Showing posts with label school health. Show all posts
Showing posts with label school health. Show all posts

Monday, August 17, 2015

Getting the Right Beat: How Do Children with Congenital Heart Disease Do in School?

By: Joann Schulte  DO, MPH; Editorial Board Member   

         You want to get to the heart of the matter when a neonate has a  murmur or cyanosis.   About 1% of US infants are born with congenital heart disease (CHD) and their lives after discharge can be complicated with follow-up care.  But what happens when such children start school?  How do they  compare to other children?
            A new study published this month in Pediatrics from Riehle-Colarusso et al. (doi: 10.1542/peds.2015-0259) explores that issue with an innovative linkage of three databases to provide a picture about how such children do when school starts.  (This last sentence is the punch line and you state it below—so would not state it here.)
            The authors, epidemiologists from the Centers for Diseases Control and a cardiologist from Emory University, used data from Georgia birth certificates, the Atlanta Congenital Defects Program (population-based surveillance of birth defects) and the Special Education Database of Metropolitan Atlanta to study 3,744 children with CHD.  They tracked a cohort of children born during a 22-year period (1982 to 2004) and compared them to a group of children without major birth defects.
            Only children with isolated CHD, not including children whose conditions was complicated by other genetic diseases or birth defects were included in the study..  The comparison group of 860,715 children was identified through Georgia birth certificates. 
            The authors followed the entire group of 864,459 children to determine if they required special education between 1992 and 2012, using the database that tracked receipt of such services.  The special education database covers nine public school districts in the five counties that make up the metro Atlanta area.  
            The results of this study indicate that 15% of the children with CHD had received special education service compared to 9% of those without birth defects. Compared to the children without birth defects, those with CHD had a higher prevalence of intellectual disability, sensory impairment, and significant developmental delay among other neurodevelopmental impairments..
              This study has implications for what kind of care and follow-up attention might be needed for children with CHD.   Since 2011, screening for congenital heart disease has been recommended through pulse oximetry screening after 24 hours of age and before discharge.  This study suggests that pediatricians taking care of children with congenital heart disease might do well to track the developmental progress of those children.  Early identification of children with special education needs can help their success in school.  Examining twenty-two years’ worth of data for a group of Atlanta children with and without CHD provides important information on neurodevelopmental outcomes that can benefit the entire pediatric population with congenital heart disease..

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Thursday, May 28, 2015

When in Doubt, Go Outside and Play

By: Terrill Bravender  MD, MH, Editorial Board Member

      Children are surrounded by entertainment so much that we adults have almost completely changed our children’s environmental sensory exposures. Screens of all sorts are the most prominent and notorious addition to the lives of kids, but the idea that children need organized activities such as soccer practice, ballet lessons, or this lesson or that enrichment class has dramatically changed the way children are able to (or not able to) entertain themselves and explore their own passions. Children of all ages need opportunities to be creative, to explore their environments, and to develop their imagination. In other words: to play. The younger the child, the more critical these opportunities are, after all, preschool children learn best through imaginative play and too much interference will just get in the way. Because our indoor environments are filled with electronic entertainment; where will children get these free play opportunities? The answer is as simple as previous generations telling their children to “go outside”. Many child advocacy groups, from Free Range Children to those concerned about “nature deficit disorder” are trying to promote outdoor activities for kids.
      The National Association for Sport and Physical Education recommends that each day preschoolers in daycare get sixty minutes of free-play time, sixty minutes of teacher-led structured physical activities time, and some opportunity to go outdoors. In the current issue of Pediatrics, Tandon et al. (doi: 10.1542/peds.2014-2750) from Seattle Children’s Hospital describe the indoor and outdoor free-play opportunities among preschoolers enrolled in various daycare settings. Their findings are disheartening, even if they are unsurprising. Children were physically active for fifty-five minutes per day, with an average of thirty-two minutes outdoors. Based on the activity monitors the children were wearing, children were more physically active when participating in unstructured free-play outdoors than when they were indoors or were participating in teacher-led activities. The children were also expected to lie quietly in “naptime” for an average of almost two hours, or more than ¼ of their time in daycare. 
     High quality daycare should be structured to the needs of the children for whom they care. Older children, adolescents, and adults, spend inordinate amounts of time sitting down indoors. The least we can do for our preschoolers is to give them the opportunity for free play, preferably outdoors. Ideally, this would comprise the majority of their day doing what children should do: running around outdoors battling dragons, finding fairy houses, and saving the universe, all without a screen in sight.

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Thursday, March 26, 2015

Inner-city children with ADHD symptoms- what helps?

By: Lydia Furman, MD Assistant Editor  

      The work of Silverstein et al, (doi:10.1542/peds.2014-3221) “Collaborative Care for children with ADHD symptoms: a randomized comparative effectiveness trial,” is highly intriguing for several reasons. The authors studied a low-income inner-city population of children (and parents) that presented with ADHD symptoms, and randomized them to Enhanced or Basic Collaborative Care.  Enhanced Care included a trained lay facilitator who met with the family up to 5 times to address barriers to treatment and parental mental health concerns, and to provide ways to reduce coercive parenting in response to difficult behaviors. 
        The title raises a very interesting question – does diagnosis of ADHD help clinicians manage symptoms of inattention and hyperactivity? The authors’ approach suggests that it may not, since they enrolled all eligible children who were being evaluated for “ADHD symptoms”, and included both those who were ultimately diagnosed with ADHD, as well as those who were not, in the clinical trial. This empiric research strategy encourages us to think more broadly about how to help children who present with symptoms of inattention, impulsivity and hyperactivity. The diagnosis of ADHD as described “was defined as meeting DSM-IV symptom criteria on both the parent and teacher Vanderbilt scales, in the absence of a plausible alternative explanation for the child’s symptoms- as determined from narrative clinical information.” Given this straightforward and pragmatic evaluation using an instrument with relatively low positive predictive value (PPV of 0.19 and 0.32, respectively; Bard et al J Dev Behav Pediatr 2013; Wolraich et al J Dev Behav Pediatr 2013), it is worth considering the possibility that the 63 “ADHD consistent presentation” subjects (40% of all subjects), as compared to the “ADHD inconsistent presentation” subjects, differed quantitatively not qualitatively from each other. In other words, did children in the former group simply have more symptoms than those in the latter group, rather than a unique disease state?
        The “ADHD consistent presentation” subjects, whose outcomes were analyzed secondarily since the study was powered to look at outcomes of all subjects, showed greater symptom improvement in the Enhanced Collaborative Care group (please read the paper to learn about the summary results for all children!). Given the study design, the authors could not determine which component of the Enhanced Care was the most helpful. However, since there was not a statistically significant difference in specialty behavior services or in medication treatment between groups (52% in basic care vs. 72% in Enhanced care, p=0.10), and there was a difference in receipt of Triple P (Positive Parenting Program with 0% in basic care vs. 47% in the Enhanced Care Group receiving the intervention, the authors speculate that this could explain the impact of the Enhanced Care. In deference to the authors, I note that they believe the clinically meaningful difference in medication use between groups likely was important also, but we know from multiple publications, including the very well monitored MTA study in which actual medication adherence was 53.5% (Pappadopulos et al Medication adherence in the MTA JAACAP 2009), that compliance with medication treatment may be surprisingly low.
        In an accompanying Perspective, Dr. Mark Wolraich,(doi:10.1542/peds.2015-0070) who is the lead author of the AAP ADHD Guidelines and of the Vanderbilt forms, notes that “while progress is being made,” no etiology has been identified for ADHD  in over a decade of research, and “therapy is likely to remain symptom based,”  which is indeed the approach that Silverstein et al take.  Dr. Wolraich also notes that long term outcomes are not yet acceptable, and that even the MTA study found no difference in intensively monitored groups 2 years after treatment ended. In fact at 24 and 36 months post formal intervention, children in the MTA who were taking medication, as compared to those who were not, showed significantly greater symptom deterioration from 24 to 36 months, as well as higher delinquency at both these time points (Jensen et al 3-Year Follow-up of NIMH MTA JAACAP August 2007), information that may be new to many clinicians. Perhaps an entirely new paradigm is needed.

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Wednesday, March 18, 2015

To Air Is Human: New Tools In At Home Asthma Treatment

By: Kathleen Walsh  MD, MS; Editorial Board Memeber
      When I ask my adolescent daughter about her asthma care goals, she replies “I don’t have any,” with a sarcastic tone and a charming, braces-filled grin.  However, I know her goals include placing well in cross country races, passing her taekwondo tests, and getting good grades in school.
       All of these require excellent control of her asthma.  When she was a baby, my goals for her asthma were to minimize exacerbation frequency and duration both for her happiness and so I could finish residency.  While achieving my goals for my daughter’s asthma care has always been my primary motivation for adhering to her treatment, only recently have our goals become a part of our discussions with her clinicians.
       In this week’s Pediatrics, the MyAsthma intervention described by Fiks et al. (doi: 10.1542/peds.2014-3167) takes an important early step toward parent and physician shared decision making regarding asthma treatment at home.  MyAsthma is a portal-based intervention, where parents enter information about their child’s asthma, including their goals and their child’s current symptoms, several times a month.  The portal uses evidence-based protocols to support decisions by the family and clinician about when they need to communicate further and when to change the home treatment plan.
      Although the study was relatively small, with twenty-six children in the treatment arm and a 57% participation rate, the authors found statistically significant improvements in some outcomes.  Specifically, children in the treatment group had significantly larger improvements in ACT scores over the study period compared to controls.  In addition, parents in the treatment group reported significantly less missed work than controls.  While other portal-based asthma interventions exist, this is the first to ask parents about their asthma management goals.
      The identification of family care goals is a key step in the parent and clinician co-management of chronic disease.  The portal-based intervention described by Fiks provides decision support for asthma management when and where the patient needs it- at the family’s convenience and at home.  It also enables a partnership between families and clinicians through goal setting, enhanced communication, and early identification and mitigation of changes in health status.  The spread of promising interventions such as this one will provide the necessary support so that families and clinicians can collaborate to improve chronic disease outcomes.  For pediatricians, this is the kind of collaborative care we would like to provide to all of our patients and their families.  

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Thursday, February 12, 2015

Does Oxytocin "Augment" ADHD?

By: Editorial Board Member Lydia Furman MD,  

    A study that is sufficiently powered to answer a question about risk for ADHD has arrived. Following a trail of suggestive evidence from smaller studies Henriksen et. al (doi:10.1542/peds.2014-1542) examined the possible relationship of oxytocin augmentation of labor to subsequent development of ADHD in offspring. I don’t want to spoil the fun of the read for you, but I will note that the study is extraordinarily well done. The authors have the great advantage of large and comprehensive national registers from their home country of Denmark, including a National Birth Registry that permits identification of all augmented labors, and a National Patient Registry, National Psychiatric Registry and Medical Products Registry that, respectively, allow identification of all admits and discharges, all ADHD-diagnosed children, and all ADHD medication prescribed. Researchers in the US can only dream of such population-wide, comprehensive data sources.
     The authors note that “ADHD” is an “American DSM diagnosis” based on the Diagnostic and Statistical Manual (DSM-V) criteria, so in this cohort ADHD was diagnosed by either the ICD-10 code for “Hyperkinetic Disorder” as used in Denmark, or by having received ADHD-specific medications, or both. The sample size is a phenomenal 546,146 births (2000 – 2008), of which 25.5% were medically augmented; 0.9% of all offspring were diagnosed with ADHD. The tables are easy to read and the analysis accounts for basic potential confounders, including birth weight, gestational age, maternal age, parity, income, education and cohabitation status.
     At first glance, when compared to US rates, the number of ADHD-diagnosed children in the Henriksen study (0.9%) looks like a misprint or decimal point error. Although the ICD-10 “Hyperkinetic Disorder” code differs from DSM coding and requires that a child have hyperactivity, impulsivity and inattention, the order of magnitude difference begs explanation. The number of children in the US who are diagnosed with Attention Deficit with Hyperactivity Disorder (ADHD) has continued to increase, “from 7.8% in 2003 to 9.5% in 2007 and to 11.0% in 2011” (source: ). The overall estimated prevalence of ADHD depends directly on the methodology used to identify cases, and in meta-analysis ranges from 4.0-13.3%, with a proposed “best estimate” of 5.9-7.1% (Wilcutt, Neurotherapeutics 2012), still lower than the CDC-documented rate of diagnosis.
     The meaning and cause of the extraordinary observed increase in diagnosed children is debated, with concern by some for under-treatment (Froehlich et al Arch Pediatr Adolesc Med 2007) and by others for over-diagnosis (Klein et al, Child Care Health Dev 2014 and Coon et al, Pediatr 2014). A proposed approach of “stepped care” and “stepped diagnosis” from colleagues in the Netherlands (Batstra et al Dev Med Child Neurol 2012 and Thomas et al BMJ 2013; 347) shows promise, particularly in light of recent work demonstrating low positive predictive values for the AAP-recommended Parent and Teacher Vanderbilt scales, of 0.19 and 0.32, respectively (Bard et al J Dev Behav Pediatr 2013; Wolraich et al J Dev Behav Pediatr 2013).
     No biological marker (serology, genetic test, neuroimaging study or neurocognitive test) defines or diagnoses ADHD, so numerous studies have sought to identify correlates of diagnosis and risk. Confusing correlation with causation, or misinterpreting risk factors as etiologic factors, are the prime hazards of such studies. Prenatal smoking, for example, has been effectively dethroned as a “cause” of ADHD as additional causality studies were completed (Nigg, JAMA Pediatr 2012); prenatal smoking may instead serve as a proxy for environmental factors that foster development of the symptoms of inattention and hyperactivity. The Henrickson study makes a meaningful contribution in this arena of study, and the authors are careful to describe their work as examining an association, rather than as defining causation.