Friday, November 21, 2014

How Teens Are Using the Internet to Learn About Sex

By: Editorial Board Member Joann Schulte, DO, MPH

Public domain photo via Pixabay
The way adolescents learn about sex is changing since the Internet has become a standard way for
people to seek information.

A new study published this month in Pediatrics (doi: 10.1542/ peds.2014-0592) explores the ways Dutch adolescents’ use of Internet sites shaped their perceptions of their body images and sexual self-perceptions.

Researchers at Utrecht University in the Netherlands and Boston Children’s Hospital explored how often teenagers looked at sexually explicit Internet material (pornography) and social networking sites.

The researchers examined the use of such sites among 1,132 Dutch children who were enrolled in the 7th through 10th grades. Ms. Suzan Doornwaard and her colleagues examined four groups of students over six-month intervals and assessed their behaviors using a computerized questionnaire that the students completed during school hours.

The researchers found boys visited pornography sites occasionally and that their use increased over time. Social networking sites were used daily and commonly by both boys and girls. Dutch researchers also reported that the adolescents who had higher initial use of sex-related online behavior or rapidly increased use were more likely to have less satisfaction with their own, actual sexual experiences. Additionally, the study's authors noted that adolescents who didn't have private access to the web and more parental rules on internet use were more likely to be involved in sex-related behavior online.

The study provides some initial, limited guidance for parents and suggests that parental guidance on Internet use for adolescents is a smart idea. Knowing where and what adolescents look at online and discussing it with them seem to be smart parenting strategies.

Thursday, November 20, 2014

Hospice and Palliative Care Competencies: Their Growth and Development

By: Lewis First, MD, MS; Editor-in-Chief 

In this era of training across the continuum using competency-based outcomes, the question arises as to whether competencies exist for all pediatric subspecialties.

This week, the field of Pediatric Hospice and Palliative Medicine (HPM) is sharing their first attempt at defining competencies for this specialty in a special article written by Klick et al. (doi: 10.1542/peds. 2014-0748).

The authors reflect the work of a group of HPM clinician-educators who came together, and using a defined methodology shared in this article, were able to provide us with the first set of pediatric HPM competencies.

Hopefully these will not just be implemented for those specializing in the field, but will be milestones defined for achievement for those early in their medical student or residency training needing introduction to baseline competencies in pediatric hospice and palliative care medicine.

How familiar are you with these HPM competencies as a practicing pediatrician? The best way to find out is to read this special article and learn more.

Related Reading:

Wednesday, November 19, 2014

The Duration of Nasal Shedding by Rhinovirus—What It Is and I(s-not)!

By: Lewis First, MD, MS; Editor-in-Chief 

Human rhinovirus-14. Photo by US Dept. of Energy.
Parents often tell us that their young child’s nose is always running. We like to say that if a child’s feet smell and her nose runs—it probably means she is upside down. But since this situation is unusual, the more common reason for rhinorrhea is a viral upper respiratory infection often caused by a strain of rhinovirus.

So just how long does rhinovirus hang around in a child’s nose? Or is it possible that children get different strains of rhinovirus mimicking a long-lasting strain?

Loeffelholz et al. (doi: 10.1542/peds. 2014-2132) set out to perform a longitudinal study of infants in their first year of life by collecting monthly nasopharyngeal samples as well as additional samples when upper respiratory infections occurred. They then ran the samples via reverse-transcription polymerase chain reaction (PCR) to look at nucleotide sequences for the strain of rhinovirus detected.

Researchers studies over 2,000 specimens from approximately 350 babies. What is most remarkable is that they identified more than 300 different rhinovirus infections involving upwards of 175 strains. Fewer than 10 infectious events represented prolonged infection more than 30 days long (i.e. found in two sequential monthly samples).

Before you start working up your patients for an immune dysfunction because their upper respiratory symptoms seem persistent, read this article. It may enable you to focus more on good URI preventive strategies of hand-washing, avoidance of second hand smoke exposure, and coughing and sneezing into an elbow rather than a hand—as time better spent than ordering a myriad of tests and cultures reflecting the spread of viral infections in otherwise healthy hosts.

The information in this article may be well worth sharing with families to avert the need for further laboratory testing and unnecessary use of antibiotics—but don’t take my word for it, you can be in the know (or in the nose) yourself if you give this study some attention.

Related Reading: 

Tuesday, November 18, 2014

Otitis Media and Antibiotic Selection: Does Race Play a Role in What Drug Is Chosen?

By: Lewis First, MD, MS; Editor-in-Chief 

Photo by Eden, Janine, and Jim via Flickr
Although the AAP’s guidelines on otitis media (OM) (doi:10.1542/peds.2012-3488) frown on automatic usage of antibiotics given the high incidence of viral infections for this disorder, there are circumstances in which an antibiotic is indicated. Though the guidelines make clear recommendations on what drug to use as first line for antibiotic treatment of otitis, variations in frequency of diagnosing otitis as well as in antimicrobial treatment regimen used do exist.

To gain a better understanding of these variations and their significance, Fleming-Dutra et al. (doi: 10.1542/peds.2014-1781) used national survey data to examine OM visits between black and non-black children and then compared amoxicillin prescription with broader spectrum antibiotic use, also by race, to determine if race was an independent factor in antibiotic selection.

While the number of OM visits per 1,000 children seen in the outpatient setting were not different in terms of race, the choice of antibiotics in this study revealed that black children were receiving amoxicillin more than broad-spectrum antimicrobials compared to white children, even when controlling for confounders in a multivariate analysis.

So what does this mean? Given the dangers of antibiotic overuse, are we providing better care to black children by limiting their antibiotics to amoxicillin, or are we discriminating against them by not offering broad-spectrum agents that we give to non-black patients?

There are many questions raised by this study and to help answer them, we have called upon infectious disease expert and one of our associate editors Dr. Charles Woods and his colleague Dr. Faye Jones (doi:10.1542/peds.2014-3056) to provide an important commentary to accompany this thought-provoking article.

Both the article and commentary are worth hearing about, and better yet reading about—so please do so and share your thoughts on the findings by responding to this blog, or via an eLetter, or commenting on Facebook or Twitter.

Related Reading:

Monday, November 17, 2014

The Challenges of Practicing Pediatrics in China

Pediatrics Assistant Editor Lydia Furman, MD, shares her perspective on a forthcoming article from our December issue. The full version of the article is available now to subscribers here, and on December 1, 2014, an extract will be freely available to all.

Chinese flag. Public domain photo via Wikimedia Commons
More than a decade ago, Shugerman and colleagues examined determinants of satisfaction among pediatricians in the US (Shugerman et al Pediatr 2001). They compared general and subspecialty pediatricians and internists and family practitioners, and found that “despite lower incomes, general pediatricians reported the highest levels of satisfaction and the least job stress of all physician groups…” and “[Pediatricians] were least likely to endorse symptoms of burnout or job stress.”

This finding likely makes good sense to many of us, and more recent work underscores this finding, with more than half of pediatricians describing themselves as “very satisfied” with their careers (Schmidt et al Health Care Manag 2014). These studies did not, and we would not expect them to, ask about personal safety and violence on the job; the focus of surveys is on burnout, job satisfaction, aspects of daily life such as patient volume and acuity, and hours worked. In general, we do not expect to fear for our physical safety while serving as pediatricians, with limited exception perhaps for those serving in uniquely high-risk environments.

Our good fortune is precisely our blind spot. The courageous Pediatrics article by Xu and colleagues (doi: 10.1542/peds.2014-1377) about the extraordinary and frightening circumstances of pediatricians in mainland China is a showstopper.

Perhaps there are knowledgeable colleagues among us who have friends or family in China who are aware that it may be physically dangerous to practice pediatrics in mainland China, but this shocking (and I believe the word is appropriate) underbelly to medical practice is not widely appreciated. Xu et al. describe instances of physical violence directed against pediatricians, with an increasing rate of medical violence unchecked by the courts or the government.

As fewer medical school graduates choose pediatrics or apply for pediatric jobs in mainland China, the wait time for patient care and the number of patients the remaining pediatricians see has risen dramatically, with each practicing doctor responsible for 80-100 visits per day (even up to 150 per day). Most US pediatricians cannot imagine this workload, and would rapidly change jobs or negotiate for better pay and better hours, citing not just personal exhaustion but patient safety as mandating a change.

Chinese pediatricians do not have ability to increase their pay, and unlike physicians in other specialties, do not have the option to perform procedures or prescribe medications that will supplement their incomes to a tolerable level. Per Xu et al., pediatricians are fleeing their jobs and the job market, with no resolution in sight and no solutions in the pipeline to prevent, improve or change working conditions.

What is our role as fellow pediatricians? What is our government’s role? Do we have any options? Shouldn’t children in every corner of the globe have the same access to health care as in the US? Shouldn’t our colleagues in every corner of the globe have the opportunity to practice medicine in a safe working environment? This brief piece raises issues many of us did not even know needed to be confronted.

Friday, November 14, 2014

“Leadiatrics”—A Field of Pediatrics for Which We Should All Be Certified

By: Lewis First, MD, MS; Editor-in-Chief 

Every issue of our journal is full of a variety of articles spanning a wide spectrum of topics involving a diverse array of pediatric specialties and subspecialties. While it is great that we are learning more and more how to improve the health of children, the complexity of our field and the wide array of options for career development in our field set the table for us to become more and more fragmented as a specialty with primary, secondary, tertiary, and quaternary care each carving out its own particular niche in pediatrics.

Yet to do what we must do in enhancing the care to infants, children and adolescents, we must be united in our mission and lead the way when it comes to improving child health. How to do this was the subject matter of an address I was honored to give at the Pediatric Academic Society meetings in Vancouver last May upon receiving the 2014 Joseph W. St. Geme Jr. Leadership Award from the Federation of Pediatric Organizations.

It has been a tradition to publish the St. Geme awardee’s address in our journal, and thus my own address is being published this month in a special article (doi:10.1542/peds.2014-3050)which, by the way, was independently peer-reviewed like all other articles that appear in our journal.

The theme of the talk I gave discusses five steps to becoming a “leadiatrician” and in doing so provides a way for all of us, no matter what we do or whatever our unique identities are, to come together and unite as pediatricians to lead the way as champions for child health. Just what are those five steps? Visit this article and learn more.

After reading what I have written, I would be curious if you agree with the points raised and what you can do to insure that you too are a leadiatrician. I welcome your comments on this blog, via an eLetter, or Twitter or Facebook.

Related Reading:

Thursday, November 13, 2014

NICU Evacuation During Hurricane Sandy

By: Editorial Board Member Joann Schulte, DO, MPH

Ambulances at the ready during Hurricane Sandy.
Photo by mlcastle via Flickr
One of the most stressful nights of my life was in a disaster shelter in Florida about 48 hours after Hurricane Charley came ashore near Port Charlotte on the west coast. As a public health physician, my job was to set up the surveillance for storm-related injuries and deaths and deal with whatever else needed medical attention.

I was relieved that the storm had taken a last-minute left hand turn into Charlotte County and spared St. Petersburg where I owned a home. But many other Florida residents had no such luck.  In the two days after Charley’s landfall on August 13, 2004, Florida opened 228 shelters housing 47,458 people. Another 59 special needs shelters housed 3,119 residents, mostly elderly, who required basic medical monitoring and administration of medications.

I found myself in the Sarasota Convention Center, dealing with new arrivals who seemed sleepy and announced that they’d been using a generator inside a garage. Diagnosing possible carbon monoxide didn't require a medical genius. After they were dispatched to a hyperbaric chamber, I wanted a rest.

But rest wasn't in the cards when I learned that a bus with 13 Alzheimer’s patients would be arriving because the nursing home’s generator had failed. “I’m sorry, but some of them are pretty combative,” was the message from the nursing director, who had performed a miracle in finding a bus to transport them to the convention center. Obviously the special needs shelters that dealt with diabetics or patients with COPD weren't ready or capable for the care of Alzheimer’s patients. I started half a dozen people on the phone making calls to find places that could take the 13 impaired men and women.

That’s why I found it easy to identify with the dilemma on the other end of life—evacuating a neonatal intensive care unit (NICU) that Dr. Michael Espiritu and his co-authors describe in the current issue of Pediatrics (doi: 10.1542/peds.2014-0936).

Portions of New York City, including the medical campus of New York University (NYU), can be flooded by the water surge driven by hurricane winds. The authors describe their experiences during 2012’s Hurricane Sandy, which arrived 15 months after Hurricane Irene.  With Irene, the neonatologists at NYU Langone Medical Center had successfully evacuated a population of 19 infants, including three who were mechanically ventilated and had done so in advance of the storm.  Sandy was another story.

The NYU hospital had an incident command structure and plans to deal with patient care. High-risk pregnant women were transferred out to minimize the odds of delivery room resuscitation or new NICU admissions; stable infants were discharged. On October 29, 2012, governmental decision makers had decreed that NYU and other hospitals would shelter in place, and the hospital had checked all the red power outlets that connect to emergency generators. The ventilators and other essential equipment had been plugged in and staffing was arranged. The NYU NICU had a census of 21 infants, including one on conventional ventilation and one on the high frequency oscillator (HFOV). Four other infants were on NCPAP. Then the power went out at 8:30 p.m.

Dr. Espiritu describes the measure taken for patient safety, and the ultimate transfer of infants to six other NYC hospitals. The infants left one by one. The NYU NICU is on the ninth floor and teams composed of nurses and respiratory therapist and a physician taking the infants down the unlighted stairs. One nurse carried an infant, sometimes holding the endotracheal tube in place. Others lugged IV pumps, oxygen tank and additional equipment. The physician ventilated each infant.

The authors report the evacuation took 10 minutes per infants, a passage lit by flashlights held by students at each landing. The infants departed between 945 p.m. and 1 a.m. The infants were all successfully transported to the receiving hospitals in ambulances contracted by FEMA.

The NYU NICU was closed for two and a half months after the Hurricane Sandy evacuation. Dr. Espiritu reports that the major problem was finding beds.  Who could accept a transfer patient was not a uniform decision – some hospitals permitted a fellow to do it. In others, it might be the chief of service. The authors suggested that future evacuations of NICUs or other hospital units might be more easily managed if the disaster response included a central bed management authority.

That was a lesson I learned from Charley with the elderly patients at the other extreme of life. It took us eight hours to find the nursing homes that could take the Alzheimer’s patients. The NYU authors describe a situation that many hospitals may have to face and suggest some concrete steps hospitals should take. Maybe your hospital isn't on the coast, but the weather isn't always sunny, and you never know what the wind might bring your way. What kind of planning and drilling have you done?