pediatrics

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Sleepy Students: A Pediatrician’s Plea For Later School Start Times

(eltpics/Flickr via Compfight)

(eltpics/Flickr via Compfight)

By Dr. Marvin Wang, M.D.

Last August, the American Academy of Pediatrics (AAP) issued a statement regarding school start times, really a plea to all middle and high schools to start the school day no earlier than 8:30 a.m.

The statement emerged as a result of accumulating evidence showing that earlier school start times effectively restrict an adolescent’s ability to get regular healthful sleep.

The timing of the AAP’s statement came on the heels of another sentinel event in my family’s life. Just a month after its publication, my daughter started school. No big deal, except for the fact that she has never been to school before. Until this year, she was exclusively homeschooled here in Jamaica Plain, Massachusetts.

My wife and I didn’t have any major agenda driving this decision, other than the fact that we knew we could do it (we work part-time) and it seemed like it would be more family fun. The many details of our homeschooling adventures are really for another time, though.

The reason I even bring up the topic is that as a homeschooler, my daughter was able to wake up when she wanted to (usually within reason). On a regular day, she was used to getting up at 8:30ish (despite sometimes our having to pry her out later).

After a whole lifetime of this, imagine the draconian lifestyle shift of being asked to get up at 6 a.m. every weekday! This is the routine that is better known to most people as “going to school.” Now, let’s be clear about a few things: 1) our daughter wanted this. She asked to take the exam for the Boston Public Schools, in hopes of going to Boston Latin School, where she watched many of her friends attend; 2) she knew the early mornings were part of the routine; and 3) BLS actually has a relatively benign start time of 7:45 a.m., compared to many of its counterparts in the district and the state.

So what’s all the fuss? It cannot be a novel idea to most adults that the typical school teenager is a surly blob on most weekday mornings. Should we be surprised to learn that we have been breeding generations of sleep-deprived adolescents? Should we, as educators, parents and “concerned citizens” be worried about this?

First, let’s look at what’s new since the AAP statement came out.

Indeed, the movement is picking up steam in some parts of the country, as whole districts have approved later start times. In Massachusetts, districts like Sharon, Easton, Duxbury and Nauset have done so.

And there are some new studies corroborating the AAP’s stance:

In looking at the neurobehavioral issues in teens, it turns out that just one night of sleep deprivation in an adolescent has marked worsening of sustained attention, reaction speed, cognitive processing speed and subjective sleepiness. When the sleep was restored, the teens were able to significantly improve all their cognitive abilities.

One study showed that sleep restricted teens (average of five hours/night) were more likely to be lower academic quartiles than those who slept more (average 6 ½ hours/night…which is still two hours less than optimal!). But looking at the results, one also finds that the perceived sleepiness among the sleep restricted group was at least twice that the sleep appropriate group. Continue reading

Five Things You Need To Know About Sharing A Bed With Your Infant

By Melissa Bartick, M.D.
Guest Contributor

My recent analysis of the current infant sleep recommendations led many people to ask a simple question: where, exactly, is it safe for my baby to sleep?

In a recent blog post that generated huge reader response, I went through why the current sleep recommendations from the American Academy of Pediatrics against all infant bed sharing have backfired.

one deep drawer/flickr

one deep drawer/flickr

Based on the analysis my colleague Linda J. Smith and I conducted, a few facts are clear: No sleeping infant situation is completely safe. Infants may die in cribs as well as in bed with their mothers. SIDS and sleep associated suffocation and strangulation are different entities, but share some overlapping risk factors.

Both result in the same tragic outcome, so the recommendations tend to be lumped together.

However, infant bed sharing is not as great a risk for sleep associated infant death as is exposure to smoke (both prenatal and after birth), falling asleep on couches or recliners with one’s infant or sleeping with an infant while under the influence of drugs and alcohol. For many years, studies have demonstrated that formula feeding is an independent risk factor for SIDS when compared to breastfeeding.

So here are five safety tips:

1. Mattress Alert

Even if you never plan to share your bed with your infant, the safest assumption is that you may sometimes unintentionally fall asleep there with him. Therefore, the best advice would be for every parent to make their bed as safe as possible. The mattress should be away from the wall or so tight that there is no gap where an infant could get entrapped. Some parents solve these issues by putting their mattress on the floor. The bed should be away from dangling cords that could cause strangulation. The surface should be firm, without heavy or fluffy covers or pillows near the baby. The baby should sleep on his back. He should be lightly dressed- no more clothing on the baby than the parents are wearing. The baby should never be swaddled in a shared sleep situation.

2. Feeding At Night

Avoid feeding your infant on a couch or recliner at night or when you are tired. (There are anecdotes about tragedies that have occurred when mothers have fed their infants in their own beds while sitting up. We don’t have any evidence on whether this is dangerous.) However, if you are breastfeeding and can do so laying down, that may be preferable to nursing in bed while sitting up so the baby cannot slide off into a dangerous location.
Continue reading

When Texting May Save Your Child’s Life

(Scott Abelman/Compfight) (Scott Abelman/Compfight)

If your child needed two doses of the flu shot this year, you’re not alone.  Yet research finds that less than half of those kids don’t get the necessary second shot.

A new study published online today in the journal Pediatrics explores a texting program to help parents remember to visit the doctor for that second dose.

Parents of 660 Latino children between the ages of 6 months and 8 years were randomly selected to receive one of three different messages.  These children, all patients in three New York City health clinics, needed to return to the for an additional dose of the vaccine. Messages given to the patients included one “conventional text message,” which simply provided the next appointment date and clinic hours, an “educational text message,” which included the appointment date, clinic hours, and health literacy information and finally a written-only reminder.

Children who received the “educational texts” were more likely to receive a second dose by the due date (72.7%) versus those receiving the “conventional text” (66.7%). Continue reading

Pediatric Politics: How Dire Warnings Against Infant Bed Sharing ‘Backfired’

sundaykofax/flickr

sundaykofax/flickr

By Dr. Melissa Bartick
Guest Contributor

Every new parent has heard the dire warning: Never sleep with your baby.

State and local health departments in Massachusetts and around the U.S. have prioritized this message. Millions of dollars have been invested in promoting it, and millions more spent on giving away cribs to poor families. It all comes from the official recommendations of the influential American Academy of Pediatrics published in 2011.

Some localities have even backed this message up with scary ads: a baby in an adult bed with a meat cleaver, stating “Your baby sleeping with you can be just as dangerous,” and another ad that says “Your baby belongs in a crib, not a casket.”

Studies Misrepresented

The problem with this widespread advice is that the AAP’s statement from which it comes is based on just four papers. Two of the studies are misrepresented, and actually show little or no risk of sharing a bed when parents do not smoke, and two of the studies do not collect data on maternal alcohol use, a known and powerful risk factor.

In addition, the AAP statement ignores many other more recent excellent papers that are not even mentioned or cited. My colleague, Linda J. Smith, and I recently published an analysis of all AAP’s statement and all the literature to date, “Speaking out on Safe Sleep: Evidence-Based Sleep Recommendations.” Along with this dissection of the AAP statement, we found that that any risk of death from a parent sharing a bed with an infant is greatly overshadowed by other risks that get far less attention.

Dangerous Sofas

We concluded that the only evidence-based universal advice to date is that sofas are hazardous places for adults to sleep with infants; that exposure to smoke, both prenatal and postnatal, increases the risk of death; and that sleeping next to an impaired caregiver increases the risk of death.

Formula feeding increases the risk of Sudden Infant Death Syndrome. No sleep environment is completely safe. But public health efforts must address the reality that tired parents must feed their infants at night somewhere and that sofas are highly risky places for parents to fall asleep with their infants.

The fact is, across the United States and the world, across all social strata and all ethnic groups, most mothers sleep with their infants at least some of the time, despite all advice to the contrary, and this is particularly true for breastfeeding mothers.

When You Avoid Bed Sharing

Unfortunately, we also know that parents who try to avoid bed sharing with their infants are far more likely to feed their babies at night on chairs and couches in futile attempts to stay awake, which actually markedly increases their infants’ risk of suffocation. Continue reading

New Pro-Circumcision Guidelines: Cutting Comments, Adolescent Choice

Preparing for a circumcision

Preparing for a circumcision (Cheskel Dovid/Wikimedia Commons)

Just days after the U.S. Centers for Disease Control and Prevention issued draft recommendations on male circumcision asserting that the health benefits outweigh the risks, more than 300 comments (and counting) have been posted on the agency’s website.

Surprise: The feedback overall reflects anger over mounting institutional support for what some call a “barbaric, outdated practice.” (The public comment period on the agency’s proposed recommendations ends on Jan. 16.)

Here are a few random comments:

When I was a little girl and discovered my little brothers had been cut, I was horrified for them and grateful I wasn’t born a boy.

The only benefit of infant circumcision is the fatter wallet of the circumciser. Wake up people! Condoms prevent sexually transmitted diseases, not circumcision. Males deserve the same protection from genital cuttings that females do. Shame on the CDC for condoning such a barbaric, outdated practice that nearly every other industrialized nation has refused to adopt!

Routine infant circumcision is morally wrong because it is non-essential cosmetic surgery performed on the body of a human being not yet old enough to give informed consent….

Your agenda clearly shows your primary purposes is for health insurance to pay for male genital mutilation. Please don’t continue to make the U.S. the continued laughing stock of the international medical community.

You get the picture.

The CDC stopped short of actually telling parents they must circumcise their baby boys; instead the agency offered guidelines — including a new recommendation that un-circumcised adolescent boys discuss the risks and benefits with their doctors — and laid out the latest research. Male circumcision, according to an AP report, can:

•Cut a man’s risk of getting HIV from an infected female partner by 50 to 60 percent.

•Reduce their risk of genital herpes and certain strains of human papillomavirus by 30 percent or more.

•Lower the risk of urinary tract infections during infancy, and cancer of the penis in adulthood.

Studies have not shown that circumcision will reduce an HIV-infected man’s chances of spreading the AIDS virus to women. And research has not found circumcision to be a help in stopping spread of HIV during gay sex.

The guidelines say circumcision is safer for newborns and infants than for older males, noting the complication rate rises from 0.5 percent in newborns to 9 percent in children ages 1 to 9, according to the CDC. Minor bleeding and pain are the most common problems, experts say.

CDC officials are recommending doctors tell parents of baby boys of the benefits and risks of circumcision…

These are the first federal guidelines on circumcision, a brief medical procedure that involves cutting away the foreskin around the tip of the penis. Germs can grow underneath the foreskin, and CDC officials say the procedure can lower a male’s risk of sexually-transmitted diseases, penile cancer and even urinary tract infections.

I asked circumcision expert Marvin Wang, co-director of the newborn nurseries at Massachusetts General Hospital (and someone who has performed thousands of circumcisions), about the new CDC draft recommendation, and he offered this thoughtful analysis:

First a little history:

For decades, the American Academy of Pediatrics (AAP) (which produces the majority of research-based policy for U.S. pediatric care) has led a relatively neutral stance on male neonatal circumcision, as the literature has shown that there is a relatively small health benefit by performing circumcision (there is huge debate on how one interprets the numbers on this, but overall, that conclusion is true). However, a game changer that tilted the balance towards claiming health benefits came in 2005-2007, when three separate World Health Organization clinical trials were performed in Africa demonstrating that circumcision among adult men in Sub-Saharan African settings reduced the acquisition of HIV by 50%.

With that, the AAP changed its recommendations in 2012 to reflect these studies. Their statement basically said that, yes, we know that there are health benefits now – enough to encourage parents to strongly consider circumcision for the newborn. However, the decision still lays with the parents, balanced by their beliefs (which may be influenced by religious, social or familial reasons). There are other tenets to the statement, but let’s just focus on this one topic, as this is most relevant to the recent CDC statement.

In light of the infectious disease issues involved, the medical community had been told that the CDC would make their recommendations regarding circumcision at about the same time as the AAP’s release. So, with this week’s statement, you are basically seeing a reaffirmation of the 2012 AAP statement. We don’t really see anything new. The health benefits touted in the CDC report have all been discussed before in the literature.

The only potentially new issue here is a topic that the 2012 AAP statement neglected: The idea of encouraging un-circumcised adolescents to discuss the option with their physician. Continue reading

Boston Survey: Most Parents Say Sure, I’d Like To Know My Newborn’s Genes

(Wikimedia Commons)

(Wikimedia Commons)

For years, futurists have foreseen an era when all newborn American babies would be sent home with a supply of self-knowledge: a readout of their full set of genes, with all it may imply about heightened chances for disease or health.

So how would you feel about that, as a new parent? Eager to absorb any possible indicator of your child’s potential future? Or wary that genes are not destiny, and you may spend a lifetime fearing something that never comes to pass?

If you answer, “I’d want to know about my baby’s genetic makeup,” your sentiments are in line with the majority of parents surveyed in the first poll of new parents about genomic screening, just out in the journal Genetics In Medicine. Researchers from Brigham and Women’s Hospital and Boston Children’s Hospital led the study. From the press release:

“Several other studies have measured parents’ interest in newborn genomic screening, but none focused on new parents in the first 48 hours,” said Robert C. Green, MD, MPH, a geneticist and researcher at BWH and Harvard Medical School and senior author of the study. “Since this is when genomic testing would be of the greatest value, it is especially important to study parents’ attitudes immediately post-partum.”

The researchers surveyed 514 parents at the well baby nursery at BWH within 48 hours of their child’s birth. After receiving a brief orientation to the genome and its impacts on human health, including information about what the genome is, what genes are and how they can affect both health and medical care, 82.7 percent of parents reported being somewhat (36 percent), very, (28 percent) or extremely (18 percent) interested in newborn genomic testing. Results were similar regardless of parents’ age, gender, race, ethnicity, level of education, family history of genetic disease, or whether or not the infant was a first-born child. Parents who had experienced concerns about the health of their newborn, however, were less likely to be interested in genomic testing. Continue reading

Mass. Parents Report Early Logjam In Care For Mentally Ill Kids

LisaLambert-140x140

Lisa Lambert of PPAL (Courtesy)

It usually happens in spring, the annual back-up of mentally ill kids who need beds in Massachusetts psychiatric hospitals or residential care centers.

But Lisa Lambert, executive director of the Parent/Professional Advocacy League, which works on behalf of mentally ill children and their families, reports that already this fall, the waits are unusually long and the resulting crises severe. (Imagine: a child in severe emotional distress, stuck in an Emergency Room for days. Or stuck in a hospital far from home, because there are no local beds.)

What’s happening? It’s not exactly clear. Might it be that state social service agencies are putting kids into residential care more than usual in the wake of the Jeremiah Oliver case? Is it a longer-term effect of having more community-based treatment for kids? Community care is widely considered a good thing, but it could mean that because children in crisis stay at home longer, their needs are more acute when they’re brought in for care. Lambert writes that the bottom line is that no one seems to be taking responsibility for alleviating the back-up, and the situation is getting dire:

At my office, the phone and emails are nonstop. Often, they spill over to the weekend. A few days ago, we heard from a mom whose 14 year old son had swallowed a bottle of Tylenol. This was his third suicide attempt. She rushed him to the emergency room and got medical treatment right away. But once that was completed, he needed inpatient mental health care. “You have to wait, his mother was told twice a day. “There are no beds.” She’s a smart and proactive parent and was trying every avenue to budge a system that told her there was nowhere to admit her son for treatment. When she called us he’d been waiting for four days and counting.

We are hearing a new term this year: boarding at home.

We are not the only state grappling with this issue. Last summer, the Sacramento Bee reported that hospitalizations for California children and teens had spiked 38% between 2007 and 2012. Nationally, hospitalizations have also increased but at a slower pace than California. Connecticut also reports an increase in children and teens coming to emergency rooms in psychiatric crisis. Data from the state’s behavioral health partnership shows that the number of children and teens stuck in emergency rooms rose by 20 percent from 2012 to 2013. Continue reading

10 Ways The Birds And The Bees Have Changed

(Courtesy Candlewick Press)

(Courtesy Candlewick Press)

Way back in 1988, children’s book author Robie H. Harris was sitting in a New York editor’s office batting around ideas for possible books. The editor proposed that she write a book about AIDS for elementary school children; she counter-proposed an all-encompassing look at “almost every single question that kids might have” about anything related to sex.

She rattled off a list of topics, and the rest is history: “It’s Perfectly Normal” is just out in its 20th-anniversary edition, with more than a million copies already in print. The mix of text by Harris and illustrations by Michael Emberley do indeed seem to cover all the sexual topics pubescent kids wonder about, from masturbation to menstruation to orientation to contraception.

“Of course,” Harris says, “over the years, I’ve added more topics as the times have changed, as information has changed, and as kids coming into puberty and adolescence have changed in some ways.”

What might those topics be? And what do they say about how kids’ worlds have changed over the last 20 years? Herewith, 10 significant changes in the book and what Harris says about them:

1. The Infosphere:
“There can be a lot of inappropriate, weird, confusing, uncomfortable, creepy, scary or even dangerous websites that you can end up on when looking for information.”

The biggest change in kids’ lives over the last 20 years, Harris says, is how they get their information. “With the explosion of information happening everywhere, kids are bombarded by sexual images, sexual words, words in songs. And then there’s the Internet: Kids can go on the Internet and find responsible information, and they can also go on the Internet and find information that is not accurate and sometimes absolutely dishonest.“

“And so the biggest change is the need to help kids know how to understand the information you get, and how do you get help with it? That’s when you go to a trusted adult. There’s just much more information to sort through for kids, and that’s why the biggest expansion in the book is the Internet chapter.”

And just a note on porn: Harris says every mental health expert she consulted says youngsters should stay away from it. (The book is for age 10 and up.) So “It’s one of the few judgments I put into the book, because I think it has to do with the health and wellbeing of our kids.”

2. Gender
“Gender is another word for whether a person is male or female. Gender is also about the thoughts and feelings a person has about being a female or being a male.”

Author Robie H. Harris (Courtesy Candlewick Press)

Author Robie H. Harris (Courtesy Candlewick Press)

That’s the broader definition of gender in the opening chapter, and the new edition also includes an explanation of “transgender” and “LGBT.” Harris acknowledges that the section on transgender youth “should have been in the book earlier, but it’s in there now.”

The section also includes a discussion of some people’s disrespect for gay and transgender people, and says it generally stems from ignorance. “I can’t write without a point of view,” Harris says. And her litmus tests has always been, “Is this what I would say to my own children?”

3. Long-acting birth control
The IUD, the implant and Depo-Provera are the most effective kinds of birth control.

The ranking of the most effective birth control methods is new, Harris says. It reflects a strong consensus among medical authorities that those long-acting methods are appropriate for teens who become sexually active — and desirable because they’re by far the most effective: they require no further action by the user — no daily pill, no pause for diaphragm insertion. Continue reading

Curb Your Hysteria: Talking Rationally To Kids About Ebola Risk

A man diagnosed with Ebola this week is being treated at Texas Health Presbyterian Hospital in Dallas. (AP)

A man diagnosed with Ebola this week is being treated at Texas Health Presbyterian Hospital in Dallas. (AP)

By Gene Beresin, MD and Steve Schlozman, MD

On Sept. 30 the first case of Ebola was diagnosed in the United States. The patient, who is currently being treated in Dallas, had recently traveled to Liberia, and was back in this country for a few days before symptoms began.

Understandably, the coverage of this news is pervasive. Although it seemed inevitable that a case in the U.S. would eventually emerge, the story still ignites a fair bit of hand-wringing among just about everyone who has learned of it.

Additionally, our country has experienced some novel infections that have ignited increased concerns in recent weeks. Enterovirus D-68 has made its way across the nation, causing severe cold-like symptoms, and, in some children with conditions such as asthma, the need for hospitalization. There’s also a potentially new contagion on the horizon that appears to cause varying degrees of muscular paralysis, and may or may not be related to Enterovirus D-68.

But, as public health officials are eager to stress, a nuanced and thoughtful approach to these issues has been as necessary as it has been fleeting. Experts agree that our medical infrastructure is well-equipped to handle even a virus as scary as Ebola, and some doctors are quick to point out that viruses like respiratory syncytial virus (RSV) and influenza are much more likely to cause harm than these new ones.

This raises a critical point:

Ebola, as scary as it is, poses a relatively minor threat to the United States; and the current cases of Enterovirus D-68 are far out-numbered by the RSV and influenza cases we experience on a yearly basis. And the currently unknown contagion that appears to cause paralysis has only happened in a very small population of kids.

So why the massive reaction in the media and among worried parents? Intellectually, at least at this point, all indications point to little danger for our children and ourselves. Why, then, do we get so frightened?

Well, let’s start with this confession: We’re frightened.

Sort of.

We know, intellectually, that the threat is minor. But, when has intellect played a leading role in the emotionally driven process of threat assessment? And, especially with regard to infectious disease, when has anyone other than the most statistically driven scientists been able to preserve perspective? We’re not saying that we should massively worry, or even that we’ll be changing our instructions to our kids or our patients on how to behave with these new bugs dancing around.

What we’re saying is that germs, especially new germs, are scary. We have a long and probably evolutionarily derived tendency to fear disease, and when new ones rear their heads, we get alarmed.

Germs In Hollywood

As a society, we think about germs a lot — and nowhere, perhaps, does that play out more than in Hollywood. The 1954 novella “I am Legend” has been made into no less than three movies (“The Last Man on Earth,” “The Omega Man” and the more recent movie of the same title as the written work). You can rattle off other movies as well — there’s “Dawn of the Dead” (in 1978 and again in 2004), “Outbreak,” “Carriers,” “Contagion,” “The Crazies” (in 1973 and again in 2010),

“Quarantine” (and “Quarantine 2″) and most recently “World War Z.” You get the picture. Continue reading

Word To Pediatricians: IUDs And Implants Top Choices For Teen Birth Control

From a Planned Parenthood video on the IUD (YouTube)

From a Planned Parenthood video on the IUD (YouTube)

By Veronica Thomas
Guest contributor

When a teen girl tells her pediatrician she’s thinking about having sex, the response is often a brief talk about abstinence, a handful of condoms, and a referral to the family planning clinic across town.

But a new recommendation makes pediatricians likelier to discuss the whole gamut of birth control methods—with IUDs and hormonal implants topping the list.

Released today by the American Academy of Pediatrics, the recommendation says doctors should discuss a broad range of birth control options with sexually active teens, but should start with the methods that protect against pregnancy best: long-acting reversible contraceptives, which include the hormonal implant, copper IUD and two hormonal IUDs.

Teen pregnancy rates have dropped dramatically over the past two decades to a record low, but the U.S. still has one of the highest rates among developed countries: more than 750,000 pregnancies each year. Though most sexually active teens use some form of birth control, they rarely pick the most effective methods and often use them incorrectly—whether it’s missing a few doses of the pill or accidentally tearing a condom.

“It’s sort of a set-and-forget method.”

– Heather Boonstra, Guttmacher Institute

Because IUDs and implants don’t rely on any action from the user, they’re a particularly good fit for teens, says Heather Boonstra, Director of Public Policy at the Guttmacher Institute.

“It’s sort of a set-and-forget method,” she says. Once inserted by a trained professional, an implant or IUD can last from three to ten years, and will be over 99 percent effective. The implant is a matchstick-sized rod inserted in the upper arm; the IUD is a small, T-shaped device placed into the uterus.

Their use has been rising for years in the general population. From 2002 to 2009, implant and IUD use nearly doubled among women overall. But while use of these long-acting methods has also been increasing among teens, less than five percent of all teen contraceptive users currently choose them.

That’s because most teens have never even heard of the implant or IUD, says Boonstra. Continue reading