.
Analysis of data quality from that pilot revealed an 8% increase in the correctness of lot numbers and 11% increase for expiration dates, with a time savings of 3.4 seconds per vaccine administration. Among the 116 staff users who completed surveys, 86% agreed that 2D bar coding improves accuracy and completeness, and 60% agreed it was easy to integrate the bar coding into their usual data recording process.
The pilot revealed challenges as well, however: not all individuals units of vaccines were 2D bar coded, users did not always consistently scan the bar codes, and some bar codes were difficult to read, such as one that was brown and wouldn’t scan. Another obstacle was having different lot numbers on the unit of use versus the unit of sale with 10% of the vaccines. Further, because inventory management typically involves unit of sale, it does not always match well with scanning unit of use.
Clinicians’ beliefs and attitudes toward 2D bar coding
As more practices consider adopting the technology, buy-in will important. At the conference, Sharon Humiston, MD, and Jill Hernandez, MPH, of Children’s Mercy Hospital in Kansas City, Mo., shared the findings of an online questionnaire about 2D bar coding and practices’ current systems for vaccine inventory and recording patient immunization information. The researchers distributed the questionnaire link to various AAP sections and committees in listservs and emails. Those eligible to complete the 15-minute survey were primary care personnel who used EMRs but not 2D bar code scanning for vaccines. They also needed to be key decision makers in the process of purchasing technology for the practice, and their practice needed to be enrolled in the Vaccines for Children program.
Among the 77 respondents who met all the inclusion criteria (61% of all who started the survey), 1 in 5 were private practices with one or two physicians, just over a third (36%) were private practices with more than two physicians, and a quarter were multispecialty group practices. Overall, respondents administered an average 116 doses of DTaP and 50 doses of Tdap each month.
Protocols for immunization management varied considerably across the respondents. For recording vaccine information, 49% reported that an administrator pre-entered it into an EMR, but 43% reported that staff manually enter it into an EMR. About 55% of practices entered the information before vaccine administration, and 42% entered it afterward. Although 57% of respondents’ practices upload the vaccination information directly from the EMR to their state’s Immunization Information System (IIS), 30% must enter it both into the EMR and into the state IIS separately, and 11% don’t enter it into a state IIS.
More than half (56%) of the respondents were extremely interested in having a bar code scanner system, and 31% were moderately to strongly interested, rating a 6 to 9 on a scale of 1 to 10. If provided evidence that 2D bar codes reduced errors in vaccine documentation, 56% of respondents said it would greatly increase their interest, and 32% said it would somewhat increase it. Only 23% said their interest would greatly increase if the bar code technology allowed the vaccine information statement to be scanned into EMRs.
Nearly all the respondents agreed that 2D bar code scanning technology would improve efficiency and accuracy of entering vaccine information into medical records and tracking vaccine inventory. Further, 81% believed it would reduce medical malpractice liability, and 85% believed it would reduce risk of harm to patients. However, 23% thought bar code technology would disrupt office work flow, and a quarter believed the technology’s costs would exceeds its benefits.
Despite the strong interest overall, respondents reported a number of barriers to adopting 2D bar code technology. The greatest barrier, reported by more than 70%, was the upfront cost of purchasing software for the EMR interface, followed by the cost of the bar code scanners. Other barriers, reported by 25%-45% of respondents, were the need for staff training, the need to service and maintain electronics for the technology, and the purchase of additional computers for scanner sites. If a bar code system cost less than $5,000, then 80% of the respondents would definitely or probably adopt such a system. Few would adopt it if the system cost $10,000 or more, but 42% probably would if it cost between $5,000 and $9,999. Even this small survey of self-selected volunteers, however, suggested strong interest in using 2D bar code technology for vaccines – although initial costs for a system presented a significant barrier to most practices.
One influenza vaccine clinic’s experience
Interest based on hypothetical questions is one thing. The process of actually implementing a 2D bar code scanning system into a health care center is another. In a separate presentation, Jane Glaser, MSN, RN, executive director of Campbell County Public Health in Gillette, Wyo., reviewed how such a system was implemented for mass influenza vaccination.
Campbell County, in the northeast corner of Wyoming, covers more than 4,800 square miles, has a population base of nearly 50,000 people, and also serves individuals from Montana, South Dakota, and North Dakota. Although the community as a whole works 24/7 in the county because of the oil, mining, and farming industries, the mass flu clinic is open 7 a.m. to 7 p.m., during which it provides an estimated 700 to 1,500 flu vaccines daily. Personnel comprises 13 public health nurses, 5 administrative assistants, and 3-4 community volunteers.
After 20 years of using an IIS, the clinic’s leadership decided to begin using 2D bar code scanners in October 2011 after observing it at a state immunization conference. Their goals in changing systems were to increase clinic flow, decrease registration time, and decrease overtime due to data entry. The new work flow went as follows: Those with Wyoming driver licenses or state ID cards have the linear bar code on their ID scanned in the immunization registry, which automatically populates the patient’s record. Then the staff member enters the vaccine information directly into the IIS registry in real time after the client receives the vaccine.
Ms. Glaser describes a number of improvements that resulted from use of the bar code scanning system, starting with reduced time for clinic registration and improved clinic flow. They also found that using bar code scanning reduced manual entry errors and improved the efficiency of assessing vaccination status and needed vaccines. Entering data in real time at point of care reduced time spent on data entry later on, thereby leading to a decrease in overtime and subsequent cost savings.
For providers and practices interested in learning more about 2D bar coding, the CDC offers a current list of 2D bar coded vaccines, data from the pilot program, training materials, and AAP guidance about 2D bar code use.
None of three presentations noted external funding, and all the researchers reported no financial relationships with companies that profit from bar code scanning technology. Deloitte Consulting, was involved in the three-part project conducted by the CDC.
ATLANTA – Since the first bar coded consumer product, a pack of gum, was scanned in June of 1974, the soon widespread use of bar codes changed little until 2D bar codes arrived toward the end of last century. Today, the increasing use of 2D bar code technology with vaccines offers practices the potential for greater accuracy and efficiency with vaccine administration and data entry – if they have the resources to take the plunge.
An overview of 2D bar code use with vaccines, presented at a conference sponsored by the Centers for Disease Control and Prevention, provided a glimpse into both the types of changes practices might see with adoption of the technology and the way some clinics have made the transition.
Ken Gerlach, MPH, of the Immunization Services Division at the CDC in Atlanta, outlined the history of bar code use in immunizations, starting with a November 1999 Institute of Medicine report that identified the contribution of human error to disease and led the Food and Drug Administration to begin requiring linear bar codes on pharmaceutical unit-of-use products to reduce errors.
Then, a meeting organized by the American Academy of Pediatrics in January 2009 with the FDA, CDC, vaccine manufacturers, and other stakeholders led to a bar code rule change by the FDA in August 2011 that allowed alternatives to the traditional linear bar codes on vaccine vials and syringes.
“They essentially indicated to the pharmaceutical companies that it’s okay to add 2D bar codes, and this is essentially the point where things began to take off,” Mr. Gerlach explained. Until then, there had been no 2D bar codes on vaccines, but today the majority of vaccine products have them, as do all Vaccine Information Statements. In addition to the standard information included on traditional bar codes – Global Trade Item Number (GTIN), lot and serial numbers, and the expiration date – 2D bar codes also can include most relevant patient information that would go into the EMR except the injection site and immunization route. But a practice cannot simply jump over to scanning the 2D bar codes without ensuring that its EMR system is configured to accept the scanning.
Mr. Gerlach described a three-part project by the CDC, from 2011 through 2017, that assesses the impact of 2D coding on vaccination data quality and work flow, facilitates the adoption of 2D bar code scanning in health care practices, and then assesses the potential for expanding 2D bar code use in a large health care system. The first part of the project, which ran from 2011 to 2014, involved two vaccine manufacturers and 217 health care practices with more than 1.4 million de-identified vaccination records, 18.1% of which had been 2D bar coded.
Analysis of data quality from that pilot revealed an 8% increase in the correctness of lot numbers and 11% increase for expiration dates, with a time savings of 3.4 seconds per vaccine administration. Among the 116 staff users who completed surveys, 86% agreed that 2D bar coding improves accuracy and completeness, and 60% agreed it was easy to integrate the bar coding into their usual data recording process.
The pilot revealed challenges as well, however: not all individuals units of vaccines were 2D bar coded, users did not always consistently scan the bar codes, and some bar codes were difficult to read, such as one that was brown and wouldn’t scan. Another obstacle was having different lot numbers on the unit of use versus the unit of sale with 10% of the vaccines. Further, because inventory management typically involves unit of sale, it does not always match well with scanning unit of use.
Clinicians’ beliefs and attitudes toward 2D bar coding
As more practices consider adopting the technology, buy-in will important. At the conference, Sharon Humiston, MD, and Jill Hernandez, MPH, of Children’s Mercy Hospital in Kansas City, Mo., shared the findings of an online questionnaire about 2D bar coding and practices’ current systems for vaccine inventory and recording patient immunization information. The researchers distributed the questionnaire link to various AAP sections and committees in listservs and emails. Those eligible to complete the 15-minute survey were primary care personnel who used EMRs but not 2D bar code scanning for vaccines. They also needed to be key decision makers in the process of purchasing technology for the practice, and their practice needed to be enrolled in the Vaccines for Children program.
Among the 77 respondents who met all the inclusion criteria (61% of all who started the survey), 1 in 5 were private practices with one or two physicians, just over a third (36%) were private practices with more than two physicians, and a quarter were multispecialty group practices. Overall, respondents administered an average 116 doses of DTaP and 50 doses of Tdap each month.
Protocols for immunization management varied considerably across the respondents. For recording vaccine information, 49% reported that an administrator pre-entered it into an EMR, but 43% reported that staff manually enter it into an EMR. About 55% of practices entered the information before vaccine administration, and 42% entered it afterward. Although 57% of respondents’ practices upload the vaccination information directly from the EMR to their state’s Immunization Information System (IIS), 30% must enter it both into the EMR and into the state IIS separately, and 11% don’t enter it into a state IIS.
More than half (56%) of the respondents were extremely interested in having a bar code scanner system, and 31% were moderately to strongly interested, rating a 6 to 9 on a scale of 1 to 10. If provided evidence that 2D bar codes reduced errors in vaccine documentation, 56% of respondents said it would greatly increase their interest, and 32% said it would somewhat increase it. Only 23% said their interest would greatly increase if the bar code technology allowed the vaccine information statement to be scanned into EMRs.
Nearly all the respondents agreed that 2D bar code scanning technology would improve efficiency and accuracy of entering vaccine information into medical records and tracking vaccine inventory. Further, 81% believed it would reduce medical malpractice liability, and 85% believed it would reduce risk of harm to patients. However, 23% thought bar code technology would disrupt office work flow, and a quarter believed the technology’s costs would exceeds its benefits.
Despite the strong interest overall, respondents reported a number of barriers to adopting 2D bar code technology. The greatest barrier, reported by more than 70%, was the upfront cost of purchasing software for the EMR interface, followed by the cost of the bar code scanners. Other barriers, reported by 25%-45% of respondents, were the need for staff training, the need to service and maintain electronics for the technology, and the purchase of additional computers for scanner sites. If a bar code system cost less than $5,000, then 80% of the respondents would definitely or probably adopt such a system. Few would adopt it if the system cost $10,000 or more, but 42% probably would if it cost between $5,000 and $9,999. Even this small survey of self-selected volunteers, however, suggested strong interest in using 2D bar code technology for vaccines – although initial costs for a system presented a significant barrier to most practices.
One influenza vaccine clinic’s experience
Interest based on hypothetical questions is one thing. The process of actually implementing a 2D bar code scanning system into a health care center is another. In a separate presentation, Jane Glaser, MSN, RN, executive director of Campbell County Public Health in Gillette, Wyo., reviewed how such a system was implemented for mass influenza vaccination.
Campbell County, in the northeast corner of Wyoming, covers more than 4,800 square miles, has a population base of nearly 50,000 people, and also serves individuals from Montana, South Dakota, and North Dakota. Although the community as a whole works 24/7 in the county because of the oil, mining, and farming industries, the mass flu clinic is open 7 a.m. to 7 p.m., during which it provides an estimated 700 to 1,500 flu vaccines daily. Personnel comprises 13 public health nurses, 5 administrative assistants, and 3-4 community volunteers.
After 20 years of using an IIS, the clinic’s leadership decided to begin using 2D bar code scanners in October 2011 after observing it at a state immunization conference. Their goals in changing systems were to increase clinic flow, decrease registration time, and decrease overtime due to data entry. The new work flow went as follows: Those with Wyoming driver licenses or state ID cards have the linear bar code on their ID scanned in the immunization registry, which automatically populates the patient’s record. Then the staff member enters the vaccine information directly into the IIS registry in real time after the client receives the vaccine.
Ms. Glaser describes a number of improvements that resulted from use of the bar code scanning system, starting with reduced time for clinic registration and improved clinic flow. They also found that using bar code scanning reduced manual entry errors and improved the efficiency of assessing vaccination status and needed vaccines. Entering data in real time at point of care reduced time spent on data entry later on, thereby leading to a decrease in overtime and subsequent cost savings.
For providers and practices interested in learning more about 2D bar coding, the CDC offers a current list of 2D bar coded vaccines, data from the pilot program, training materials, and AAP guidance about 2D bar code use.
None of three presentations noted external funding, and all the researchers reported no financial relationships with companies that profit from bar code scanning technology. Deloitte Consulting, was involved in the three-part project conducted by the CDC.
EXPERT ANALYSIS FROM AAP 16
Key clinical point: 2D bar coding with vaccines offers benefits and challenges.
Major finding:
Data source: A CDC study, an online questionnaire, and experience in a Wyoming flu clinic.
Disclosures: None of three presentations noted external funding, and all researchers reported no financial relationships with companies that profit from bar code scanning technology. Deloitte Consulting was involved in the three-part project conducted by the CDC.
Prenatal SSRI exposure linked to speech, language disorders
Selective serotonin reuptake inhibitors taken during pregnancy are linked to a 37% increased risk of speech and language disorders in the children prenatally exposed to them, according to a prospective birth cohort study.
That risk occurs when children exposed prenatally are compared with children whose mothers did not take SSRIs but who had a diagnosis for which the antidepressants are indicated.
“The finding was observed only in offspring of mothers who purchased at least two SSRI prescriptions during pregnancy,” reported Alan S. Brown, MD, of New York State Psychiatric Institute in New York City, and his associates (JAMA Psychiatry. 2016 Oct 12. doi: 10.1001/jamapsychiatry.2016.2594). “This finding is particularly noteworthy because these women were more likely to have taken these medications and were exposed for a longer period and to larger amounts of SSRIs during pregnancy, compared with women who filled only one prescription.”
From among an initial cohort of 845,345 pregnant women in Finland, the researchers followed a final cohort of 56,340 offspring. Most of the children (86.6%) were 9 years old or younger at the end of study follow-up, running from 1996 to 2010, and the oldest children were aged 14 years. The researchers used Finland’s national registries to determine the children’s and mothers’ diagnoses and the mothers’ history of prescriptions from 30 days before pregnancy through delivery.
Among all children, 15,596 children were born to women who took SSRIs for depression or another SSRI-indicated psychiatric condition, and 31,207 children were born to mothers who had neither a psychiatric diagnosis nor a history of taking SSRIs during pregnancy. The remaining 9,537 children had mothers with a psychiatric diagnosis but who did not take SSRIs during pregnancy.
The average ages of the children at diagnosis were 4.4 years for speech or language disorders, 3.6 years for scholastic problems, and 7.7 years for motor disorders. When the researchers compared the children prenatally exposed to SSRIs to the children of mothers with a depression-related diagnosis but not taking SSRIs during pregnancy, the rates of scholastic or motor disorders did not differ.
For language and speech disorders, however, children whose mothers purchased two SSRI prescriptions had a 37% increased risk of a disorder, compared with children whose mothers had a diagnosis but did not purchase SSRIs. Without the requirement of at least two prescriptions, the statistical difference did not exist.
That increased risk occurred after adjustment for sex, mother’s parity, marital status, socioeconomic status, place of residence, both parents’ ages, the children’s gestational age at birth, prenatal exposure to antiepileptic drugs, exposure to anxiolytics/sedatives, history of chronic diseases, death of the child’s parent, mother’s country of birth, maternal smoking or substance abuse, and the psychiatric history of both parents. Data on maternal alcohol consumption were unavailable. Both the children exposed to SSRIs and the children of unmedicated mothers with a psychiatric condition had a higher risk of speech and language disorders.
The research was funded by the National Institutes of Health; the Sackler Foundation of Columbia University, New York; and the University of Turku (Finland). One of the researchers, David Gyllenberg, MD, reported receiving research funding from the Sigrid Juselius Foundation, the Foundation for Pediatric Research in Finland, and the Finnish Medical Foundation. No other conflicts of interest were disclosed.
Alan S. Brown, MD, and his associates examined a great deal of data, but the clinical implications of their findings are fuzzy, wrote Lee S. Cohen, MD, and Ruta Nonacs, MD, in an accompanying editorial (JAMA Psychiatry. 2016 Oct 12. doi: 10.1001/jamapsychiatry.2016.2705).
“The frequency of speech/language problems following referral to specialized health care services are relatively small; disorders occurred in 1.6% of patients from the SSRI-exposed group, 1.9% from the unmedicated group, and 1.0% from the nonexposed group,” Dr. Cohen and Dr. Nonacs wrote. “Are the data presented a signal of concern requiring further study or just background noise?”
Dr. Cohen has received support from several companies, including Cephalon, Takeda/Lundbeck Pharmaceuticals, GlaxoSmithKline, and JayMac Pharmaceuticals. Dr. Nonacs reported no disclosures. Dr. Cohen and Dr. Nonacs are affiliated with the department of psychiatry at Massachusetts General Hospital and Harvard Medical School, both in Boston.
Alan S. Brown, MD, and his associates examined a great deal of data, but the clinical implications of their findings are fuzzy, wrote Lee S. Cohen, MD, and Ruta Nonacs, MD, in an accompanying editorial (JAMA Psychiatry. 2016 Oct 12. doi: 10.1001/jamapsychiatry.2016.2705).
“The frequency of speech/language problems following referral to specialized health care services are relatively small; disorders occurred in 1.6% of patients from the SSRI-exposed group, 1.9% from the unmedicated group, and 1.0% from the nonexposed group,” Dr. Cohen and Dr. Nonacs wrote. “Are the data presented a signal of concern requiring further study or just background noise?”
Dr. Cohen has received support from several companies, including Cephalon, Takeda/Lundbeck Pharmaceuticals, GlaxoSmithKline, and JayMac Pharmaceuticals. Dr. Nonacs reported no disclosures. Dr. Cohen and Dr. Nonacs are affiliated with the department of psychiatry at Massachusetts General Hospital and Harvard Medical School, both in Boston.
Alan S. Brown, MD, and his associates examined a great deal of data, but the clinical implications of their findings are fuzzy, wrote Lee S. Cohen, MD, and Ruta Nonacs, MD, in an accompanying editorial (JAMA Psychiatry. 2016 Oct 12. doi: 10.1001/jamapsychiatry.2016.2705).
“The frequency of speech/language problems following referral to specialized health care services are relatively small; disorders occurred in 1.6% of patients from the SSRI-exposed group, 1.9% from the unmedicated group, and 1.0% from the nonexposed group,” Dr. Cohen and Dr. Nonacs wrote. “Are the data presented a signal of concern requiring further study or just background noise?”
Dr. Cohen has received support from several companies, including Cephalon, Takeda/Lundbeck Pharmaceuticals, GlaxoSmithKline, and JayMac Pharmaceuticals. Dr. Nonacs reported no disclosures. Dr. Cohen and Dr. Nonacs are affiliated with the department of psychiatry at Massachusetts General Hospital and Harvard Medical School, both in Boston.
Selective serotonin reuptake inhibitors taken during pregnancy are linked to a 37% increased risk of speech and language disorders in the children prenatally exposed to them, according to a prospective birth cohort study.
That risk occurs when children exposed prenatally are compared with children whose mothers did not take SSRIs but who had a diagnosis for which the antidepressants are indicated.
“The finding was observed only in offspring of mothers who purchased at least two SSRI prescriptions during pregnancy,” reported Alan S. Brown, MD, of New York State Psychiatric Institute in New York City, and his associates (JAMA Psychiatry. 2016 Oct 12. doi: 10.1001/jamapsychiatry.2016.2594). “This finding is particularly noteworthy because these women were more likely to have taken these medications and were exposed for a longer period and to larger amounts of SSRIs during pregnancy, compared with women who filled only one prescription.”
From among an initial cohort of 845,345 pregnant women in Finland, the researchers followed a final cohort of 56,340 offspring. Most of the children (86.6%) were 9 years old or younger at the end of study follow-up, running from 1996 to 2010, and the oldest children were aged 14 years. The researchers used Finland’s national registries to determine the children’s and mothers’ diagnoses and the mothers’ history of prescriptions from 30 days before pregnancy through delivery.
Among all children, 15,596 children were born to women who took SSRIs for depression or another SSRI-indicated psychiatric condition, and 31,207 children were born to mothers who had neither a psychiatric diagnosis nor a history of taking SSRIs during pregnancy. The remaining 9,537 children had mothers with a psychiatric diagnosis but who did not take SSRIs during pregnancy.
The average ages of the children at diagnosis were 4.4 years for speech or language disorders, 3.6 years for scholastic problems, and 7.7 years for motor disorders. When the researchers compared the children prenatally exposed to SSRIs to the children of mothers with a depression-related diagnosis but not taking SSRIs during pregnancy, the rates of scholastic or motor disorders did not differ.
For language and speech disorders, however, children whose mothers purchased two SSRI prescriptions had a 37% increased risk of a disorder, compared with children whose mothers had a diagnosis but did not purchase SSRIs. Without the requirement of at least two prescriptions, the statistical difference did not exist.
That increased risk occurred after adjustment for sex, mother’s parity, marital status, socioeconomic status, place of residence, both parents’ ages, the children’s gestational age at birth, prenatal exposure to antiepileptic drugs, exposure to anxiolytics/sedatives, history of chronic diseases, death of the child’s parent, mother’s country of birth, maternal smoking or substance abuse, and the psychiatric history of both parents. Data on maternal alcohol consumption were unavailable. Both the children exposed to SSRIs and the children of unmedicated mothers with a psychiatric condition had a higher risk of speech and language disorders.
The research was funded by the National Institutes of Health; the Sackler Foundation of Columbia University, New York; and the University of Turku (Finland). One of the researchers, David Gyllenberg, MD, reported receiving research funding from the Sigrid Juselius Foundation, the Foundation for Pediatric Research in Finland, and the Finnish Medical Foundation. No other conflicts of interest were disclosed.
Selective serotonin reuptake inhibitors taken during pregnancy are linked to a 37% increased risk of speech and language disorders in the children prenatally exposed to them, according to a prospective birth cohort study.
That risk occurs when children exposed prenatally are compared with children whose mothers did not take SSRIs but who had a diagnosis for which the antidepressants are indicated.
“The finding was observed only in offspring of mothers who purchased at least two SSRI prescriptions during pregnancy,” reported Alan S. Brown, MD, of New York State Psychiatric Institute in New York City, and his associates (JAMA Psychiatry. 2016 Oct 12. doi: 10.1001/jamapsychiatry.2016.2594). “This finding is particularly noteworthy because these women were more likely to have taken these medications and were exposed for a longer period and to larger amounts of SSRIs during pregnancy, compared with women who filled only one prescription.”
From among an initial cohort of 845,345 pregnant women in Finland, the researchers followed a final cohort of 56,340 offspring. Most of the children (86.6%) were 9 years old or younger at the end of study follow-up, running from 1996 to 2010, and the oldest children were aged 14 years. The researchers used Finland’s national registries to determine the children’s and mothers’ diagnoses and the mothers’ history of prescriptions from 30 days before pregnancy through delivery.
Among all children, 15,596 children were born to women who took SSRIs for depression or another SSRI-indicated psychiatric condition, and 31,207 children were born to mothers who had neither a psychiatric diagnosis nor a history of taking SSRIs during pregnancy. The remaining 9,537 children had mothers with a psychiatric diagnosis but who did not take SSRIs during pregnancy.
The average ages of the children at diagnosis were 4.4 years for speech or language disorders, 3.6 years for scholastic problems, and 7.7 years for motor disorders. When the researchers compared the children prenatally exposed to SSRIs to the children of mothers with a depression-related diagnosis but not taking SSRIs during pregnancy, the rates of scholastic or motor disorders did not differ.
For language and speech disorders, however, children whose mothers purchased two SSRI prescriptions had a 37% increased risk of a disorder, compared with children whose mothers had a diagnosis but did not purchase SSRIs. Without the requirement of at least two prescriptions, the statistical difference did not exist.
That increased risk occurred after adjustment for sex, mother’s parity, marital status, socioeconomic status, place of residence, both parents’ ages, the children’s gestational age at birth, prenatal exposure to antiepileptic drugs, exposure to anxiolytics/sedatives, history of chronic diseases, death of the child’s parent, mother’s country of birth, maternal smoking or substance abuse, and the psychiatric history of both parents. Data on maternal alcohol consumption were unavailable. Both the children exposed to SSRIs and the children of unmedicated mothers with a psychiatric condition had a higher risk of speech and language disorders.
The research was funded by the National Institutes of Health; the Sackler Foundation of Columbia University, New York; and the University of Turku (Finland). One of the researchers, David Gyllenberg, MD, reported receiving research funding from the Sigrid Juselius Foundation, the Foundation for Pediatric Research in Finland, and the Finnish Medical Foundation. No other conflicts of interest were disclosed.
FROM JAMA PSYCHIATRY
Key clinical point: Selective serotonin reuptake inhibitors taken during pregnancy may increase the risk of speech/language disorders in the offspring.
Major finding: Children of mothers taking SSRIs during pregnancy had a 37% increased risk of speech/language disorders, compared with children of unmedicated mothers with a diagnosis of depression.
Data source: The findings are based on a prospective birth cohort involving 56,340 children tracked in Finland from 1996 to 2010.
Disclosures: The research was funded by the National Institutes of Health; the Sackler Foundation of Columbia University, New York; and the University of Turku (Finland). One of the researchers, David Gyllenberg, MD, reported receiving research funding from the Sigrid Juselius Foundation, the Foundation for Pediatric Research in Finland, and the Finnish Medical Foundation. No other conflicts of interest were disclosed.
Promise of effective RSV vaccines on horizon
ATLANTA – A new vaccine for respiratory syncytial virus may truly be on the horizon, given recent advances in basic science and a marked increase in interest in the pharmaceutical industry.
That’s the conclusion of Larry Anderson, MD, professor of infectious disease in the Emory University department of pediatrics, who presented the most updated research and progress on a respiratory syncytial virus (RSV) vaccine during a conference sponsored by the Centers for Disease Control and Prevention.
The high hospitalization rates of infants with RSV, also associated with later development of reactive airway disease and asthma, highlight the challenge of developing a vaccine, Dr. Anderson said.
“The infant has an immature immune system less able to respond vigorously to a vaccine,” he said. “Also, it is highly susceptible to the disease of RSV, and therefore safety becomes an issue at least in terms of the live virus vaccine.” Furthermore, RSV causes multiple repeat infections throughout life, “which underlines the difficulty in inducing a protective immune response,” he added.
But Dr. Anderson said he believes there is light at the end of the tunnel when it comes to a vaccine for the virus.
“I think in terms of [the] potential of having an RSV vaccine in the near future, now is the most promising time, recognizing that work on an RSV vaccine has been going on for over 50 years without success to date,” he said. Significant advances in basic biology, immunology, and vaccinology have led to a better understanding of the virus, and new tools such as reverse genetics make “it possible to make any live virus you want as long as you know what you want,” he added.
Dr. Anderson provided an overview of published and preliminary data on the progress of more than five dozen groups working on an RSV vaccine. About 70% of these candidates remain in preclinical research, primarily in animal models. Of the dozen in phase I, several look promising, he said. Another six vaccines are in phase II or phase III testing, and MedImmune’s Synagis is market approved. But not all target infants.
“The first and highest priority is the young infant, particularly the under 2- to 4-month-old,” he said. In infants aged 4-6 months, it’s likely easier to induce an immune response, and there’s less susceptibility to disease with replication of the virus, he said. The elderly, also at high risk for RSV, would be another target population.
Potentially “the lowest apple on the tree for immunization,” Dr. Anderson said, would be pregnant women because a vaccine could prevent infection, disease, and transmission to their infant before he might be able to be vaccinated.
“There, the primary purpose is to increase the kind of antibody that is transferred across the placenta to the fetus to protect from RSV disease” in the infant after birth, he said. Data suggest it’s possible to increase titer antibodies in infants up to 4 months from maternal immunization, possibly longer, depending on how much the vaccine can induce antibodies in the woman.
For young children, he noted that five live attenuated RSV vaccines are in phase I testing, and four others are in phase I that use a virus vector to deliver the F protein – three using adenovirus and one with a modified vaccinia Ankara virus. A handful of subunit vaccines have reached phase II, and Novavax is furthest along in phase III, but these target older children and adults, including pregnant women.
“There’s going to be a lot of data in the coming year on completed clinical trials, and that’s going to tell us a lot about where we are,” Dr. Anderson said. “The young infant is the most challenging for a vaccine.” But, he added, “new information on protective immunity and disease pathogenesis should help achieve or improve vaccines in the future.”
Dr. Anderson has consulted on RSV vaccines for MedImmune, Novartis, Crucell Holland, and AVC, and has served on a Moderna Therapeutics scientific advisory board. His lab also has received grant funding from Trellis RSV Holdings, and he coinvented several RSV-related vaccine and treatment patents held by the CDC.
ATLANTA – A new vaccine for respiratory syncytial virus may truly be on the horizon, given recent advances in basic science and a marked increase in interest in the pharmaceutical industry.
That’s the conclusion of Larry Anderson, MD, professor of infectious disease in the Emory University department of pediatrics, who presented the most updated research and progress on a respiratory syncytial virus (RSV) vaccine during a conference sponsored by the Centers for Disease Control and Prevention.
The high hospitalization rates of infants with RSV, also associated with later development of reactive airway disease and asthma, highlight the challenge of developing a vaccine, Dr. Anderson said.
“The infant has an immature immune system less able to respond vigorously to a vaccine,” he said. “Also, it is highly susceptible to the disease of RSV, and therefore safety becomes an issue at least in terms of the live virus vaccine.” Furthermore, RSV causes multiple repeat infections throughout life, “which underlines the difficulty in inducing a protective immune response,” he added.
But Dr. Anderson said he believes there is light at the end of the tunnel when it comes to a vaccine for the virus.
“I think in terms of [the] potential of having an RSV vaccine in the near future, now is the most promising time, recognizing that work on an RSV vaccine has been going on for over 50 years without success to date,” he said. Significant advances in basic biology, immunology, and vaccinology have led to a better understanding of the virus, and new tools such as reverse genetics make “it possible to make any live virus you want as long as you know what you want,” he added.
Dr. Anderson provided an overview of published and preliminary data on the progress of more than five dozen groups working on an RSV vaccine. About 70% of these candidates remain in preclinical research, primarily in animal models. Of the dozen in phase I, several look promising, he said. Another six vaccines are in phase II or phase III testing, and MedImmune’s Synagis is market approved. But not all target infants.
“The first and highest priority is the young infant, particularly the under 2- to 4-month-old,” he said. In infants aged 4-6 months, it’s likely easier to induce an immune response, and there’s less susceptibility to disease with replication of the virus, he said. The elderly, also at high risk for RSV, would be another target population.
Potentially “the lowest apple on the tree for immunization,” Dr. Anderson said, would be pregnant women because a vaccine could prevent infection, disease, and transmission to their infant before he might be able to be vaccinated.
“There, the primary purpose is to increase the kind of antibody that is transferred across the placenta to the fetus to protect from RSV disease” in the infant after birth, he said. Data suggest it’s possible to increase titer antibodies in infants up to 4 months from maternal immunization, possibly longer, depending on how much the vaccine can induce antibodies in the woman.
For young children, he noted that five live attenuated RSV vaccines are in phase I testing, and four others are in phase I that use a virus vector to deliver the F protein – three using adenovirus and one with a modified vaccinia Ankara virus. A handful of subunit vaccines have reached phase II, and Novavax is furthest along in phase III, but these target older children and adults, including pregnant women.
“There’s going to be a lot of data in the coming year on completed clinical trials, and that’s going to tell us a lot about where we are,” Dr. Anderson said. “The young infant is the most challenging for a vaccine.” But, he added, “new information on protective immunity and disease pathogenesis should help achieve or improve vaccines in the future.”
Dr. Anderson has consulted on RSV vaccines for MedImmune, Novartis, Crucell Holland, and AVC, and has served on a Moderna Therapeutics scientific advisory board. His lab also has received grant funding from Trellis RSV Holdings, and he coinvented several RSV-related vaccine and treatment patents held by the CDC.
ATLANTA – A new vaccine for respiratory syncytial virus may truly be on the horizon, given recent advances in basic science and a marked increase in interest in the pharmaceutical industry.
That’s the conclusion of Larry Anderson, MD, professor of infectious disease in the Emory University department of pediatrics, who presented the most updated research and progress on a respiratory syncytial virus (RSV) vaccine during a conference sponsored by the Centers for Disease Control and Prevention.
The high hospitalization rates of infants with RSV, also associated with later development of reactive airway disease and asthma, highlight the challenge of developing a vaccine, Dr. Anderson said.
“The infant has an immature immune system less able to respond vigorously to a vaccine,” he said. “Also, it is highly susceptible to the disease of RSV, and therefore safety becomes an issue at least in terms of the live virus vaccine.” Furthermore, RSV causes multiple repeat infections throughout life, “which underlines the difficulty in inducing a protective immune response,” he added.
But Dr. Anderson said he believes there is light at the end of the tunnel when it comes to a vaccine for the virus.
“I think in terms of [the] potential of having an RSV vaccine in the near future, now is the most promising time, recognizing that work on an RSV vaccine has been going on for over 50 years without success to date,” he said. Significant advances in basic biology, immunology, and vaccinology have led to a better understanding of the virus, and new tools such as reverse genetics make “it possible to make any live virus you want as long as you know what you want,” he added.
Dr. Anderson provided an overview of published and preliminary data on the progress of more than five dozen groups working on an RSV vaccine. About 70% of these candidates remain in preclinical research, primarily in animal models. Of the dozen in phase I, several look promising, he said. Another six vaccines are in phase II or phase III testing, and MedImmune’s Synagis is market approved. But not all target infants.
“The first and highest priority is the young infant, particularly the under 2- to 4-month-old,” he said. In infants aged 4-6 months, it’s likely easier to induce an immune response, and there’s less susceptibility to disease with replication of the virus, he said. The elderly, also at high risk for RSV, would be another target population.
Potentially “the lowest apple on the tree for immunization,” Dr. Anderson said, would be pregnant women because a vaccine could prevent infection, disease, and transmission to their infant before he might be able to be vaccinated.
“There, the primary purpose is to increase the kind of antibody that is transferred across the placenta to the fetus to protect from RSV disease” in the infant after birth, he said. Data suggest it’s possible to increase titer antibodies in infants up to 4 months from maternal immunization, possibly longer, depending on how much the vaccine can induce antibodies in the woman.
For young children, he noted that five live attenuated RSV vaccines are in phase I testing, and four others are in phase I that use a virus vector to deliver the F protein – three using adenovirus and one with a modified vaccinia Ankara virus. A handful of subunit vaccines have reached phase II, and Novavax is furthest along in phase III, but these target older children and adults, including pregnant women.
“There’s going to be a lot of data in the coming year on completed clinical trials, and that’s going to tell us a lot about where we are,” Dr. Anderson said. “The young infant is the most challenging for a vaccine.” But, he added, “new information on protective immunity and disease pathogenesis should help achieve or improve vaccines in the future.”
Dr. Anderson has consulted on RSV vaccines for MedImmune, Novartis, Crucell Holland, and AVC, and has served on a Moderna Therapeutics scientific advisory board. His lab also has received grant funding from Trellis RSV Holdings, and he coinvented several RSV-related vaccine and treatment patents held by the CDC.
EXPERT ANALYSIS FROM THE NATIONAL IMMUNIZATION CONFERENCE
Key clinical point: A respiratory syncytial virus vaccine is closer to reality now than at any other time.
Major finding: 62 RSV vaccines are in development, with approximately 70% in preclinical studies.
Data source: Based on a review of the current state of research into an RSV vaccine and the burden of RSV disease.
Disclosures: Dr. Anderson has consulted on RSV vaccines for MedImmune, Novartis, Crucell Holland, and AVC, and has served on a Moderna Therapeutics scientific advisory board. His lab also has received grant funding from Trellis RSV Holdings, and he coinvented several RSV-related vaccine and treatment patents held by the CDC.
October 2016: Click for Credit
Here are 5 articles in the October issue of Clinician Reviews (individual articles are valid for one year from date of publication—expiration dates below):
1. Autism Follow-up Screening by PCPs Yields High Accuracy
To take the posttest, go to: http://bit.ly/2bTLhFS
Expires August 19, 2017
VITALS
Key clinical point:
Primary care providers can conduct the M-CHAT/F following a positive M-CHAT screening for autism spectrum disorders.
Major finding:
Primary care providers and trained interviewers agreed 86.6% of the time on the screening results of the M-CHAT/F for ASDs.
Data source:
A cohort study of 5,071 children, mean age 23 months, screened with the M-CHAT, and a subsequent 197 children screened with the M-CHAT/F in 22 Maryland primary care practices.
Disclosures:
The National Institutes of Mental Health funded the research. Dr. Sturner is director of Total Child Health (TCH), a for-profit subsidiary of the Center for Promotion of Child Development through Primary Care, which conducted the study. Barbara Howard, MD, is president of TCH. Tanya Morrel, PhD, is an employee of and stockholder in TCH, and Paul Bergmann has consulted for the company. The remaining authors had no relevant disclosures.
2. Gallstone Disease Boosts Heart Risk
To take the posttest, go to: http://bit.ly/2c7TP7D
Expires August 18, 2017
VITALS
Key clinical point:
Gallstone disease is associated with an increased risk for coronary heart disease; preventing the former can help mitigate chances of developing the latter.
Major finding:
A meta-analysis revealed a 23% increased chance of CHD in gallstone disease patients.
Data source:
A meta-analysis of seven studies involving 842,553 subjects, and a prospective cohort study of 269,142 participants in three separate studies that took place from 1980 to 2011.
Disclosures:
Funding provided by NIH, Boston Obesity Nutrition Research Center, and United States-Israel Binational Science Foundation. The authors had no relevant financial disclosures.
3. New HER2-testing Guidelines Result in More Women Eligible for Directed Treatment
To take the posttest, go to: http://bit.ly/2cd9llO
Expires July 25, 2017
VITALS
Key clinical point:
New IHC and FISH pathology guidelines categorize more breast cancers as "equivocal" regarding HER2 positivity and ultimately lead to identifying more of them as HER2 positive.
Major finding:
By using 2013 guidelines, 358 additional tumors were interpreted as positive, compared with the 2007 guidelines and 298 additional tumors were considered positive, compared with the FDA criteria.
Data source:
A cohort study involving 2,851 breast cancer samples analyzed according to three different pathology guidelines during a 1-year period.
Disclosures:
This study was supported by the Mayo Clinic. Dr. Shah reported having no relevant financial disclosures; his associates reported ties to Merck, Hospira, Ariad Pharmaceuticals, Abbott Molecular, and Genome Diagnostics.
4. Extreme Alcohol Use Worsens HIV Disease
To take the posttest, go to: http://bit.ly/2coIzG3
Expires August 14, 2017
VITALS
Key clinical point:
A pattern of heavy alcohol use over time in HIV-infected patients was associated with accelerated HIV disease progression.
Major finding:
Long-term heavy alcohol use by middle-aged, HIV-infected military veterans was associated with a 1.83-fold increased likelihood of also being in the highest-risk group for accelerated progression of HIV disease.
Data source:
This study included 3,539 U.S. military veterans receiving care for HIV infection at eight VA centers. The impact of their long-term pattern of alcohol use on HIV disease progression was assessed over an 8-year period by annual assessments using validated instruments.
Disclosures:
The presenter reported having no financial conflicts of interest regarding the study, funded by the National Institute on Alcohol Abuse and Alcoholism and the National Institute of Allergy and Infectious Diseases.
5. Weight Loss Boosts TNFis' Psoriatic Arthritis Efficacy
To take the posttest, go to: http://bit.ly/2chD4M1
Expires July 23, 2017
Here are 5 articles in the October issue of Clinician Reviews (individual articles are valid for one year from date of publication—expiration dates below):
1. Autism Follow-up Screening by PCPs Yields High Accuracy
To take the posttest, go to: http://bit.ly/2bTLhFS
Expires August 19, 2017
VITALS
Key clinical point:
Primary care providers can conduct the M-CHAT/F following a positive M-CHAT screening for autism spectrum disorders.
Major finding:
Primary care providers and trained interviewers agreed 86.6% of the time on the screening results of the M-CHAT/F for ASDs.
Data source:
A cohort study of 5,071 children, mean age 23 months, screened with the M-CHAT, and a subsequent 197 children screened with the M-CHAT/F in 22 Maryland primary care practices.
Disclosures:
The National Institutes of Mental Health funded the research. Dr. Sturner is director of Total Child Health (TCH), a for-profit subsidiary of the Center for Promotion of Child Development through Primary Care, which conducted the study. Barbara Howard, MD, is president of TCH. Tanya Morrel, PhD, is an employee of and stockholder in TCH, and Paul Bergmann has consulted for the company. The remaining authors had no relevant disclosures.
2. Gallstone Disease Boosts Heart Risk
To take the posttest, go to: http://bit.ly/2c7TP7D
Expires August 18, 2017
VITALS
Key clinical point:
Gallstone disease is associated with an increased risk for coronary heart disease; preventing the former can help mitigate chances of developing the latter.
Major finding:
A meta-analysis revealed a 23% increased chance of CHD in gallstone disease patients.
Data source:
A meta-analysis of seven studies involving 842,553 subjects, and a prospective cohort study of 269,142 participants in three separate studies that took place from 1980 to 2011.
Disclosures:
Funding provided by NIH, Boston Obesity Nutrition Research Center, and United States-Israel Binational Science Foundation. The authors had no relevant financial disclosures.
3. New HER2-testing Guidelines Result in More Women Eligible for Directed Treatment
To take the posttest, go to: http://bit.ly/2cd9llO
Expires July 25, 2017
VITALS
Key clinical point:
New IHC and FISH pathology guidelines categorize more breast cancers as "equivocal" regarding HER2 positivity and ultimately lead to identifying more of them as HER2 positive.
Major finding:
By using 2013 guidelines, 358 additional tumors were interpreted as positive, compared with the 2007 guidelines and 298 additional tumors were considered positive, compared with the FDA criteria.
Data source:
A cohort study involving 2,851 breast cancer samples analyzed according to three different pathology guidelines during a 1-year period.
Disclosures:
This study was supported by the Mayo Clinic. Dr. Shah reported having no relevant financial disclosures; his associates reported ties to Merck, Hospira, Ariad Pharmaceuticals, Abbott Molecular, and Genome Diagnostics.
4. Extreme Alcohol Use Worsens HIV Disease
To take the posttest, go to: http://bit.ly/2coIzG3
Expires August 14, 2017
VITALS
Key clinical point:
A pattern of heavy alcohol use over time in HIV-infected patients was associated with accelerated HIV disease progression.
Major finding:
Long-term heavy alcohol use by middle-aged, HIV-infected military veterans was associated with a 1.83-fold increased likelihood of also being in the highest-risk group for accelerated progression of HIV disease.
Data source:
This study included 3,539 U.S. military veterans receiving care for HIV infection at eight VA centers. The impact of their long-term pattern of alcohol use on HIV disease progression was assessed over an 8-year period by annual assessments using validated instruments.
Disclosures:
The presenter reported having no financial conflicts of interest regarding the study, funded by the National Institute on Alcohol Abuse and Alcoholism and the National Institute of Allergy and Infectious Diseases.
5. Weight Loss Boosts TNFis' Psoriatic Arthritis Efficacy
To take the posttest, go to: http://bit.ly/2chD4M1
Expires July 23, 2017
Here are 5 articles in the October issue of Clinician Reviews (individual articles are valid for one year from date of publication—expiration dates below):
1. Autism Follow-up Screening by PCPs Yields High Accuracy
To take the posttest, go to: http://bit.ly/2bTLhFS
Expires August 19, 2017
VITALS
Key clinical point:
Primary care providers can conduct the M-CHAT/F following a positive M-CHAT screening for autism spectrum disorders.
Major finding:
Primary care providers and trained interviewers agreed 86.6% of the time on the screening results of the M-CHAT/F for ASDs.
Data source:
A cohort study of 5,071 children, mean age 23 months, screened with the M-CHAT, and a subsequent 197 children screened with the M-CHAT/F in 22 Maryland primary care practices.
Disclosures:
The National Institutes of Mental Health funded the research. Dr. Sturner is director of Total Child Health (TCH), a for-profit subsidiary of the Center for Promotion of Child Development through Primary Care, which conducted the study. Barbara Howard, MD, is president of TCH. Tanya Morrel, PhD, is an employee of and stockholder in TCH, and Paul Bergmann has consulted for the company. The remaining authors had no relevant disclosures.
2. Gallstone Disease Boosts Heart Risk
To take the posttest, go to: http://bit.ly/2c7TP7D
Expires August 18, 2017
VITALS
Key clinical point:
Gallstone disease is associated with an increased risk for coronary heart disease; preventing the former can help mitigate chances of developing the latter.
Major finding:
A meta-analysis revealed a 23% increased chance of CHD in gallstone disease patients.
Data source:
A meta-analysis of seven studies involving 842,553 subjects, and a prospective cohort study of 269,142 participants in three separate studies that took place from 1980 to 2011.
Disclosures:
Funding provided by NIH, Boston Obesity Nutrition Research Center, and United States-Israel Binational Science Foundation. The authors had no relevant financial disclosures.
3. New HER2-testing Guidelines Result in More Women Eligible for Directed Treatment
To take the posttest, go to: http://bit.ly/2cd9llO
Expires July 25, 2017
VITALS
Key clinical point:
New IHC and FISH pathology guidelines categorize more breast cancers as "equivocal" regarding HER2 positivity and ultimately lead to identifying more of them as HER2 positive.
Major finding:
By using 2013 guidelines, 358 additional tumors were interpreted as positive, compared with the 2007 guidelines and 298 additional tumors were considered positive, compared with the FDA criteria.
Data source:
A cohort study involving 2,851 breast cancer samples analyzed according to three different pathology guidelines during a 1-year period.
Disclosures:
This study was supported by the Mayo Clinic. Dr. Shah reported having no relevant financial disclosures; his associates reported ties to Merck, Hospira, Ariad Pharmaceuticals, Abbott Molecular, and Genome Diagnostics.
4. Extreme Alcohol Use Worsens HIV Disease
To take the posttest, go to: http://bit.ly/2coIzG3
Expires August 14, 2017
VITALS
Key clinical point:
A pattern of heavy alcohol use over time in HIV-infected patients was associated with accelerated HIV disease progression.
Major finding:
Long-term heavy alcohol use by middle-aged, HIV-infected military veterans was associated with a 1.83-fold increased likelihood of also being in the highest-risk group for accelerated progression of HIV disease.
Data source:
This study included 3,539 U.S. military veterans receiving care for HIV infection at eight VA centers. The impact of their long-term pattern of alcohol use on HIV disease progression was assessed over an 8-year period by annual assessments using validated instruments.
Disclosures:
The presenter reported having no financial conflicts of interest regarding the study, funded by the National Institute on Alcohol Abuse and Alcoholism and the National Institute of Allergy and Infectious Diseases.
5. Weight Loss Boosts TNFis' Psoriatic Arthritis Efficacy
To take the posttest, go to: http://bit.ly/2chD4M1
Expires July 23, 2017
