Tara Haelle

The rate of pediatric hospitalizations for infectious diseases has decreased overall among U.S. children from 2000 to 2012, though skin infection hospitalizations have climbed, a recent study found.

“The observed reduction in infectious disease hospitalizations (vaccine-preventable diseases and others) supports a cautious optimism that the infectious disease-related morbidity can be further reduced,” Dr. Tadahiro Goto of the department of emergency medicine at Massachusetts General Hospital, Boston, and coauthors reported online. Yet approximately 625,000 children were still hospitalized for infectious diseases in 2012. “These findings should facilitate continued efforts, such as bridging the gaps in immunization coverage, to reduce the infectious disease–related morbidity and health care utilization nationally,” the authors wrote (Pediatr Infect Dis J. 2016 Mar 10. doi: 10.1097/INF.0000000000001134).

©monkeybusinessimages/Thinkstock.com

The researchers analyzed all cases of youth under age 20 years with an infectious disease diagnosis who were included in the nationally representative Kids’ Inpatient Database for 2000, 2003, 2006, 2009 and 2012.

In their cross-sectional analysis, the authors identified more than 2.2 million pediatric infectious disease hospitalizations, which translated to a weighted estimate of nearly 3.7 million across the five datasets. These hospitalizations comprised almost a quarter (24.5%) of all pediatric hospitalizations over those 12 years, but their rate dropped 16.5%, from 91/10,000 children in 2000 to 75.8/10,000 children in 2012 (P less than .001). A 30.3% decrease in hospitalizations among infants less than 1 year old primarily drove the overall rate decline, alongside a slighter (13.4%) drop in children aged 1-4 years.

Lower respiratory infections, including pneumonia and bronchiolitis, were the most common infectious diseases leading to pediatric hospitalization. Although these accounted for 42.8% of all infectious disease hospitalizations in 2012, their hospitalization rate had dropped 19.1% since 2000, from 40.1 children to 32.5 children per 10,000, driven mostly by a 25.5% drop in pneumonia hospitalizations.

Abdominal and rectal infections comprised 13.8% of all infectious disease hospitalizations in 2012 but had declined 6.9% since 2000. Upper respiratory infections had been the third most common subgroup in 2000 but was replaced by skin infections in 2012.

Hospitalization rates decreased for all infectious disease subgroups except skin infections, perinatal infections, septicemia, and postoperative infections. Skin infections had the biggest jump, 67.6% over the period studied (P less than .001), followed by a 16.7% increase in perinatal infections and smaller increases in the other two subgroups.

The biggest subgroup declines were HIV/AIDS, with an 81.5% drop, and nonviral meningitis, with a 64.9% drop. Mortality in the hospital also declined among children admitted for infectious disease: those admitted in 2012 had 37% reduced odds of death, compared with those admitted in 2000.

The median length of a hospital stay, 2 days, did not change across time, and the median cost for each hospitalization increased 9.6%, from $3,452 in 2003 to $3,784 in 2012. Nationwide, however, infectious disease hospitalizations cost $4.4 billion in 2012.

The research was funded by the National Institutes of Health. Information on disclosures was not provided.

The rate of pediatric hospitalizations for infectious diseases has decreased overall among U.S. children from 2000 to 2012, though skin infection hospitalizations have climbed, a recent study found.

“The observed reduction in infectious disease hospitalizations (vaccine-preventable diseases and others) supports a cautious optimism that the infectious disease-related morbidity can be further reduced,” Dr. Tadahiro Goto of the department of emergency medicine at Massachusetts General Hospital, Boston, and coauthors reported online. Yet approximately 625,000 children were still hospitalized for infectious diseases in 2012. “These findings should facilitate continued efforts, such as bridging the gaps in immunization coverage, to reduce the infectious disease–related morbidity and health care utilization nationally,” the authors wrote (Pediatr Infect Dis J. 2016 Mar 10. doi: 10.1097/INF.0000000000001134).

©monkeybusinessimages/Thinkstock.com

The researchers analyzed all cases of youth under age 20 years with an infectious disease diagnosis who were included in the nationally representative Kids’ Inpatient Database for 2000, 2003, 2006, 2009 and 2012.

In their cross-sectional analysis, the authors identified more than 2.2 million pediatric infectious disease hospitalizations, which translated to a weighted estimate of nearly 3.7 million across the five datasets. These hospitalizations comprised almost a quarter (24.5%) of all pediatric hospitalizations over those 12 years, but their rate dropped 16.5%, from 91/10,000 children in 2000 to 75.8/10,000 children in 2012 (P less than .001). A 30.3% decrease in hospitalizations among infants less than 1 year old primarily drove the overall rate decline, alongside a slighter (13.4%) drop in children aged 1-4 years.

Lower respiratory infections, including pneumonia and bronchiolitis, were the most common infectious diseases leading to pediatric hospitalization. Although these accounted for 42.8% of all infectious disease hospitalizations in 2012, their hospitalization rate had dropped 19.1% since 2000, from 40.1 children to 32.5 children per 10,000, driven mostly by a 25.5% drop in pneumonia hospitalizations.

Abdominal and rectal infections comprised 13.8% of all infectious disease hospitalizations in 2012 but had declined 6.9% since 2000. Upper respiratory infections had been the third most common subgroup in 2000 but was replaced by skin infections in 2012.

Hospitalization rates decreased for all infectious disease subgroups except skin infections, perinatal infections, septicemia, and postoperative infections. Skin infections had the biggest jump, 67.6% over the period studied (P less than .001), followed by a 16.7% increase in perinatal infections and smaller increases in the other two subgroups.

The biggest subgroup declines were HIV/AIDS, with an 81.5% drop, and nonviral meningitis, with a 64.9% drop. Mortality in the hospital also declined among children admitted for infectious disease: those admitted in 2012 had 37% reduced odds of death, compared with those admitted in 2000.

The median length of a hospital stay, 2 days, did not change across time, and the median cost for each hospitalization increased 9.6%, from $3,452 in 2003 to $3,784 in 2012. Nationwide, however, infectious disease hospitalizations cost $4.4 billion in 2012.

The research was funded by the National Institutes of Health. Information on disclosures was not provided.

The rate of pediatric hospitalizations for infectious diseases has decreased overall among U.S. children from 2000 to 2012, though skin infection hospitalizations have climbed, a recent study found.

“The observed reduction in infectious disease hospitalizations (vaccine-preventable diseases and others) supports a cautious optimism that the infectious disease-related morbidity can be further reduced,” Dr. Tadahiro Goto of the department of emergency medicine at Massachusetts General Hospital, Boston, and coauthors reported online. Yet approximately 625,000 children were still hospitalized for infectious diseases in 2012. “These findings should facilitate continued efforts, such as bridging the gaps in immunization coverage, to reduce the infectious disease–related morbidity and health care utilization nationally,” the authors wrote (Pediatr Infect Dis J. 2016 Mar 10. doi: 10.1097/INF.0000000000001134).

©monkeybusinessimages/Thinkstock.com

The researchers analyzed all cases of youth under age 20 years with an infectious disease diagnosis who were included in the nationally representative Kids’ Inpatient Database for 2000, 2003, 2006, 2009 and 2012.

In their cross-sectional analysis, the authors identified more than 2.2 million pediatric infectious disease hospitalizations, which translated to a weighted estimate of nearly 3.7 million across the five datasets. These hospitalizations comprised almost a quarter (24.5%) of all pediatric hospitalizations over those 12 years, but their rate dropped 16.5%, from 91/10,000 children in 2000 to 75.8/10,000 children in 2012 (P less than .001). A 30.3% decrease in hospitalizations among infants less than 1 year old primarily drove the overall rate decline, alongside a slighter (13.4%) drop in children aged 1-4 years.

Lower respiratory infections, including pneumonia and bronchiolitis, were the most common infectious diseases leading to pediatric hospitalization. Although these accounted for 42.8% of all infectious disease hospitalizations in 2012, their hospitalization rate had dropped 19.1% since 2000, from 40.1 children to 32.5 children per 10,000, driven mostly by a 25.5% drop in pneumonia hospitalizations.

Abdominal and rectal infections comprised 13.8% of all infectious disease hospitalizations in 2012 but had declined 6.9% since 2000. Upper respiratory infections had been the third most common subgroup in 2000 but was replaced by skin infections in 2012.

Hospitalization rates decreased for all infectious disease subgroups except skin infections, perinatal infections, septicemia, and postoperative infections. Skin infections had the biggest jump, 67.6% over the period studied (P less than .001), followed by a 16.7% increase in perinatal infections and smaller increases in the other two subgroups.

The biggest subgroup declines were HIV/AIDS, with an 81.5% drop, and nonviral meningitis, with a 64.9% drop. Mortality in the hospital also declined among children admitted for infectious disease: those admitted in 2012 had 37% reduced odds of death, compared with those admitted in 2000.

The median length of a hospital stay, 2 days, did not change across time, and the median cost for each hospitalization increased 9.6%, from $3,452 in 2003 to $3,784 in 2012. Nationwide, however, infectious disease hospitalizations cost $4.4 billion in 2012.

The research was funded by the National Institutes of Health. Information on disclosures was not provided.

Here are 4 articles in the April issue of Clinician Reviews (individual articles are valid for one year from date of publication—expiration dates below):

1. Later Menopause Lowers Risk for Later Depression
To take the posttest, go to: http://bit.ly/1U7I7f3
Expires January 6, 2017

VITALS
Key clinical point: Later menopause, with its longer estrogen exposure, appears tied to a lower risk of postmenopausal depression.
Major finding: The risk of depression decreased by 2% for each 2 premenopausal years after age 40.
Data source: The meta-analysis comprised 14 studies with more than 67,700 women.
Disclosures: Neither Dr. Georgakis nor any of the coauthors declared any financial conflicts.

2. Preschool ASD Prevalence Estimates Lower Than Grade School Estimates
To take the posttest, go to: http://bit.ly/24Mec0X
Expires January 5, 2017

VITALS
Key clinical point: The prevalence of autism spectrum disorders among 4-year-olds is about 30% lower than among 8-year-olds.
Major finding: Prevalence of ASD among 4-year-olds was 13/1,000 children across five U.S. states.
Data source: A comparison of health and medical records for nationally representative cohorts involving 58,467 4-year-olds and 56,727 8-year-olds in five U.S. states in 2010.
Disclosures: The Centers for Disease Control and Prevention funded the research. Dr. Christensen and her associates reported no disclosures.

3. Long-term PPI Use Linked to Increased Risk for Dementia
To take the posttest, go to: http://bit.ly/1nrCdsb
Expires February 24, 2017

VITALS
Key clinical point: Proton pump inhibitors may add to the risk of dementia in older adults. 
Major finding: The risk of incident dementia was 44% higher in adults who used PPIs long term, compared with those who did not. 
Data source: The prospective cohort study included 73,679 adults aged 75 years and older.
Disclosures: The researchers had no financial conflicts to disclose.

4. Elevated Cardiovascular Risks Linked to Hidradenitis Suppurativa
To take the posttest, go to: http://bit.ly/1nrEFz3
Expires February 17, 2017

VITALS
Key clinical point: Hidradenitis suppurativa is associated with a significantly increased risk of adverse cardiovascular events and all-cause mortality.
Major finding: Individuals with hidradenitis suppurativa had a 57% greater risk of myocardial infarction and 33% greater risk of ischemic stroke, compared with the general population. 
Data source: A population-based cohort study in 5,964 patients with hidradenitis suppurativa.
Disclosures: No conflicts of interest were declared.

Here are 4 articles in the April issue of Clinician Reviews (individual articles are valid for one year from date of publication—expiration dates below):

1. Later Menopause Lowers Risk for Later Depression
To take the posttest, go to: http://bit.ly/1U7I7f3
Expires January 6, 2017

VITALS
Key clinical point: Later menopause, with its longer estrogen exposure, appears tied to a lower risk of postmenopausal depression.
Major finding: The risk of depression decreased by 2% for each 2 premenopausal years after age 40.
Data source: The meta-analysis comprised 14 studies with more than 67,700 women.
Disclosures: Neither Dr. Georgakis nor any of the coauthors declared any financial conflicts.

2. Preschool ASD Prevalence Estimates Lower Than Grade School Estimates
To take the posttest, go to: http://bit.ly/24Mec0X
Expires January 5, 2017

VITALS
Key clinical point: The prevalence of autism spectrum disorders among 4-year-olds is about 30% lower than among 8-year-olds.
Major finding: Prevalence of ASD among 4-year-olds was 13/1,000 children across five U.S. states.
Data source: A comparison of health and medical records for nationally representative cohorts involving 58,467 4-year-olds and 56,727 8-year-olds in five U.S. states in 2010.
Disclosures: The Centers for Disease Control and Prevention funded the research. Dr. Christensen and her associates reported no disclosures.

3. Long-term PPI Use Linked to Increased Risk for Dementia
To take the posttest, go to: http://bit.ly/1nrCdsb
Expires February 24, 2017

VITALS
Key clinical point: Proton pump inhibitors may add to the risk of dementia in older adults. 
Major finding: The risk of incident dementia was 44% higher in adults who used PPIs long term, compared with those who did not. 
Data source: The prospective cohort study included 73,679 adults aged 75 years and older.
Disclosures: The researchers had no financial conflicts to disclose.

4. Elevated Cardiovascular Risks Linked to Hidradenitis Suppurativa
To take the posttest, go to: http://bit.ly/1nrEFz3
Expires February 17, 2017

VITALS
Key clinical point: Hidradenitis suppurativa is associated with a significantly increased risk of adverse cardiovascular events and all-cause mortality.
Major finding: Individuals with hidradenitis suppurativa had a 57% greater risk of myocardial infarction and 33% greater risk of ischemic stroke, compared with the general population. 
Data source: A population-based cohort study in 5,964 patients with hidradenitis suppurativa.
Disclosures: No conflicts of interest were declared.

Here are 4 articles in the April issue of Clinician Reviews (individual articles are valid for one year from date of publication—expiration dates below):

1. Later Menopause Lowers Risk for Later Depression
To take the posttest, go to: http://bit.ly/1U7I7f3
Expires January 6, 2017

VITALS
Key clinical point: Later menopause, with its longer estrogen exposure, appears tied to a lower risk of postmenopausal depression.
Major finding: The risk of depression decreased by 2% for each 2 premenopausal years after age 40.
Data source: The meta-analysis comprised 14 studies with more than 67,700 women.
Disclosures: Neither Dr. Georgakis nor any of the coauthors declared any financial conflicts.

2. Preschool ASD Prevalence Estimates Lower Than Grade School Estimates
To take the posttest, go to: http://bit.ly/24Mec0X
Expires January 5, 2017

VITALS
Key clinical point: The prevalence of autism spectrum disorders among 4-year-olds is about 30% lower than among 8-year-olds.
Major finding: Prevalence of ASD among 4-year-olds was 13/1,000 children across five U.S. states.
Data source: A comparison of health and medical records for nationally representative cohorts involving 58,467 4-year-olds and 56,727 8-year-olds in five U.S. states in 2010.
Disclosures: The Centers for Disease Control and Prevention funded the research. Dr. Christensen and her associates reported no disclosures.

3. Long-term PPI Use Linked to Increased Risk for Dementia
To take the posttest, go to: http://bit.ly/1nrCdsb
Expires February 24, 2017

VITALS
Key clinical point: Proton pump inhibitors may add to the risk of dementia in older adults. 
Major finding: The risk of incident dementia was 44% higher in adults who used PPIs long term, compared with those who did not. 
Data source: The prospective cohort study included 73,679 adults aged 75 years and older.
Disclosures: The researchers had no financial conflicts to disclose.

4. Elevated Cardiovascular Risks Linked to Hidradenitis Suppurativa
To take the posttest, go to: http://bit.ly/1nrEFz3
Expires February 17, 2017

VITALS
Key clinical point: Hidradenitis suppurativa is associated with a significantly increased risk of adverse cardiovascular events and all-cause mortality.
Major finding: Individuals with hidradenitis suppurativa had a 57% greater risk of myocardial infarction and 33% greater risk of ischemic stroke, compared with the general population. 
Data source: A population-based cohort study in 5,964 patients with hidradenitis suppurativa.
Disclosures: No conflicts of interest were declared.

Health care providers working in labor and delivery rooms should employ the standard precautions for infection control to reduce the theoretical risk of Zika transmission, according to recommendations from the Centers for Disease Control and Prevention.

“Because of the potential for exposure to large volumes of body fluids during the labor and delivery process and the sometimes unpredictable and fast-paced nature of obstetrical care, the use of Standard Precautions in these settings is essential to prevent possible transmission of Zika virus from patients to health care personnel,” Dr. Christine K. Olson and her colleagues at the CDC wrote in the Morbidity and Mortality Weekly Report.

©AlexLMX/Thinkstock

No cases of occupational transmission of Zika via bodily fluids have been reported so far, but sexual transmission has occurred and the virus’s RNA has been found in blood, urine, saliva, and amniotic fluid. The risk of occupational exposure therefore theoretically exists, the authors wrote (MMWR. 2016 Mar 22. doi: 10.15585/mmwr.mm6511e3er).

The standard precautions are aimed at preventing transmission of any infectious agent present in blood, body fluids, secretions, nonperspiration excretions, nonintact skin, and mucous membranes. They include five main elements: hand hygiene, use of personal protection equipment (PPE), respiratory hygiene and cough etiquette, safe injection practices, and safe handling of potentially contaminated equipment or surfaces in the patient environment.

Standard PPE recommendations in labor and delivery rooms include eye protection during deliveries to prevent contamination from blood and bodily fluids and the use of double-gloving since the outer layer often contains perforations.

Health care personnel should already be following these standard precautions in all health care settings, but the CDC report will likely remind providers of the importance of these infection control procedures and improve compliance, said Dr. Aaron Caughey, chair of the department of obstetrics and gynecology and associate dean for Women’s Health Research and Policy at Oregon Health and Science University, Portland.

“Those are the standard recommendations on every labor floor for delivery currently, so absolutely it’s feasible,” he said in an interview. However, “for a low-risk woman doing a vaginal delivery without complications, I know that some people skimp on eyewear, and I know there are occasionally people who will wear just one pair of gloves,” he said.

The CDC report also noted varying levels of adherence to the standard precautions.

“Numerous barriers to the appropriate use of PPE have been cited, including the perception that PPE is uncomfortable and limits dexterity, fogging of goggles or face masks, the misperception that prescription eyeglasses provide adequate eye protection, lack of available PPE, forgetting to use PPE, lack of time in urgent clinical situations to don appropriate PPE, the perception that the patient poses minimal risk, and concerns about interference with patient care,” Dr. Olson and her colleagues wrote.

Dr. Caughey drew parallels to the late 1980s and early 1990s, when compliance with eye safety and glove safety precautions increased dramatically alongside the HIV epidemic.

“With these recommendations, it will probably get a little more heightened, particularly if there are parts of the country where Zika becomes endemic,” he said. “The big difference with Zika is if a man contracts Zika or a woman who’s not pregnant contracts Zika, the risks to them are very, very low. It’s really about pregnant women and the risk to the fetus.”

The CDC authors specifically noted that the theoretical risk for Zika transmission is most relevant for female health care personnel who may be pregnant, or for male or female health care personnel attempting to conceive. They recommended that personnel determine the most appropriate PPE based on the likelihood of body fluid exposure for each type of procedure or activity.

An amniotomy or placement of an intrauterine pressure catheter may require mask, eye protection, gloves and an impermeable gown, for example, but vaginal exams of pregnant women with minimal cervical dilation and intact membranes likely only call for the use of gloves. Anesthesia providers should wear sterile gloves and a surgical mask when they place catheters or administer intrathecal injections, and all providers should wear double gloves while handling sharps.

“When performing procedures including vaginal deliveries, manual placenta removal, bimanual uterine massage, and repair of vaginal lacerations, PPE should include (in addition to mucous membrane and skin protection) impermeable gowns and knee-high impermeable shoe covers,” they wrote.

Health care providers working in labor and delivery rooms should employ the standard precautions for infection control to reduce the theoretical risk of Zika transmission, according to recommendations from the Centers for Disease Control and Prevention.

“Because of the potential for exposure to large volumes of body fluids during the labor and delivery process and the sometimes unpredictable and fast-paced nature of obstetrical care, the use of Standard Precautions in these settings is essential to prevent possible transmission of Zika virus from patients to health care personnel,” Dr. Christine K. Olson and her colleagues at the CDC wrote in the Morbidity and Mortality Weekly Report.

©AlexLMX/Thinkstock

No cases of occupational transmission of Zika via bodily fluids have been reported so far, but sexual transmission has occurred and the virus’s RNA has been found in blood, urine, saliva, and amniotic fluid. The risk of occupational exposure therefore theoretically exists, the authors wrote (MMWR. 2016 Mar 22. doi: 10.15585/mmwr.mm6511e3er).

The standard precautions are aimed at preventing transmission of any infectious agent present in blood, body fluids, secretions, nonperspiration excretions, nonintact skin, and mucous membranes. They include five main elements: hand hygiene, use of personal protection equipment (PPE), respiratory hygiene and cough etiquette, safe injection practices, and safe handling of potentially contaminated equipment or surfaces in the patient environment.

Standard PPE recommendations in labor and delivery rooms include eye protection during deliveries to prevent contamination from blood and bodily fluids and the use of double-gloving since the outer layer often contains perforations.

Health care personnel should already be following these standard precautions in all health care settings, but the CDC report will likely remind providers of the importance of these infection control procedures and improve compliance, said Dr. Aaron Caughey, chair of the department of obstetrics and gynecology and associate dean for Women’s Health Research and Policy at Oregon Health and Science University, Portland.

“Those are the standard recommendations on every labor floor for delivery currently, so absolutely it’s feasible,” he said in an interview. However, “for a low-risk woman doing a vaginal delivery without complications, I know that some people skimp on eyewear, and I know there are occasionally people who will wear just one pair of gloves,” he said.

The CDC report also noted varying levels of adherence to the standard precautions.

“Numerous barriers to the appropriate use of PPE have been cited, including the perception that PPE is uncomfortable and limits dexterity, fogging of goggles or face masks, the misperception that prescription eyeglasses provide adequate eye protection, lack of available PPE, forgetting to use PPE, lack of time in urgent clinical situations to don appropriate PPE, the perception that the patient poses minimal risk, and concerns about interference with patient care,” Dr. Olson and her colleagues wrote.

Dr. Caughey drew parallels to the late 1980s and early 1990s, when compliance with eye safety and glove safety precautions increased dramatically alongside the HIV epidemic.

“With these recommendations, it will probably get a little more heightened, particularly if there are parts of the country where Zika becomes endemic,” he said. “The big difference with Zika is if a man contracts Zika or a woman who’s not pregnant contracts Zika, the risks to them are very, very low. It’s really about pregnant women and the risk to the fetus.”

The CDC authors specifically noted that the theoretical risk for Zika transmission is most relevant for female health care personnel who may be pregnant, or for male or female health care personnel attempting to conceive. They recommended that personnel determine the most appropriate PPE based on the likelihood of body fluid exposure for each type of procedure or activity.

An amniotomy or placement of an intrauterine pressure catheter may require mask, eye protection, gloves and an impermeable gown, for example, but vaginal exams of pregnant women with minimal cervical dilation and intact membranes likely only call for the use of gloves. Anesthesia providers should wear sterile gloves and a surgical mask when they place catheters or administer intrathecal injections, and all providers should wear double gloves while handling sharps.

“When performing procedures including vaginal deliveries, manual placenta removal, bimanual uterine massage, and repair of vaginal lacerations, PPE should include (in addition to mucous membrane and skin protection) impermeable gowns and knee-high impermeable shoe covers,” they wrote.

Health care providers working in labor and delivery rooms should employ the standard precautions for infection control to reduce the theoretical risk of Zika transmission, according to recommendations from the Centers for Disease Control and Prevention.

“Because of the potential for exposure to large volumes of body fluids during the labor and delivery process and the sometimes unpredictable and fast-paced nature of obstetrical care, the use of Standard Precautions in these settings is essential to prevent possible transmission of Zika virus from patients to health care personnel,” Dr. Christine K. Olson and her colleagues at the CDC wrote in the Morbidity and Mortality Weekly Report.

©AlexLMX/Thinkstock

No cases of occupational transmission of Zika via bodily fluids have been reported so far, but sexual transmission has occurred and the virus’s RNA has been found in blood, urine, saliva, and amniotic fluid. The risk of occupational exposure therefore theoretically exists, the authors wrote (MMWR. 2016 Mar 22. doi: 10.15585/mmwr.mm6511e3er).

The standard precautions are aimed at preventing transmission of any infectious agent present in blood, body fluids, secretions, nonperspiration excretions, nonintact skin, and mucous membranes. They include five main elements: hand hygiene, use of personal protection equipment (PPE), respiratory hygiene and cough etiquette, safe injection practices, and safe handling of potentially contaminated equipment or surfaces in the patient environment.

Standard PPE recommendations in labor and delivery rooms include eye protection during deliveries to prevent contamination from blood and bodily fluids and the use of double-gloving since the outer layer often contains perforations.

Health care personnel should already be following these standard precautions in all health care settings, but the CDC report will likely remind providers of the importance of these infection control procedures and improve compliance, said Dr. Aaron Caughey, chair of the department of obstetrics and gynecology and associate dean for Women’s Health Research and Policy at Oregon Health and Science University, Portland.

“Those are the standard recommendations on every labor floor for delivery currently, so absolutely it’s feasible,” he said in an interview. However, “for a low-risk woman doing a vaginal delivery without complications, I know that some people skimp on eyewear, and I know there are occasionally people who will wear just one pair of gloves,” he said.

The CDC report also noted varying levels of adherence to the standard precautions.

“Numerous barriers to the appropriate use of PPE have been cited, including the perception that PPE is uncomfortable and limits dexterity, fogging of goggles or face masks, the misperception that prescription eyeglasses provide adequate eye protection, lack of available PPE, forgetting to use PPE, lack of time in urgent clinical situations to don appropriate PPE, the perception that the patient poses minimal risk, and concerns about interference with patient care,” Dr. Olson and her colleagues wrote.

Dr. Caughey drew parallels to the late 1980s and early 1990s, when compliance with eye safety and glove safety precautions increased dramatically alongside the HIV epidemic.

“With these recommendations, it will probably get a little more heightened, particularly if there are parts of the country where Zika becomes endemic,” he said. “The big difference with Zika is if a man contracts Zika or a woman who’s not pregnant contracts Zika, the risks to them are very, very low. It’s really about pregnant women and the risk to the fetus.”

The CDC authors specifically noted that the theoretical risk for Zika transmission is most relevant for female health care personnel who may be pregnant, or for male or female health care personnel attempting to conceive. They recommended that personnel determine the most appropriate PPE based on the likelihood of body fluid exposure for each type of procedure or activity.

An amniotomy or placement of an intrauterine pressure catheter may require mask, eye protection, gloves and an impermeable gown, for example, but vaginal exams of pregnant women with minimal cervical dilation and intact membranes likely only call for the use of gloves. Anesthesia providers should wear sterile gloves and a surgical mask when they place catheters or administer intrathecal injections, and all providers should wear double gloves while handling sharps.

“When performing procedures including vaginal deliveries, manual placenta removal, bimanual uterine massage, and repair of vaginal lacerations, PPE should include (in addition to mucous membrane and skin protection) impermeable gowns and knee-high impermeable shoe covers,” they wrote.

A faster diagnostic tool for Zika virus infection than those currently used received approval by the Food and Drug Administration under an Emergency Use Authorization, the agency reported Friday, the same day the Centers for Disease Control and Prevention reported that 116 U.S. residents have tested positive for Zika as of Feb. 26.

The Trioplex Real­time RT-­PCR Assay requires only a single test to differentiate current chikungunya, dengue or Zika infections instead of three separate tests. The CDC will start distributing the test to qualified domestic and international labs over the next two weeks, but U.S. hospitals and similar primary care settings will not have the test.

©Felipe Caparrós Cruz/Thinkstock

Nearly a quarter (24%) of the 116 cases reported by the CDC were diagnosed using reverse transcription-polymerase chain reaction (RT-PCR) to detect Zika RNA, and nearly all the remaining (76%) relied on detection of anti-Zika antibodies with ELISA serologic testing. Two cases were determined based on epidemiological links to a confirmed case and serologic evidence of an unspecified flavivirus infection. These cases do not include additional onesdiagnosed and reported from state and territorial departments with local lab testing.

“Zika virus disease should be considered in patients with acute onset of fever, rash, arthralgia or conjunctivitis who traveled to areas with ongoing transmission or had unprotected sex with someone who traveled to those areas and developed compatible symptoms within two weeks of returning,” said Dr. Paige Armstrong, of the Epidemic Intelligence Service at the CDC in Atlanta, and her associates (MMWR 2016 March 18).

The researchers reported on all U.S. residents who received positive lab tests for Zika infection from the CDC between January 1, 2015, and February 26, 2016. Among the cases, from 33 states and Washington, D.C., one was an infant with microcephaly who contracted the virus congenitally, five had recently had sexual contact with someone who had traveled to an area where Zika was actively circulating, and 110 had traveled to a region active with Zika. Haiti, El Salvador, Colombia, Honduras and Guatemala comprised the most commonly visited countries among the cases.

Most infections of Zika, transmitted primarily by the Aedes aegypti mosquito, remain asymptomatic, and even those with the characteristic symptoms of rash, fever, arthralgia and nonpurulent conjunctivitis tend to have a mild illness. Nearly all (96%) of the 116 cases had at least two of these symptoms, and 65% had three or more. Among all the cases, 98% experienced a rash, 82% a fever, 66% joint pain, 57% headache, 55% myalgia and 37% conjunctivitis. Four were hospitalized, and none died.

“Until more is known about the effects of Zika virus infection on the developing fetus, pregnant women should postpone travel to areas where Zika virus transmission is ongoing,” Dr. Armstrong and associates wrote. “Pregnant women who develop a clinically compatible illness during or within two weeks of returning from an area with Zika virus transmission should be tested for Zika virus infection; testing may also be offered to asymptomatic pregnant women 2–12 weeks after travel to an area with active Zika transmission.”

The study was funded by the CDC, and the authors reported no disclosures.

A faster diagnostic tool for Zika virus infection than those currently used received approval by the Food and Drug Administration under an Emergency Use Authorization, the agency reported Friday, the same day the Centers for Disease Control and Prevention reported that 116 U.S. residents have tested positive for Zika as of Feb. 26.

The Trioplex Real­time RT-­PCR Assay requires only a single test to differentiate current chikungunya, dengue or Zika infections instead of three separate tests. The CDC will start distributing the test to qualified domestic and international labs over the next two weeks, but U.S. hospitals and similar primary care settings will not have the test.

©Felipe Caparrós Cruz/Thinkstock

Nearly a quarter (24%) of the 116 cases reported by the CDC were diagnosed using reverse transcription-polymerase chain reaction (RT-PCR) to detect Zika RNA, and nearly all the remaining (76%) relied on detection of anti-Zika antibodies with ELISA serologic testing. Two cases were determined based on epidemiological links to a confirmed case and serologic evidence of an unspecified flavivirus infection. These cases do not include additional onesdiagnosed and reported from state and territorial departments with local lab testing.

“Zika virus disease should be considered in patients with acute onset of fever, rash, arthralgia or conjunctivitis who traveled to areas with ongoing transmission or had unprotected sex with someone who traveled to those areas and developed compatible symptoms within two weeks of returning,” said Dr. Paige Armstrong, of the Epidemic Intelligence Service at the CDC in Atlanta, and her associates (MMWR 2016 March 18).

The researchers reported on all U.S. residents who received positive lab tests for Zika infection from the CDC between January 1, 2015, and February 26, 2016. Among the cases, from 33 states and Washington, D.C., one was an infant with microcephaly who contracted the virus congenitally, five had recently had sexual contact with someone who had traveled to an area where Zika was actively circulating, and 110 had traveled to a region active with Zika. Haiti, El Salvador, Colombia, Honduras and Guatemala comprised the most commonly visited countries among the cases.

Most infections of Zika, transmitted primarily by the Aedes aegypti mosquito, remain asymptomatic, and even those with the characteristic symptoms of rash, fever, arthralgia and nonpurulent conjunctivitis tend to have a mild illness. Nearly all (96%) of the 116 cases had at least two of these symptoms, and 65% had three or more. Among all the cases, 98% experienced a rash, 82% a fever, 66% joint pain, 57% headache, 55% myalgia and 37% conjunctivitis. Four were hospitalized, and none died.

“Until more is known about the effects of Zika virus infection on the developing fetus, pregnant women should postpone travel to areas where Zika virus transmission is ongoing,” Dr. Armstrong and associates wrote. “Pregnant women who develop a clinically compatible illness during or within two weeks of returning from an area with Zika virus transmission should be tested for Zika virus infection; testing may also be offered to asymptomatic pregnant women 2–12 weeks after travel to an area with active Zika transmission.”

The study was funded by the CDC, and the authors reported no disclosures.

A faster diagnostic tool for Zika virus infection than those currently used received approval by the Food and Drug Administration under an Emergency Use Authorization, the agency reported Friday, the same day the Centers for Disease Control and Prevention reported that 116 U.S. residents have tested positive for Zika as of Feb. 26.

The Trioplex Real­time RT-­PCR Assay requires only a single test to differentiate current chikungunya, dengue or Zika infections instead of three separate tests. The CDC will start distributing the test to qualified domestic and international labs over the next two weeks, but U.S. hospitals and similar primary care settings will not have the test.

©Felipe Caparrós Cruz/Thinkstock

Nearly a quarter (24%) of the 116 cases reported by the CDC were diagnosed using reverse transcription-polymerase chain reaction (RT-PCR) to detect Zika RNA, and nearly all the remaining (76%) relied on detection of anti-Zika antibodies with ELISA serologic testing. Two cases were determined based on epidemiological links to a confirmed case and serologic evidence of an unspecified flavivirus infection. These cases do not include additional onesdiagnosed and reported from state and territorial departments with local lab testing.

“Zika virus disease should be considered in patients with acute onset of fever, rash, arthralgia or conjunctivitis who traveled to areas with ongoing transmission or had unprotected sex with someone who traveled to those areas and developed compatible symptoms within two weeks of returning,” said Dr. Paige Armstrong, of the Epidemic Intelligence Service at the CDC in Atlanta, and her associates (MMWR 2016 March 18).

The researchers reported on all U.S. residents who received positive lab tests for Zika infection from the CDC between January 1, 2015, and February 26, 2016. Among the cases, from 33 states and Washington, D.C., one was an infant with microcephaly who contracted the virus congenitally, five had recently had sexual contact with someone who had traveled to an area where Zika was actively circulating, and 110 had traveled to a region active with Zika. Haiti, El Salvador, Colombia, Honduras and Guatemala comprised the most commonly visited countries among the cases.

Most infections of Zika, transmitted primarily by the Aedes aegypti mosquito, remain asymptomatic, and even those with the characteristic symptoms of rash, fever, arthralgia and nonpurulent conjunctivitis tend to have a mild illness. Nearly all (96%) of the 116 cases had at least two of these symptoms, and 65% had three or more. Among all the cases, 98% experienced a rash, 82% a fever, 66% joint pain, 57% headache, 55% myalgia and 37% conjunctivitis. Four were hospitalized, and none died.

“Until more is known about the effects of Zika virus infection on the developing fetus, pregnant women should postpone travel to areas where Zika virus transmission is ongoing,” Dr. Armstrong and associates wrote. “Pregnant women who develop a clinically compatible illness during or within two weeks of returning from an area with Zika virus transmission should be tested for Zika virus infection; testing may also be offered to asymptomatic pregnant women 2–12 weeks after travel to an area with active Zika transmission.”

The study was funded by the CDC, and the authors reported no disclosures.

Prenatal ultrasounds for nonmedical purposes and routine use of robotic assisted laparoscopic surgery for benign gynecologic disease are among the interventions physicians and patients should question, according to the American College of Obstetricians and Gynecologists.

The organization produced the list of five interventions to be questioned as part of the ABIM (American Board of Internal Medicine) Foundation’s Choosing Wisely initiative, which “aims to promote conversations between clinicians and patients by helping patients choose care that is supported by evidence, not duplicative of other tests or procedures already received, free from harm, and truly necessary,” according to the Choosing Wisely website.

©kjekol/Thinkstock

ACOG released its first Choosing Wisely list in 2003, advising clinicians to avoid elective labor inductions before 39 weeks as well as annual pap tests in women aged 30-65.

“These are good topics to bring up in discussion with patients,” said Dr. Gerardo Bustillo, an ob.gyn. at Orange Coast Memorial Medical Center in Fountain Valley, Calif. “Patients may ask for inappropriate interventions such as early induction of labor, and these recommendations will equip physicians and other healthcare providers in explaining the dangers of certain interventions.”

The five new items include:

1. Avoid using robotic assisted laparoscopic surgery for benign gynecologic disease when it is feasible to use a conventional laparoscopic or vaginal approach.

ACOG states that comparable perioperative outcomes, intraoperative complications, length of hospital stay, and rate of conversion to open surgery result from both robotic-assisted and conventional laparoscopic surgeries but that robotic-assisted techniques cost more and can take longer. But Dr. Bustillo questioned this item’s addition to the list in light of new evidence that “robotic-assisted hysterectomies resulted in fewer postoperative complications than conventional laparoscopic and vaginal hysterectomies, when performed by high-volume robotic gynecologic surgeons,” he said.

The patients undergoing robotic-assisted hysterectomy, he added, experienced the same or decreased intraoperative and postoperative complications compared with those undergoing conventional techniques despite being more complex patients. They were older with higher rates of adhesive disease, large uteri, and morbid obesity.

2. Don’t perform prenatal ultrasounds for nonmedical purposes, for example, solely to create keepsake videos or photographs.

Keepsake imaging is not an approved use of a medical device by the Food and Drug Administration and is also discouraged by the American Institute of Ultrasound in Medicine. These “comfort ultrasounds” are often performed by the request of the patient and are done without true medical indications,” said Dr. Sherry Ross, an ob.gyn. at Providence Saint John’s Health Center in Santa Monica, Calif.

“Not only are these types of ultrasounds excessive, but they are costly as well,” she said. “Counseling the pregnant woman is the best way to reduce unnecessary ultrasounds, especially those performed at the local mall.”

3. Don’t routinely transfuse stable, asymptomatic hospitalized patients with a hemoglobin level greater than 7-8 grams.

“Arbitrary hemoglobin or hematocrit thresholds should not be used as the only criterion for transfusions of packed red blood cells,” ACOG advises. The potential risks of transfusion make this item the most important of the additions, according to Dr. Bustillo. “These risks include infection with certain pathogens, allergic and immune transfusion reactions, volume overload, hyperkalemia, and iron overload,” he said.

4. Don’t perform pelvic ultrasound in average risk women to screen for ovarian cancer.

With an age-adjusted incidence of just 13 ovarian cancer cases per 100,000 women annually, the positive predictive value is low for screening for ovarian cancer, leading to a high rate of false positives, ACOG notes.

“The tools that are currently available for screening women who are high risk include transvaginal pelvic ultrasound and CA 125 blood tests done every 6 months to 1 year along with pelvic examinations,” Dr. Ross said. “Those at high risk include those with a family history or who test positive for BRCA1 and 2 mutations and Ashkenazi women with a single family member with breast cancer before age 50 or with ovarian cancer.” Without a family history or other risk factors, a CA 125 or pelvic ultrasound in asymptomatic women does not reduce deaths, she added.

5. Don’t routinely recommend activity restriction or bed rest during pregnancy for any indication.

Historically, physicians have recommended bed rest for a range of pregnancy conditions, including multiple gestation, intrauterine growth restriction, preterm labor, premature rupture of membranes, vaginal bleeding, and hypertensive disorders in pregnancy, ACOG notes. “The negative financial and psychosocial implications of putting women on activity restriction, specifically bed rest, are well documented,” said Dr. Anthony C. Sciscione, director of Maternal-Fetal Medicine at Christiana Care Health System and program director for Christiana Care’s ob.gyn. residency program in Wilmington, Del. “However, no study has demonstrated a benefit to activity restriction during pregnancy for any diagnosis.”

The only clinical benefit resulting from bed rest has been a modest decrease in blood pressure that does not translate to improved outcomes, Dr. Sciscione said. Additional risks of activity restriction include an increase in maternal anxiety and depression, significant financial impact on the family, physical deconditioning, bone loss, and a potential increase in blood clots. Being active in pregnancy, however, is linked to a decrease in preterm birth, he added.

The 2013 list

Among the previous five items included in the 2013 list are not scheduling elective, nonmedically indicated inductions of labor or cesarean deliveries before 39 weeks 0 days of gestational age and not scheduling elective, non-medically indicated labor inductions between 39 weeks 0 days and 41 weeks 0 days unless the cervix is favorable.

ACOG also recommended that asymptomatic women of average risk do not receive screenings for ovarian cancer, that patients with mild dysplasia for less than 2 years do not receive treatment, and that women aged 30-65 years do not receive routine annual cervical cytology screenings.

Prenatal ultrasounds for nonmedical purposes and routine use of robotic assisted laparoscopic surgery for benign gynecologic disease are among the interventions physicians and patients should question, according to the American College of Obstetricians and Gynecologists.

The organization produced the list of five interventions to be questioned as part of the ABIM (American Board of Internal Medicine) Foundation’s Choosing Wisely initiative, which “aims to promote conversations between clinicians and patients by helping patients choose care that is supported by evidence, not duplicative of other tests or procedures already received, free from harm, and truly necessary,” according to the Choosing Wisely website.

©kjekol/Thinkstock

ACOG released its first Choosing Wisely list in 2003, advising clinicians to avoid elective labor inductions before 39 weeks as well as annual pap tests in women aged 30-65.

“These are good topics to bring up in discussion with patients,” said Dr. Gerardo Bustillo, an ob.gyn. at Orange Coast Memorial Medical Center in Fountain Valley, Calif. “Patients may ask for inappropriate interventions such as early induction of labor, and these recommendations will equip physicians and other healthcare providers in explaining the dangers of certain interventions.”

The five new items include:

1. Avoid using robotic assisted laparoscopic surgery for benign gynecologic disease when it is feasible to use a conventional laparoscopic or vaginal approach.

ACOG states that comparable perioperative outcomes, intraoperative complications, length of hospital stay, and rate of conversion to open surgery result from both robotic-assisted and conventional laparoscopic surgeries but that robotic-assisted techniques cost more and can take longer. But Dr. Bustillo questioned this item’s addition to the list in light of new evidence that “robotic-assisted hysterectomies resulted in fewer postoperative complications than conventional laparoscopic and vaginal hysterectomies, when performed by high-volume robotic gynecologic surgeons,” he said.

The patients undergoing robotic-assisted hysterectomy, he added, experienced the same or decreased intraoperative and postoperative complications compared with those undergoing conventional techniques despite being more complex patients. They were older with higher rates of adhesive disease, large uteri, and morbid obesity.

2. Don’t perform prenatal ultrasounds for nonmedical purposes, for example, solely to create keepsake videos or photographs.

Keepsake imaging is not an approved use of a medical device by the Food and Drug Administration and is also discouraged by the American Institute of Ultrasound in Medicine. These “comfort ultrasounds” are often performed by the request of the patient and are done without true medical indications,” said Dr. Sherry Ross, an ob.gyn. at Providence Saint John’s Health Center in Santa Monica, Calif.

“Not only are these types of ultrasounds excessive, but they are costly as well,” she said. “Counseling the pregnant woman is the best way to reduce unnecessary ultrasounds, especially those performed at the local mall.”

3. Don’t routinely transfuse stable, asymptomatic hospitalized patients with a hemoglobin level greater than 7-8 grams.

“Arbitrary hemoglobin or hematocrit thresholds should not be used as the only criterion for transfusions of packed red blood cells,” ACOG advises. The potential risks of transfusion make this item the most important of the additions, according to Dr. Bustillo. “These risks include infection with certain pathogens, allergic and immune transfusion reactions, volume overload, hyperkalemia, and iron overload,” he said.

4. Don’t perform pelvic ultrasound in average risk women to screen for ovarian cancer.

With an age-adjusted incidence of just 13 ovarian cancer cases per 100,000 women annually, the positive predictive value is low for screening for ovarian cancer, leading to a high rate of false positives, ACOG notes.

“The tools that are currently available for screening women who are high risk include transvaginal pelvic ultrasound and CA 125 blood tests done every 6 months to 1 year along with pelvic examinations,” Dr. Ross said. “Those at high risk include those with a family history or who test positive for BRCA1 and 2 mutations and Ashkenazi women with a single family member with breast cancer before age 50 or with ovarian cancer.” Without a family history or other risk factors, a CA 125 or pelvic ultrasound in asymptomatic women does not reduce deaths, she added.

5. Don’t routinely recommend activity restriction or bed rest during pregnancy for any indication.

Historically, physicians have recommended bed rest for a range of pregnancy conditions, including multiple gestation, intrauterine growth restriction, preterm labor, premature rupture of membranes, vaginal bleeding, and hypertensive disorders in pregnancy, ACOG notes. “The negative financial and psychosocial implications of putting women on activity restriction, specifically bed rest, are well documented,” said Dr. Anthony C. Sciscione, director of Maternal-Fetal Medicine at Christiana Care Health System and program director for Christiana Care’s ob.gyn. residency program in Wilmington, Del. “However, no study has demonstrated a benefit to activity restriction during pregnancy for any diagnosis.”

The only clinical benefit resulting from bed rest has been a modest decrease in blood pressure that does not translate to improved outcomes, Dr. Sciscione said. Additional risks of activity restriction include an increase in maternal anxiety and depression, significant financial impact on the family, physical deconditioning, bone loss, and a potential increase in blood clots. Being active in pregnancy, however, is linked to a decrease in preterm birth, he added.

The 2013 list

Among the previous five items included in the 2013 list are not scheduling elective, nonmedically indicated inductions of labor or cesarean deliveries before 39 weeks 0 days of gestational age and not scheduling elective, non-medically indicated labor inductions between 39 weeks 0 days and 41 weeks 0 days unless the cervix is favorable.

ACOG also recommended that asymptomatic women of average risk do not receive screenings for ovarian cancer, that patients with mild dysplasia for less than 2 years do not receive treatment, and that women aged 30-65 years do not receive routine annual cervical cytology screenings.

Prenatal ultrasounds for nonmedical purposes and routine use of robotic assisted laparoscopic surgery for benign gynecologic disease are among the interventions physicians and patients should question, according to the American College of Obstetricians and Gynecologists.

The organization produced the list of five interventions to be questioned as part of the ABIM (American Board of Internal Medicine) Foundation’s Choosing Wisely initiative, which “aims to promote conversations between clinicians and patients by helping patients choose care that is supported by evidence, not duplicative of other tests or procedures already received, free from harm, and truly necessary,” according to the Choosing Wisely website.

©kjekol/Thinkstock

ACOG released its first Choosing Wisely list in 2003, advising clinicians to avoid elective labor inductions before 39 weeks as well as annual pap tests in women aged 30-65.

“These are good topics to bring up in discussion with patients,” said Dr. Gerardo Bustillo, an ob.gyn. at Orange Coast Memorial Medical Center in Fountain Valley, Calif. “Patients may ask for inappropriate interventions such as early induction of labor, and these recommendations will equip physicians and other healthcare providers in explaining the dangers of certain interventions.”

The five new items include:

1. Avoid using robotic assisted laparoscopic surgery for benign gynecologic disease when it is feasible to use a conventional laparoscopic or vaginal approach.

ACOG states that comparable perioperative outcomes, intraoperative complications, length of hospital stay, and rate of conversion to open surgery result from both robotic-assisted and conventional laparoscopic surgeries but that robotic-assisted techniques cost more and can take longer. But Dr. Bustillo questioned this item’s addition to the list in light of new evidence that “robotic-assisted hysterectomies resulted in fewer postoperative complications than conventional laparoscopic and vaginal hysterectomies, when performed by high-volume robotic gynecologic surgeons,” he said.

The patients undergoing robotic-assisted hysterectomy, he added, experienced the same or decreased intraoperative and postoperative complications compared with those undergoing conventional techniques despite being more complex patients. They were older with higher rates of adhesive disease, large uteri, and morbid obesity.

2. Don’t perform prenatal ultrasounds for nonmedical purposes, for example, solely to create keepsake videos or photographs.

Keepsake imaging is not an approved use of a medical device by the Food and Drug Administration and is also discouraged by the American Institute of Ultrasound in Medicine. These “comfort ultrasounds” are often performed by the request of the patient and are done without true medical indications,” said Dr. Sherry Ross, an ob.gyn. at Providence Saint John’s Health Center in Santa Monica, Calif.

“Not only are these types of ultrasounds excessive, but they are costly as well,” she said. “Counseling the pregnant woman is the best way to reduce unnecessary ultrasounds, especially those performed at the local mall.”

3. Don’t routinely transfuse stable, asymptomatic hospitalized patients with a hemoglobin level greater than 7-8 grams.

“Arbitrary hemoglobin or hematocrit thresholds should not be used as the only criterion for transfusions of packed red blood cells,” ACOG advises. The potential risks of transfusion make this item the most important of the additions, according to Dr. Bustillo. “These risks include infection with certain pathogens, allergic and immune transfusion reactions, volume overload, hyperkalemia, and iron overload,” he said.

4. Don’t perform pelvic ultrasound in average risk women to screen for ovarian cancer.

With an age-adjusted incidence of just 13 ovarian cancer cases per 100,000 women annually, the positive predictive value is low for screening for ovarian cancer, leading to a high rate of false positives, ACOG notes.

“The tools that are currently available for screening women who are high risk include transvaginal pelvic ultrasound and CA 125 blood tests done every 6 months to 1 year along with pelvic examinations,” Dr. Ross said. “Those at high risk include those with a family history or who test positive for BRCA1 and 2 mutations and Ashkenazi women with a single family member with breast cancer before age 50 or with ovarian cancer.” Without a family history or other risk factors, a CA 125 or pelvic ultrasound in asymptomatic women does not reduce deaths, she added.

5. Don’t routinely recommend activity restriction or bed rest during pregnancy for any indication.

Historically, physicians have recommended bed rest for a range of pregnancy conditions, including multiple gestation, intrauterine growth restriction, preterm labor, premature rupture of membranes, vaginal bleeding, and hypertensive disorders in pregnancy, ACOG notes. “The negative financial and psychosocial implications of putting women on activity restriction, specifically bed rest, are well documented,” said Dr. Anthony C. Sciscione, director of Maternal-Fetal Medicine at Christiana Care Health System and program director for Christiana Care’s ob.gyn. residency program in Wilmington, Del. “However, no study has demonstrated a benefit to activity restriction during pregnancy for any diagnosis.”

The only clinical benefit resulting from bed rest has been a modest decrease in blood pressure that does not translate to improved outcomes, Dr. Sciscione said. Additional risks of activity restriction include an increase in maternal anxiety and depression, significant financial impact on the family, physical deconditioning, bone loss, and a potential increase in blood clots. Being active in pregnancy, however, is linked to a decrease in preterm birth, he added.

The 2013 list

Among the previous five items included in the 2013 list are not scheduling elective, nonmedically indicated inductions of labor or cesarean deliveries before 39 weeks 0 days of gestational age and not scheduling elective, non-medically indicated labor inductions between 39 weeks 0 days and 41 weeks 0 days unless the cervix is favorable.

ACOG also recommended that asymptomatic women of average risk do not receive screenings for ovarian cancer, that patients with mild dysplasia for less than 2 years do not receive treatment, and that women aged 30-65 years do not receive routine annual cervical cytology screenings.

Receiving two doses of a combination tetanus and meningococcal vaccine in infancy did not result in additional protection among children 5 years later, a study found.

Researchers followed up on children receiving one or two doses of the quadrivalent meningococcal serogroups A, C, W, and Y tetanus toxoid conjugate vaccine (MenACWY-TT).

©dina2001/thinkstockphotos.com

“Overall, 5 years after primary vaccination with MenACWY-TT, there was no clear evidence of benefit of receiving two versus one dose of vaccine in infancy,” reported Dr. Nicola P. Klein of the Kaiser Permanente Vaccine Study Center in Oakland, Calif., and her associates online (Pediatr Infect Dis J. 2016 Feb 26. doi: 10.1097/INF.0000000000001123).

In the initial phase II, open multicenter study, the researchers randomized 349 infants to receive either a single dose of MenACWY-TT at 12 months of age or a first dose of MenACWY-TT at 9 months of age followed by a booster dose at 12 months.

Using a per-protocol analysis, the researchers compared the titers of 186 children at 3 years’ follow-up and 135 children at 5 years’ follow-up. In the group that received one dose, 64%-75% of the children had titers of 8 or higher for MenC, MenW, and MenY 5 years later, compared with 75%-86% of the children who received two doses.

Also at 5 years, MenA titers were 8 or higher in 32% of children receiving one dose and 38% of children receiving two doses. Titers for all serotypes had waned by 5 years after vaccination, but only MenA was low enough that most children were seronegative by 1 year after vaccination. Overall average titers were higher in the group that had received two doses than in the group that had received one.

Dr. Klein’s team also evaluated the immune response and safety of a booster dose of MenACWY-TT to 38 children who had received one dose in infancy and 46 children who had received two doses in infancy, and a primary dose in 100 children of the same age who had never received a meningococcal vaccine. All children receiving the booster dose had antibody titers of 8 or higher against all serotypes 1 month after the dose. Among those receiving the vaccine for the first time, titers were 8 or higher at 1 month in 79% of children for MenA, 86% for MenC, 90% for MenW, and 94% for MenY.

No significant differences existed in terms of average titer levels, vaccine response, or titer levels of greater than or equal to 4 or greater than or equal to 8 between the children who received one dose and the children who received two doses in infancy. Children who received one or two vaccine doses in infancy had higher average titers and more vaccine responses to all serogroups than the children receiving a dose at age 5 years for the first time.

The most common adverse event was pain at the injection site and fatigue within 4 days of vaccination, and no fevers or serious adverse events occurred in any children in this time. Within the month after vaccination, 24% of children who received one dose in infancy, 13% of those who received two, and 29% of children receiving the first dose at age 5 years had at least one adverse event. One child had an upper respiratory tract infection and rash, one had diarrhea and vomiting, and one had Raynaud’s phenomenon within the month after vaccination.

The research was funded by GlaxoSmithKline Biologicals SA. Dr. Miller, Dr. Baine, Dr. Van der Wielen, Dr. Baccarini, and Dr. Kolhe are employees of GSK, and all but Dr. Kolhe and Dr. Klein have restricted shares in GSK. Dr. Miller and Dr. Baine coinvented a patent, which, if granted, will be owned by GSK. Dr. Klein has received research grants from GSK, Sanofi Pasteur, Pfizer, Novartis, Merck, Nuron, and Protein Science, outside the submitted work.

Receiving two doses of a combination tetanus and meningococcal vaccine in infancy did not result in additional protection among children 5 years later, a study found.

Researchers followed up on children receiving one or two doses of the quadrivalent meningococcal serogroups A, C, W, and Y tetanus toxoid conjugate vaccine (MenACWY-TT).

©dina2001/thinkstockphotos.com

“Overall, 5 years after primary vaccination with MenACWY-TT, there was no clear evidence of benefit of receiving two versus one dose of vaccine in infancy,” reported Dr. Nicola P. Klein of the Kaiser Permanente Vaccine Study Center in Oakland, Calif., and her associates online (Pediatr Infect Dis J. 2016 Feb 26. doi: 10.1097/INF.0000000000001123).

In the initial phase II, open multicenter study, the researchers randomized 349 infants to receive either a single dose of MenACWY-TT at 12 months of age or a first dose of MenACWY-TT at 9 months of age followed by a booster dose at 12 months.

Using a per-protocol analysis, the researchers compared the titers of 186 children at 3 years’ follow-up and 135 children at 5 years’ follow-up. In the group that received one dose, 64%-75% of the children had titers of 8 or higher for MenC, MenW, and MenY 5 years later, compared with 75%-86% of the children who received two doses.

Also at 5 years, MenA titers were 8 or higher in 32% of children receiving one dose and 38% of children receiving two doses. Titers for all serotypes had waned by 5 years after vaccination, but only MenA was low enough that most children were seronegative by 1 year after vaccination. Overall average titers were higher in the group that had received two doses than in the group that had received one.

Dr. Klein’s team also evaluated the immune response and safety of a booster dose of MenACWY-TT to 38 children who had received one dose in infancy and 46 children who had received two doses in infancy, and a primary dose in 100 children of the same age who had never received a meningococcal vaccine. All children receiving the booster dose had antibody titers of 8 or higher against all serotypes 1 month after the dose. Among those receiving the vaccine for the first time, titers were 8 or higher at 1 month in 79% of children for MenA, 86% for MenC, 90% for MenW, and 94% for MenY.

No significant differences existed in terms of average titer levels, vaccine response, or titer levels of greater than or equal to 4 or greater than or equal to 8 between the children who received one dose and the children who received two doses in infancy. Children who received one or two vaccine doses in infancy had higher average titers and more vaccine responses to all serogroups than the children receiving a dose at age 5 years for the first time.

The most common adverse event was pain at the injection site and fatigue within 4 days of vaccination, and no fevers or serious adverse events occurred in any children in this time. Within the month after vaccination, 24% of children who received one dose in infancy, 13% of those who received two, and 29% of children receiving the first dose at age 5 years had at least one adverse event. One child had an upper respiratory tract infection and rash, one had diarrhea and vomiting, and one had Raynaud’s phenomenon within the month after vaccination.

The research was funded by GlaxoSmithKline Biologicals SA. Dr. Miller, Dr. Baine, Dr. Van der Wielen, Dr. Baccarini, and Dr. Kolhe are employees of GSK, and all but Dr. Kolhe and Dr. Klein have restricted shares in GSK. Dr. Miller and Dr. Baine coinvented a patent, which, if granted, will be owned by GSK. Dr. Klein has received research grants from GSK, Sanofi Pasteur, Pfizer, Novartis, Merck, Nuron, and Protein Science, outside the submitted work.

Receiving two doses of a combination tetanus and meningococcal vaccine in infancy did not result in additional protection among children 5 years later, a study found.

Researchers followed up on children receiving one or two doses of the quadrivalent meningococcal serogroups A, C, W, and Y tetanus toxoid conjugate vaccine (MenACWY-TT).

©dina2001/thinkstockphotos.com

“Overall, 5 years after primary vaccination with MenACWY-TT, there was no clear evidence of benefit of receiving two versus one dose of vaccine in infancy,” reported Dr. Nicola P. Klein of the Kaiser Permanente Vaccine Study Center in Oakland, Calif., and her associates online (Pediatr Infect Dis J. 2016 Feb 26. doi: 10.1097/INF.0000000000001123).

In the initial phase II, open multicenter study, the researchers randomized 349 infants to receive either a single dose of MenACWY-TT at 12 months of age or a first dose of MenACWY-TT at 9 months of age followed by a booster dose at 12 months.

Using a per-protocol analysis, the researchers compared the titers of 186 children at 3 years’ follow-up and 135 children at 5 years’ follow-up. In the group that received one dose, 64%-75% of the children had titers of 8 or higher for MenC, MenW, and MenY 5 years later, compared with 75%-86% of the children who received two doses.

Also at 5 years, MenA titers were 8 or higher in 32% of children receiving one dose and 38% of children receiving two doses. Titers for all serotypes had waned by 5 years after vaccination, but only MenA was low enough that most children were seronegative by 1 year after vaccination. Overall average titers were higher in the group that had received two doses than in the group that had received one.

Dr. Klein’s team also evaluated the immune response and safety of a booster dose of MenACWY-TT to 38 children who had received one dose in infancy and 46 children who had received two doses in infancy, and a primary dose in 100 children of the same age who had never received a meningococcal vaccine. All children receiving the booster dose had antibody titers of 8 or higher against all serotypes 1 month after the dose. Among those receiving the vaccine for the first time, titers were 8 or higher at 1 month in 79% of children for MenA, 86% for MenC, 90% for MenW, and 94% for MenY.

No significant differences existed in terms of average titer levels, vaccine response, or titer levels of greater than or equal to 4 or greater than or equal to 8 between the children who received one dose and the children who received two doses in infancy. Children who received one or two vaccine doses in infancy had higher average titers and more vaccine responses to all serogroups than the children receiving a dose at age 5 years for the first time.

The most common adverse event was pain at the injection site and fatigue within 4 days of vaccination, and no fevers or serious adverse events occurred in any children in this time. Within the month after vaccination, 24% of children who received one dose in infancy, 13% of those who received two, and 29% of children receiving the first dose at age 5 years had at least one adverse event. One child had an upper respiratory tract infection and rash, one had diarrhea and vomiting, and one had Raynaud’s phenomenon within the month after vaccination.

The research was funded by GlaxoSmithKline Biologicals SA. Dr. Miller, Dr. Baine, Dr. Van der Wielen, Dr. Baccarini, and Dr. Kolhe are employees of GSK, and all but Dr. Kolhe and Dr. Klein have restricted shares in GSK. Dr. Miller and Dr. Baine coinvented a patent, which, if granted, will be owned by GSK. Dr. Klein has received research grants from GSK, Sanofi Pasteur, Pfizer, Novartis, Merck, Nuron, and Protein Science, outside the submitted work.

The role that health care providers can and should play in promoting breastfeeding has come under scrutiny in recent years, often leaving doctors uncertain about how to discuss infant-feeding intentions with patients.

There’s been a backlash against the public health promotion of breastfeeding and “lactivism,” with critics saying that the efforts lead to shame or guilt in women who do not breastfeed. And often mothers, and their physicians, have been caught in the crossfire.

©Maxim Tupikov/iStockphoto.com

The American College of Obstetricians and Gynecologists attempted to build a bridge across this divide in their updated Committee Opinion on breastfeeding in February.

In a departure from the language typically included in policy statements or clinical guidelines from other medical organizations, the new ACOG guidelines urged ob.gyns. and other obstetric care providers to “support each woman’s informed decision about whether to initiate or continue breastfeeding, recognizing that she is uniquely qualified to decide whether exclusive breastfeeding, mixed feeding, or formula feeding is optimal for her and her infant.”

At the same time, however, the organization also “recommends exclusive breastfeeding for the first 6 months of life, with continued breastfeeding as complementary foods are introduced through the infant’s first year of life, or longer as mutually desired by the woman and her infant.”

Striking the right balance in providing women with adequate information to make informed choices without inadvertently causing a woman discomfort requires clinicians to start by finding out what their patients already know, according to Dr. Alison Stuebe, lead author of the ACOG opinion and an assistant professor of maternal-fetal medicine at the University of North Carolina at Chapel Hill.

“The clinician’s role is to help that mom make an informed decision, and it’s hard to help her do that if you don’t know where she’s coming from,” Dr. Stuebe said. “It’s important not to assume that a woman knows everything or knows nothing.”

How to start the conversation

Dr. Stuebe, who is also a distinguished scholar of infant and young child feeding in the Gillings School of Global Public Health at UNC, recommended bringing up the subject of breastfeeding early in a woman’s prenatal care with a simple open-ended question: “What have you heard about breastfeeding?” The answer helps tailor the counseling to the mother’s knowledge, feelings, and attitudes.

“We have some moms who have read 47 books on breastfeeding, and then there are women who live in a family where they’ve only seen bottle feeding,” Dr. Stuebe said.

Next, validate what the mother says, and ask for more information from the mom. When the conversation begins early in the physician-patient relationship, there is time to have the conversation over several visits, Dr. Stuebe said.

“I think asking the question in a nonjudgmental, truly open-ended way and listening to what mom says and paraphrasing it back to her hopefully helps her feel comfortable enough to go into a bit more detail,” she said. “I don’t ask people to commit. I take notes and we talk about it at another visit.”

Dr. Stuebe also suggested making sure mothers are aware of the benefits of breastfeeding for their own health – such as a reduced risk of type 2 diabetes and breast cancer – so that the conversation is not framed entirely in terms of benefits for their child.

Fear of upsetting a patient, however, should not dissuade physicians from broaching the subject, she added. “In the fear of making moms feel bad, we sometimes tiptoe and miss an opportunity to provide moms with an opportunity to make an informed choice.”

That would be especially unfortunate given the respect individuals continue to have for advice from their physicians, said Lora Ebert Wallace, Ph.D., professor of sociology at Western Illinois University in Macomb, who has studied the impact of language used in breastfeeding discourse.

“Medical authority is a real thing,” Dr. Wallace said. “People listen to their doctors and respect them, and doctors want to be really thoughtful about how to communicate, starting with questions instead of prescriptions.”

Avoiding ‘risk’ language

In reality, much of the backlash against breastfeeding prescriptivism has not involved the ob.gyn. community, Dr. Wallace noted.

“I think generally ob.gyns. have not been on the forefront of the type of advocacy that people have objected to,” she said. “I think that’s come from other areas of medicine.”

Some of that advocacy has employed “risk language,” in which breastfeeding is presented as the only appropriate choice and the conversation centers around the “risk” of formula feeding instead of the “benefits” of breastfeeding.

“Our research suggests that the use of risk language is premature at this point because it has not been well evaluated, and the evaluations that have been done suggest that it doesn’t increase breastfeeding among people exposed to it,” Dr. Wallace said. “There is some suggestion from qualitative research that you can create a backlash to the information.”

The thinking behind risk language is that using stronger language to encourage breastfeeding will somehow make more women choose to do it, but such a rationale ignores the fact that parents are already trying to do the absolute best they can for their children, Dr. Wallace said.

“I don’t think the research supports the idea that women aren’t breastfeeding because they don’t know it’s good for their babies,” she said. “They’re not breastfeeding because it’s hard because of the way we structure our society and our workplaces.”

Another statement to avoid is “every woman can breastfeed,” said Laura Lallande, the lactation services coordinator at Oregon Health and Science University, Portland.

“There are real, legitimate physical reasons some women cannot or choose not to breastfeed, and we need to stop propagating the myth that formula feeding is equivalent to moral failure,” Ms. Lallande said. “As with anything in health care, our job is to meet clients where they are, not where we want them to be. If we start from a point of judgment, we block progress before it starts.”

Potential sources of shame

It is the “everyone can if you try hard enough” language that can lead to shame, Dr. Stuebe said.

The feelings of shame some women may feel if they don’t breastfeed can arise from the inappropriate conflation of breastfeeding and being a good mother. “Particularly for first-time mothers, the transition from what I want to be as a parent to what I can be as a parent is wrenching for some women,” Dr. Stuebe said.

The social infrastructure in the United States means that breastfeeding is not actually a “choice” for all women, Dr. Stuebe said. This reality is reflected in the ACOG statement, which encourages ob.gyns. to “be in the forefront of policy efforts to enable women to breastfeed, whether through individual patient education, change in hospital practices, community efforts, or supportive legislation” and to promote policies that accommodate milk expression, such as paid maternity leave, on-site child care, break time, and a location other than a bathroom for expressing milk.

Even the way the health care system is set up makes it hard for mothers to get holistic care, Dr. Stuebe said.

“What happens is moms get conflicting advice from [their] provider and the baby’s provider, and sometimes even from a third source such as a lactation consultant, and they’re left trying to triangulate that information,” Dr. Stuebe said. “Nobody is saying, ‘How is this whole mother doing and how can we meet her needs?’ ”

That’s why it’s important to follow up with patients and ask how breastfeeding is going, Dr. Stuebe explained. If it’s not working out, women need to know it’s okay to stop.

“Breast milk is important, but a woman’s well-being is also important and if everything about breastfeeding is awful, that’s not helping her or her baby,” Dr. Stuebe said.

Physicians have a responsibility to tell women that breastfeeding is advantageous, Dr. Wallace said, but they also have a responsibility to listen to patients and be sensitive to what they’re hearing.

“To the parent in the moment, if they’re facing something really important about employment or housing, the breastfeeding decision may not look as important to them,” Dr. Wallace said.

Yet ob.gyns. should never discount how critical their role is in helping mothers successfully breastfeed if they choose to, Ms. Lallande said.

“Even when things are great, breastfeeding is physically and emotionally challenging,” Ms. Lallande said. “Women need support from providers who listen to them and help them navigate the sleep-deprived early weeks of motherhood. Especially with first-time moms, the relationship with the OB is much stronger than the relationship with the pediatrician, so they call the OB for help.”

The role that health care providers can and should play in promoting breastfeeding has come under scrutiny in recent years, often leaving doctors uncertain about how to discuss infant-feeding intentions with patients.

There’s been a backlash against the public health promotion of breastfeeding and “lactivism,” with critics saying that the efforts lead to shame or guilt in women who do not breastfeed. And often mothers, and their physicians, have been caught in the crossfire.

©Maxim Tupikov/iStockphoto.com

The American College of Obstetricians and Gynecologists attempted to build a bridge across this divide in their updated Committee Opinion on breastfeeding in February.

In a departure from the language typically included in policy statements or clinical guidelines from other medical organizations, the new ACOG guidelines urged ob.gyns. and other obstetric care providers to “support each woman’s informed decision about whether to initiate or continue breastfeeding, recognizing that she is uniquely qualified to decide whether exclusive breastfeeding, mixed feeding, or formula feeding is optimal for her and her infant.”

At the same time, however, the organization also “recommends exclusive breastfeeding for the first 6 months of life, with continued breastfeeding as complementary foods are introduced through the infant’s first year of life, or longer as mutually desired by the woman and her infant.”

Striking the right balance in providing women with adequate information to make informed choices without inadvertently causing a woman discomfort requires clinicians to start by finding out what their patients already know, according to Dr. Alison Stuebe, lead author of the ACOG opinion and an assistant professor of maternal-fetal medicine at the University of North Carolina at Chapel Hill.

“The clinician’s role is to help that mom make an informed decision, and it’s hard to help her do that if you don’t know where she’s coming from,” Dr. Stuebe said. “It’s important not to assume that a woman knows everything or knows nothing.”

How to start the conversation

Dr. Stuebe, who is also a distinguished scholar of infant and young child feeding in the Gillings School of Global Public Health at UNC, recommended bringing up the subject of breastfeeding early in a woman’s prenatal care with a simple open-ended question: “What have you heard about breastfeeding?” The answer helps tailor the counseling to the mother’s knowledge, feelings, and attitudes.

“We have some moms who have read 47 books on breastfeeding, and then there are women who live in a family where they’ve only seen bottle feeding,” Dr. Stuebe said.

Next, validate what the mother says, and ask for more information from the mom. When the conversation begins early in the physician-patient relationship, there is time to have the conversation over several visits, Dr. Stuebe said.

“I think asking the question in a nonjudgmental, truly open-ended way and listening to what mom says and paraphrasing it back to her hopefully helps her feel comfortable enough to go into a bit more detail,” she said. “I don’t ask people to commit. I take notes and we talk about it at another visit.”

Dr. Stuebe also suggested making sure mothers are aware of the benefits of breastfeeding for their own health – such as a reduced risk of type 2 diabetes and breast cancer – so that the conversation is not framed entirely in terms of benefits for their child.

Fear of upsetting a patient, however, should not dissuade physicians from broaching the subject, she added. “In the fear of making moms feel bad, we sometimes tiptoe and miss an opportunity to provide moms with an opportunity to make an informed choice.”

That would be especially unfortunate given the respect individuals continue to have for advice from their physicians, said Lora Ebert Wallace, Ph.D., professor of sociology at Western Illinois University in Macomb, who has studied the impact of language used in breastfeeding discourse.

“Medical authority is a real thing,” Dr. Wallace said. “People listen to their doctors and respect them, and doctors want to be really thoughtful about how to communicate, starting with questions instead of prescriptions.”

Avoiding ‘risk’ language

In reality, much of the backlash against breastfeeding prescriptivism has not involved the ob.gyn. community, Dr. Wallace noted.

“I think generally ob.gyns. have not been on the forefront of the type of advocacy that people have objected to,” she said. “I think that’s come from other areas of medicine.”

Some of that advocacy has employed “risk language,” in which breastfeeding is presented as the only appropriate choice and the conversation centers around the “risk” of formula feeding instead of the “benefits” of breastfeeding.

“Our research suggests that the use of risk language is premature at this point because it has not been well evaluated, and the evaluations that have been done suggest that it doesn’t increase breastfeeding among people exposed to it,” Dr. Wallace said. “There is some suggestion from qualitative research that you can create a backlash to the information.”

The thinking behind risk language is that using stronger language to encourage breastfeeding will somehow make more women choose to do it, but such a rationale ignores the fact that parents are already trying to do the absolute best they can for their children, Dr. Wallace said.

“I don’t think the research supports the idea that women aren’t breastfeeding because they don’t know it’s good for their babies,” she said. “They’re not breastfeeding because it’s hard because of the way we structure our society and our workplaces.”

Another statement to avoid is “every woman can breastfeed,” said Laura Lallande, the lactation services coordinator at Oregon Health and Science University, Portland.

“There are real, legitimate physical reasons some women cannot or choose not to breastfeed, and we need to stop propagating the myth that formula feeding is equivalent to moral failure,” Ms. Lallande said. “As with anything in health care, our job is to meet clients where they are, not where we want them to be. If we start from a point of judgment, we block progress before it starts.”

Potential sources of shame

It is the “everyone can if you try hard enough” language that can lead to shame, Dr. Stuebe said.

The feelings of shame some women may feel if they don’t breastfeed can arise from the inappropriate conflation of breastfeeding and being a good mother. “Particularly for first-time mothers, the transition from what I want to be as a parent to what I can be as a parent is wrenching for some women,” Dr. Stuebe said.

The social infrastructure in the United States means that breastfeeding is not actually a “choice” for all women, Dr. Stuebe said. This reality is reflected in the ACOG statement, which encourages ob.gyns. to “be in the forefront of policy efforts to enable women to breastfeed, whether through individual patient education, change in hospital practices, community efforts, or supportive legislation” and to promote policies that accommodate milk expression, such as paid maternity leave, on-site child care, break time, and a location other than a bathroom for expressing milk.

Even the way the health care system is set up makes it hard for mothers to get holistic care, Dr. Stuebe said.

“What happens is moms get conflicting advice from [their] provider and the baby’s provider, and sometimes even from a third source such as a lactation consultant, and they’re left trying to triangulate that information,” Dr. Stuebe said. “Nobody is saying, ‘How is this whole mother doing and how can we meet her needs?’ ”

That’s why it’s important to follow up with patients and ask how breastfeeding is going, Dr. Stuebe explained. If it’s not working out, women need to know it’s okay to stop.

“Breast milk is important, but a woman’s well-being is also important and if everything about breastfeeding is awful, that’s not helping her or her baby,” Dr. Stuebe said.

Physicians have a responsibility to tell women that breastfeeding is advantageous, Dr. Wallace said, but they also have a responsibility to listen to patients and be sensitive to what they’re hearing.

“To the parent in the moment, if they’re facing something really important about employment or housing, the breastfeeding decision may not look as important to them,” Dr. Wallace said.

Yet ob.gyns. should never discount how critical their role is in helping mothers successfully breastfeed if they choose to, Ms. Lallande said.

“Even when things are great, breastfeeding is physically and emotionally challenging,” Ms. Lallande said. “Women need support from providers who listen to them and help them navigate the sleep-deprived early weeks of motherhood. Especially with first-time moms, the relationship with the OB is much stronger than the relationship with the pediatrician, so they call the OB for help.”

The role that health care providers can and should play in promoting breastfeeding has come under scrutiny in recent years, often leaving doctors uncertain about how to discuss infant-feeding intentions with patients.

There’s been a backlash against the public health promotion of breastfeeding and “lactivism,” with critics saying that the efforts lead to shame or guilt in women who do not breastfeed. And often mothers, and their physicians, have been caught in the crossfire.

©Maxim Tupikov/iStockphoto.com

The American College of Obstetricians and Gynecologists attempted to build a bridge across this divide in their updated Committee Opinion on breastfeeding in February.

In a departure from the language typically included in policy statements or clinical guidelines from other medical organizations, the new ACOG guidelines urged ob.gyns. and other obstetric care providers to “support each woman’s informed decision about whether to initiate or continue breastfeeding, recognizing that she is uniquely qualified to decide whether exclusive breastfeeding, mixed feeding, or formula feeding is optimal for her and her infant.”

At the same time, however, the organization also “recommends exclusive breastfeeding for the first 6 months of life, with continued breastfeeding as complementary foods are introduced through the infant’s first year of life, or longer as mutually desired by the woman and her infant.”

Striking the right balance in providing women with adequate information to make informed choices without inadvertently causing a woman discomfort requires clinicians to start by finding out what their patients already know, according to Dr. Alison Stuebe, lead author of the ACOG opinion and an assistant professor of maternal-fetal medicine at the University of North Carolina at Chapel Hill.

“The clinician’s role is to help that mom make an informed decision, and it’s hard to help her do that if you don’t know where she’s coming from,” Dr. Stuebe said. “It’s important not to assume that a woman knows everything or knows nothing.”

How to start the conversation

Dr. Stuebe, who is also a distinguished scholar of infant and young child feeding in the Gillings School of Global Public Health at UNC, recommended bringing up the subject of breastfeeding early in a woman’s prenatal care with a simple open-ended question: “What have you heard about breastfeeding?” The answer helps tailor the counseling to the mother’s knowledge, feelings, and attitudes.

“We have some moms who have read 47 books on breastfeeding, and then there are women who live in a family where they’ve only seen bottle feeding,” Dr. Stuebe said.

Next, validate what the mother says, and ask for more information from the mom. When the conversation begins early in the physician-patient relationship, there is time to have the conversation over several visits, Dr. Stuebe said.

“I think asking the question in a nonjudgmental, truly open-ended way and listening to what mom says and paraphrasing it back to her hopefully helps her feel comfortable enough to go into a bit more detail,” she said. “I don’t ask people to commit. I take notes and we talk about it at another visit.”

Dr. Stuebe also suggested making sure mothers are aware of the benefits of breastfeeding for their own health – such as a reduced risk of type 2 diabetes and breast cancer – so that the conversation is not framed entirely in terms of benefits for their child.

Fear of upsetting a patient, however, should not dissuade physicians from broaching the subject, she added. “In the fear of making moms feel bad, we sometimes tiptoe and miss an opportunity to provide moms with an opportunity to make an informed choice.”

That would be especially unfortunate given the respect individuals continue to have for advice from their physicians, said Lora Ebert Wallace, Ph.D., professor of sociology at Western Illinois University in Macomb, who has studied the impact of language used in breastfeeding discourse.

“Medical authority is a real thing,” Dr. Wallace said. “People listen to their doctors and respect them, and doctors want to be really thoughtful about how to communicate, starting with questions instead of prescriptions.”

Avoiding ‘risk’ language

In reality, much of the backlash against breastfeeding prescriptivism has not involved the ob.gyn. community, Dr. Wallace noted.

“I think generally ob.gyns. have not been on the forefront of the type of advocacy that people have objected to,” she said. “I think that’s come from other areas of medicine.”

Some of that advocacy has employed “risk language,” in which breastfeeding is presented as the only appropriate choice and the conversation centers around the “risk” of formula feeding instead of the “benefits” of breastfeeding.

“Our research suggests that the use of risk language is premature at this point because it has not been well evaluated, and the evaluations that have been done suggest that it doesn’t increase breastfeeding among people exposed to it,” Dr. Wallace said. “There is some suggestion from qualitative research that you can create a backlash to the information.”

The thinking behind risk language is that using stronger language to encourage breastfeeding will somehow make more women choose to do it, but such a rationale ignores the fact that parents are already trying to do the absolute best they can for their children, Dr. Wallace said.

“I don’t think the research supports the idea that women aren’t breastfeeding because they don’t know it’s good for their babies,” she said. “They’re not breastfeeding because it’s hard because of the way we structure our society and our workplaces.”

Another statement to avoid is “every woman can breastfeed,” said Laura Lallande, the lactation services coordinator at Oregon Health and Science University, Portland.

“There are real, legitimate physical reasons some women cannot or choose not to breastfeed, and we need to stop propagating the myth that formula feeding is equivalent to moral failure,” Ms. Lallande said. “As with anything in health care, our job is to meet clients where they are, not where we want them to be. If we start from a point of judgment, we block progress before it starts.”

Potential sources of shame

It is the “everyone can if you try hard enough” language that can lead to shame, Dr. Stuebe said.

The feelings of shame some women may feel if they don’t breastfeed can arise from the inappropriate conflation of breastfeeding and being a good mother. “Particularly for first-time mothers, the transition from what I want to be as a parent to what I can be as a parent is wrenching for some women,” Dr. Stuebe said.

The social infrastructure in the United States means that breastfeeding is not actually a “choice” for all women, Dr. Stuebe said. This reality is reflected in the ACOG statement, which encourages ob.gyns. to “be in the forefront of policy efforts to enable women to breastfeed, whether through individual patient education, change in hospital practices, community efforts, or supportive legislation” and to promote policies that accommodate milk expression, such as paid maternity leave, on-site child care, break time, and a location other than a bathroom for expressing milk.

Even the way the health care system is set up makes it hard for mothers to get holistic care, Dr. Stuebe said.

“What happens is moms get conflicting advice from [their] provider and the baby’s provider, and sometimes even from a third source such as a lactation consultant, and they’re left trying to triangulate that information,” Dr. Stuebe said. “Nobody is saying, ‘How is this whole mother doing and how can we meet her needs?’ ”

That’s why it’s important to follow up with patients and ask how breastfeeding is going, Dr. Stuebe explained. If it’s not working out, women need to know it’s okay to stop.

“Breast milk is important, but a woman’s well-being is also important and if everything about breastfeeding is awful, that’s not helping her or her baby,” Dr. Stuebe said.

Physicians have a responsibility to tell women that breastfeeding is advantageous, Dr. Wallace said, but they also have a responsibility to listen to patients and be sensitive to what they’re hearing.

“To the parent in the moment, if they’re facing something really important about employment or housing, the breastfeeding decision may not look as important to them,” Dr. Wallace said.

Yet ob.gyns. should never discount how critical their role is in helping mothers successfully breastfeed if they choose to, Ms. Lallande said.

“Even when things are great, breastfeeding is physically and emotionally challenging,” Ms. Lallande said. “Women need support from providers who listen to them and help them navigate the sleep-deprived early weeks of motherhood. Especially with first-time moms, the relationship with the OB is much stronger than the relationship with the pediatrician, so they call the OB for help.”

Transgender children who receive support for their gender identity are no more likely to be depressed than are other children and had only slightly higher anxiety symptoms, a recent study found.

“Critically, transgender children supported in their identities had internalizing symptoms that were well below even the preclinical range,” reported Kristina R. Olson, Ph.D., and her associates in the department of psychology at the University of (Seattle) Washington (Pediatrics 2016 Feb 19. doi: 10.1542/peds.2015-3223). “These findings suggest that familial support in general, or specifically via the decision to allow their children to socially transition, may be associated with better mental health outcomes among transgender children.”

The authors recruited 73 transgender children between the ages of 3 and 12 years. All the children identified as a gender different from the sex they were assigned at birth, used the pronouns associated with that gender, and presented in that gender in all social situations, including during everyday life, at school, and at home. Among the 22 born-females and 51 born-males, the average age of the children was 8 years.

The researchers compared these children’s mental health to that of 49 of their siblings and 73 age-matched control children with no history of cross-gender behavior. Approximately three quarters of the children across all three groups were white, and smaller numbers of children were Hispanic, Asian, or multiracial. Nearly all the children lived in homes with an annual family income above $75,000, and about half lived in homes with an annual income over $125,000.

Parents filled out assessments of their children’s symptoms of depression and anxiety. Scores for transgender children were similar to those of the general population in terms of depression and only slightly elevated for anxiety, although still below even the subclinical range. No statistical differences in depression symptoms existed between the transgender children and either their siblings or the control children, and again, anxiety levels were only slightly increased.

The authors point out that most previous studies of mental health among transgender people have focused on teens and adults and have consistently found “dramatically elevated rates of anxiety, depression and suicidality among transgender people.” These findings likely reflect “years of prejudice, discrimination, and stigma; conflict between one’s appearance and stated identity; and general rejection by people in their social environments, including their families,” Dr. Olson and her associates wrote. “There is now growing evidence that social support is linked to better mental health outcomes among transgender adolescents and adults.”

The findings of this study reveal that “socially transitioned transgender children showed substantially lower rates of internalizing symptoms than children with gender identity disorder reported in previous studies,” they said. “Allowing children to present in everyday life as their gender identity rather than their natal sex is associated with developmentally normative levels of depression and anxiety.”

A significant potential limitation of this study, however, is that the children transitioned at a young age when such transitions tend to be controversial and “yet did so anyway,” Dr. Olson and her associates pointed out. “Surely not all families with transgender children make this decision, meaning there are likely characteristics that are unique to these families,” they wrote. “In addition, the transgender children in this study all socially transitioned much earlier than nearly all transgender adults alive today in the United States and Canada.” The reasons for this also may play a role in the findings.

The Royalty Research Fund at the University of Washington, the National Institute of Mental Health, and the National Institutes of Health funded the research. The authors reported no relevant financial disclosures.

Transgender children who receive support for their gender identity are no more likely to be depressed than are other children and had only slightly higher anxiety symptoms, a recent study found.

“Critically, transgender children supported in their identities had internalizing symptoms that were well below even the preclinical range,” reported Kristina R. Olson, Ph.D., and her associates in the department of psychology at the University of (Seattle) Washington (Pediatrics 2016 Feb 19. doi: 10.1542/peds.2015-3223). “These findings suggest that familial support in general, or specifically via the decision to allow their children to socially transition, may be associated with better mental health outcomes among transgender children.”

The authors recruited 73 transgender children between the ages of 3 and 12 years. All the children identified as a gender different from the sex they were assigned at birth, used the pronouns associated with that gender, and presented in that gender in all social situations, including during everyday life, at school, and at home. Among the 22 born-females and 51 born-males, the average age of the children was 8 years.

The researchers compared these children’s mental health to that of 49 of their siblings and 73 age-matched control children with no history of cross-gender behavior. Approximately three quarters of the children across all three groups were white, and smaller numbers of children were Hispanic, Asian, or multiracial. Nearly all the children lived in homes with an annual family income above $75,000, and about half lived in homes with an annual income over $125,000.

Parents filled out assessments of their children’s symptoms of depression and anxiety. Scores for transgender children were similar to those of the general population in terms of depression and only slightly elevated for anxiety, although still below even the subclinical range. No statistical differences in depression symptoms existed between the transgender children and either their siblings or the control children, and again, anxiety levels were only slightly increased.

The authors point out that most previous studies of mental health among transgender people have focused on teens and adults and have consistently found “dramatically elevated rates of anxiety, depression and suicidality among transgender people.” These findings likely reflect “years of prejudice, discrimination, and stigma; conflict between one’s appearance and stated identity; and general rejection by people in their social environments, including their families,” Dr. Olson and her associates wrote. “There is now growing evidence that social support is linked to better mental health outcomes among transgender adolescents and adults.”

The findings of this study reveal that “socially transitioned transgender children showed substantially lower rates of internalizing symptoms than children with gender identity disorder reported in previous studies,” they said. “Allowing children to present in everyday life as their gender identity rather than their natal sex is associated with developmentally normative levels of depression and anxiety.”

A significant potential limitation of this study, however, is that the children transitioned at a young age when such transitions tend to be controversial and “yet did so anyway,” Dr. Olson and her associates pointed out. “Surely not all families with transgender children make this decision, meaning there are likely characteristics that are unique to these families,” they wrote. “In addition, the transgender children in this study all socially transitioned much earlier than nearly all transgender adults alive today in the United States and Canada.” The reasons for this also may play a role in the findings.

The Royalty Research Fund at the University of Washington, the National Institute of Mental Health, and the National Institutes of Health funded the research. The authors reported no relevant financial disclosures.

Transgender children who receive support for their gender identity are no more likely to be depressed than are other children and had only slightly higher anxiety symptoms, a recent study found.

“Critically, transgender children supported in their identities had internalizing symptoms that were well below even the preclinical range,” reported Kristina R. Olson, Ph.D., and her associates in the department of psychology at the University of (Seattle) Washington (Pediatrics 2016 Feb 19. doi: 10.1542/peds.2015-3223). “These findings suggest that familial support in general, or specifically via the decision to allow their children to socially transition, may be associated with better mental health outcomes among transgender children.”

The authors recruited 73 transgender children between the ages of 3 and 12 years. All the children identified as a gender different from the sex they were assigned at birth, used the pronouns associated with that gender, and presented in that gender in all social situations, including during everyday life, at school, and at home. Among the 22 born-females and 51 born-males, the average age of the children was 8 years.

The researchers compared these children’s mental health to that of 49 of their siblings and 73 age-matched control children with no history of cross-gender behavior. Approximately three quarters of the children across all three groups were white, and smaller numbers of children were Hispanic, Asian, or multiracial. Nearly all the children lived in homes with an annual family income above $75,000, and about half lived in homes with an annual income over $125,000.

Parents filled out assessments of their children’s symptoms of depression and anxiety. Scores for transgender children were similar to those of the general population in terms of depression and only slightly elevated for anxiety, although still below even the subclinical range. No statistical differences in depression symptoms existed between the transgender children and either their siblings or the control children, and again, anxiety levels were only slightly increased.

The authors point out that most previous studies of mental health among transgender people have focused on teens and adults and have consistently found “dramatically elevated rates of anxiety, depression and suicidality among transgender people.” These findings likely reflect “years of prejudice, discrimination, and stigma; conflict between one’s appearance and stated identity; and general rejection by people in their social environments, including their families,” Dr. Olson and her associates wrote. “There is now growing evidence that social support is linked to better mental health outcomes among transgender adolescents and adults.”

The findings of this study reveal that “socially transitioned transgender children showed substantially lower rates of internalizing symptoms than children with gender identity disorder reported in previous studies,” they said. “Allowing children to present in everyday life as their gender identity rather than their natal sex is associated with developmentally normative levels of depression and anxiety.”

A significant potential limitation of this study, however, is that the children transitioned at a young age when such transitions tend to be controversial and “yet did so anyway,” Dr. Olson and her associates pointed out. “Surely not all families with transgender children make this decision, meaning there are likely characteristics that are unique to these families,” they wrote. “In addition, the transgender children in this study all socially transitioned much earlier than nearly all transgender adults alive today in the United States and Canada.” The reasons for this also may play a role in the findings.

The Royalty Research Fund at the University of Washington, the National Institute of Mental Health, and the National Institutes of Health funded the research. The authors reported no relevant financial disclosures.