Pediatric Clinical Practice Guidelines & Policies [18th Edition] 9781610021494

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Pediatric Clinical Practice Guidelines & Policies [18th Edition]
 9781610021494

Table of contents :
Table of Contents......Page 6
Section 1: Clinical Practice Guidelines From the American Academy of Pediatrics......Page 20
Foreword......Page 22
ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents......Page 24
Attention-Deficit/Hyperactivity Disorder Clinical Practice Guideline Quick Reference Tools......Page 42
Brief Resolved Unexplained Events......Page 66
Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants......Page 68
Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants: Executive Summary......Page 100
Brief Resolved Unexplained Events Clinical Practice Guideline Quick Reference Tools......Page 104
Bronchiolitis......Page 108
Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis......Page 110
Bronchiolitis Clinical Practice Guideline Quick Reference Tools......Page 140
Diabetes......Page 144
Management of Newly Diagnosed Type 2 Diabetes Mellitus (T2DM) in Children and Adolescents......Page 146
Diabetes Clinical Practice Guideline Quick Reference Tools......Page 166
Dysplasia of the Hip......Page 170
Clinical Practice Guideline: Early Detection of Developmental Dysplasia of the Hip......Page 172
Dysplasia of the Hip Clinical Practice Guideline Quick Reference Tools......Page 182
Febrile Seizures......Page 186
Febrile Seizures: Clinical Practice Guideline for the Long-term Management of the Child With Simple Febrile Seizures......Page 188
Clinical Practice Guideline—Febrile Seizures: Guideline for the Neurodiagnostic Evaluation of the Child With a Simple Febrile Seizure......Page 196
Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents......Page 206
High Blood Pressure Clinical Practice Guideline Quick Reference Tools......Page 280
Hyperbilirubinemia......Page 284
Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation......Page 286
Hyperbilirubinemia Clinical Practice Guideline Quick Reference Tools......Page 308
Otitis Media......Page 312
The Diagnosis and Management of Acute Otitis Media......Page 314
Otitis Media With Effusion......Page 350
Otitis Media Clinical Practice Guidelines Quick Reference Tools......Page 370
Sinusitis......Page 380
Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis in Children Aged 1 to 18 Years......Page 382
Sinusitis Clinical Practice Guideline Quick Reference Tools......Page 402
Sleep Apnea......Page 406
Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome......Page 408
Sleep Apnea Clinical Practice Guideline Quick Reference Tools......Page 418
Urinary Tract Infection......Page 422
Reaffirmation of AAP Clinical Practice Guideline: The Diagnosis and Management of the Initial Urinary Tract Infection in Febrile Infants and Young Children 2–24 Monthsof Age......Page 424
Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months......Page 430
Urinary Tract Infection Clinical Practice Guideline Quick Reference Tools......Page 446
Section 2: Endorsed Clinical Practice Guidelines......Page 450
Congenital Adrenal Hyperplasia Due to Steroid 21-hydroxylase Deficiency: An Endocrine Society Clinical Practice Guideline......Page 452
Guidelines for Adolescent Depression in Primary Care (GLAD-PC): II. Treatment and Ongoing Management......Page 453
Prevention of Infective Endocarditis: Guidelines From the American Heart Association......Page 454
Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-Exposed and HIV-Infected Children......Page 455
Evidence-based Guideline Update: Medical Treatment of Infantile Spasms......Page 456
Neuroimaging of the Neonate......Page 457
Diagnostic Assessment of the Child With Status Epilepticus (An Evidence-based Review)......Page 458
Treating Tobacco Use and Dependence: 2008 Update......Page 459
Report on the Management of Primary Vesicoureteral Reflux in Children......Page 461
Section 3: Affirmation of Value Clinical Practice Guidelines......Page 462
Care of Girls and Women With Turner Syndrome: A Guideline of the Turner Syndrome Study Group......Page 464
Section 4: 2017 Policies From the American Academy of Pediatrics......Page 466
Introduction......Page 468
2017 Recommendations for Preventive Pediatric Health Care......Page 470
Adolescent and Young Adult Tattooing, Piercing, and Scarification......Page 476
The Adolescent’s Right to Confidential Care When Considering Abortion......Page 494
Age Limit of Pediatrics......Page 508
The Breastfeeding-Friendly Pediatric Office Practice......Page 514
The Care of Children With Congenital Heart Disease in Their Primary Medical Home......Page 526
Care of the Adolescent After an Acute Sexual Assault......Page 538
The Child Witness in the Courtroom......Page 556
Clinical Considerations Related to the Behavioral Manifestations of Child Maltreatment......Page 568
Clinical Tools to Assess Asthma Control in Children......Page 584
Consent by Proxy for Nonurgent Pediatric Care......Page 596
Cord Blood Banking for Potential Future Transplantation......Page 608
Counseling Parents and Teens About Marijuana Use in the Era of Legalization of Marijuana......Page 620
Detention of Immigrant Children......Page 628
Diagnosis, Treatment, and Prevention of Congenital Toxoplasmosis in the United States......Page 644
Diagnosis of Pregnancy and Providing Options Counseling for the Adolescent Patient......Page 698
Disaster Preparedness in Neonatal Intensive Care Units......Page 710
Donor Human Milk for the High-Risk Infant: Preparation, Safety, and Usage Options in the United States......Page 724
Early Childhood Home Visiting......Page 732
Elimination of Perinatal Hepatitis B: Providing the First Vaccine Dose Within 24 Hours of Birth......Page 746
Epinephrine for First-aid Management of Anaphylaxis......Page 754
Expert Witness Participation in Civil and Criminal Proceedings......Page 766
Expert Witness Participation in Civil and Criminal Proceedings......Page 772
Financing of Pediatric Home Health Care......Page 788
Fruit Juice in Infants, Children, and Adolescents: Current Recommendations......Page 796
Global Human Trafficking and Child Victimization......Page 806
Guidance on Completing a Written Allergy and Anaphylaxis Emergency Plan......Page 820
Guidance on Forgoing Life-Sustaining Medical Treatment......Page 832
Guiding Principles for Team-Based Pediatric Care......Page 844
Infection Prevention and Control in Pediatric Ambulatory Settings......Page 854
Infectious Diseases Associated With Organized Sports and Outbreak Control......Page 880
The Metabolic Syndrome in Children and Adolescents: Shifting the Focus to Cardiometabolic Risk Factor Clustering......Page 906
The Need to Optimize Adolescent Immunization......Page 920
Needs of Kinship Care Families and Pediatric Practice......Page 938
A New Era in Quality Measurement: The Development and Application of Quality Measures......Page 950
Nicotine and Tobacco as Substances of Abuse in Children and Adolescents......Page 964
Nonemergency Acute Care: When It’s Not the Medical Home......Page 980
Off-Label Use of Medical Devices in Children......Page 992
Options Counseling for the Pregnant Adolescent Patient......Page 998
Oral and Dental Aspects of Child Abuse and Neglect......Page 1006
Pain Assessment and Treatment in Children With Significant Impairment of the Central Nervous System......Page 1016
Pediatric Integrative Medicine......Page 1046
Practical Approaches to Optimize Adolescent Immunization......Page 1070
The Primary Care Pediatrician and the Care of Children With Cleft Lip and/or Cleft Palate......Page 1086
Principles of Child Health Care Financing......Page 1102
Promotion of Healthy Weight-Control Practices in Young Athletes......Page 1112
A Public Health Response to Opioid Use in Pregnancy......Page 1128
Quality Early Education and Child Care From Birth to Kindergarten......Page 1138
Recommendations for Prevention and Control of Influenza in Children, 2017–2018......Page 1146
Recommended Childhood and Adolescent Immunization Schedule—United States, 2018......Page 1168
Responsible Innovation in Children’s Surgical Care......Page 1172
Sexual and Reproductive Health Care Services in the Pediatric Setting......Page 1184
Shared Decision-Making and Children With Disabilities: Pathway to Consensus......Page 1200
Stigma Experienced by Children and Adolescents With Obesity......Page 1212
Section 5: Current Policies From the American Academy of Pediatrics......Page 1226
Addressing Early Childhood Emotional and Behavioral Problems (Technical Report)......Page 1228
Adolescents and HIV Infection: The Pediatrician’s Role in Promoting Routine Testing......Page 1229
All-Terrain Vehicle Injury Prevention: Two-, Three-, and Four-Wheeled Unlicensed Motor Vehicles......Page 1230
Application of the Resource-Based Relative Value Scale System to Pediatrics......Page 1231
Binge Drinking......Page 1232
The Breastfeeding-Friendly Pediatric Office Practice......Page 1233
Care of the Adolescent After an Acute Sexual Assault......Page 1234
Child Abuse, Confidentiality, and the Health Insurance Portability and Accountability Act......Page 1235
Child Sex Trafficking and Commercial Sexual Exploitation: Health Care Needs of Victims......Page 1236
Children’s Health Insurance Program (CHIP): Accomplishments, Challenges, and Policy Recommendations......Page 1237
Climatic Heat Stress and Exercising Children and Adolescents......Page 1238
Cochlear Implants in Children: Surgical Site Infections and Prevention and Treatment of Acute Otitis Media and Meningitis......Page 1239
Comprehensive Evaluation of the Child With Intellectual Disability or Global Developmental Delays......Page 1240
A Consensus Statement on Health Care Transitions for Young Adults With Special Health Care Needs......Page 1241
Contraception for HIV-Infected Adolescents......Page 1242
Countering Vaccine Hesitancy......Page 1243
Definition of a Pediatrician......Page 1244
Diagnosis, Treatment, and Prevention of Congenital Toxoplasmosis in the United States......Page 1245
Diagnosis and Management of Infantile Hemangioma: Executive Summary......Page 1246
Disaster Planning for Schools......Page 1247
Donor Human Milk for the High-Risk Infant: Preparation, Safety, and Usage Options in the United States......Page 1248
Early Childhood Caries in Indigenous Communities......Page 1249
Electronic Nicotine Delivery Systems......Page 1250
Emergency Contraception......Page 1251
Epidemiology and Diagnosis of Health Care– Associated Infections in the NICU......Page 1252
Essential Contractual Language for Medical Necessity in Children......Page 1253
Evaluating for Suspected Child Abuse: Conditions That Predispose to Bleeding......Page 1254
Evaluation and Management of Children and Adolescents With Acute Mental Health or Behavioral Problems. Part I: Common Clinical Challenges of Patients With Mental Health and/or Behavioral Emergencies— Executive Summary......Page 1255
Evaluation and Management of the Infant Exposed to HIV-1 in the United States......Page 1256
Evaluation for Bleeding Disorders in Suspected Child Abuse......Page 1257
An Evidence-Based Review of Important Issues Concerning Neonatal Hyperbilirubinemia......Page 1258
Families Affected by Parental Substance Use......Page 1259
Financing Graduate Medical Education to Meet the Needs of Children and the Future Pediatrician Workforce......Page 1260
Folic Acid for the Prevention of Neural Tube Defects......Page 1261
Gastroesophageal Reflux: Management Guidance for the Pediatrician......Page 1262
Guidance for the Administration of Medication in School......Page 1263
Guidelines for Care of Children in the Emergency Department......Page 1264
Guidelines for the Determination of Brain Death in Infants and Children: An Update of the 1987 Task Force Recommendations......Page 1265
Handoffs: Transitions of Care for Children in the Emergency Department......Page 1266
Health Care of Youth Aging Out of Foster Care......Page 1267
Health Supervision for Children With Fragile X Syndrome......Page 1268
High-Deductible Health Plans......Page 1269
Hospital Discharge of the High-Risk Neonate......Page 1270
Identification and Evaluation of Children With Autism Spectrum Disorders......Page 1271
Immunization for Streptococcus pneumoniae Infections in High-Risk Children......Page 1272
The Importance of Play in Promoting Healthy Child Development and Maintaining Strong Parent-Child Bond: Focus on Children in Poverty......Page 1273
Increasing Immunization Coverage......Page 1274
Infection Prevention and Control in Pediatric Ambulatory Settings......Page 1275
Injuries Associated With Infant Walkers......Page 1276
Insufficient Sleep in Adolescents and Young Adults: An Update on Causes and Consequences......Page 1277
Lactose Intolerance in Infants, Children, and Adolescents......Page 1278
The Lifelong Effects of Early Childhood Adversity and Toxic Stress......Page 1279
Male Adolescent Sexual and Reproductive Health Care......Page 1280
Maltreatment of Children With Disabilities......Page 1281
Management of Type 2 Diabetes Mellitus in Children and Adolescents......Page 1282
Media Education......Page 1283
Medical Countermeasures for Children in Public Health Emergencies, Disasters, or Terrorism......Page 1284
Menstrual Management for Adolescents With Disabilities......Page 1285
Motor Delays: Early Identification and Evaluation......Page 1286
Newborn Screening Expands: Recommendations for Pediatricians and Medical Homes—Implications for the System......Page 1287
Noninvasive Respiratory Support......Page 1288
Office-Based Counseling for Unintentional Injury Prevention......Page 1289
Oral and Dental Aspects of Child Abuse and Neglect......Page 1290
Out-of-Home Placement for Children and Adolescents With Disabilities......Page 1291
Oxygen Targeting in Extremely Low Birth Weight Infants......Page 1292
Parent-Provider-Community Partnerships: Optimizing Outcomes for Children With Disabilities......Page 1293
Patient Safety in the Pediatric Emergency Care Setting......Page 1294
Pediatric Aspects of Inpatient Health Information Technology Systems......Page 1295
Pediatric Palliative Care and Hospice Care Commitments, Guidelines, and Recommendations......Page 1296
Pediatrician Workforce Policy Statement......Page 1297
The Pediatrician’s Role in the Evaluation and Preparation of Pediatric Patients Undergoing Anesthesia......Page 1298
Phototherapy to Prevent Severe Neonatal Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation......Page 1299
Point-of-Care Ultrasonography by Pediatric Emergency Medicine Physicians......Page 1300
Practical Approaches to Optimize Adolescent Immunization......Page 1301
Prescribing Assistive-Technology Systems: Focus on Children With Impaired Communication......Page 1302
Prevention of Childhood Lead Toxicity......Page 1303
The Primary Care Pediatrician and the Care of Children With Cleft Lip and/or Cleft Palate......Page 1304
Probiotics and Prebiotics in Pediatrics......Page 1305
Promoting Optimal Development: Screening for Behavioral and Emotional Problems......Page 1306
Protecting Children From Sexual Abuse by Health Care Providers......Page 1307
Providing Psychosocial Support to Children and Families in the Aftermath of Disasters and Crises......Page 1308
Psychosocial Support for Youth Living With HIV......Page 1309
Racial and Ethnic Disparities in the Health and Health Care of Children......Page 1310
Recognition and Management of Medical Complexity......Page 1311
Reducing Injury Risk From Body Checking in Boys’ Youth Ice Hockey......Page 1312
Responding to Parental Refusals of Immunization of Children......Page 1313
Role of Pulse Oximetry in Examining Newborns for Congenital Heart Disease: A Scientific Statement from the AHA and AAP......Page 1314
Safe Sleep and Skin-to-Skin Care in the Neonatal Period for Healthy Term Newborns......Page 1315
School Transportation Safety......Page 1316
Screening for Retinopathy in the Pediatric Patient With Type 1 Diabetes Mellitus......Page 1317
Sexuality Education for Children and Adolescents......Page 1318
SIDS and Other Sleep-Related Infant Deaths: Updated 2016 Recommendations for a Safe Infant Sleeping Environment......Page 1319
Special Requirements of Electronic Health Record Systems in Pediatrics......Page 1320
Sports Specialization and Intensive Training in Young Athletes......Page 1321
Strength Training by Children and Adolescents......Page 1322
Supporting the Grieving Child and Family......Page 1323
Telemedicine: Pediatric Applications......Page 1324
The Transfer of Drugs and Therapeutics Into Human Breast Milk: An Update on Selected Topics......Page 1325
Ultraviolet Radiation: A Hazard to Children and Adolescents (Technical Report)......Page 1326
Updated Guidance for Palivizumab Prophylaxis Among Infants and Young Children at Increased Risk of Hospitalization for Respiratory Syncytial Virus Infection......Page 1327
Use of Inhaled Nitric Oxide in Preterm Infants......Page 1328
Ventricular Fibrillation and the Use of Automated External Defibrillators on Children......Page 1329
Youth Participation and Injury Risk in Martial Arts......Page 1330
Section 6: Endorsed Policies......Page 1332
Appropriate Use Criteria for Initial Transthoracic Echocardiography in Outpatient Pediatric Cardiology......Page 1334
Consensus Communication on Early Peanut Introduction and the Prevention of Peanut Allergy in High-risk Infants......Page 1335
Dietary Recommendations for Children and Adolescents: A Guide for Practitioners......Page 1336
Guidelines for Referral of Children and Adolescents to Pediatric Rheumatologists......Page 1337
National Adoption Center: Open Records......Page 1338
A Practical Guide for Primary Care Physicians: Instrument-Based Vision Screening in Children......Page 1339
Response to Cardiac Arrest and Selected Life- Threatening Medical Emergencies: The Medical Emergency Response Plan for Schools. A Statement for Healthcare Providers, Policymakers, School Administrators, and Community Leaders......Page 1340
Supplement to the JCIH 2007 Position Statement: Principles and Guidelines for Early Intervention After Confirmation That a Child Is Deaf or Hard of Hearing......Page 1341
Weighing All Patients in Kilograms......Page 1342
Appendix 1: PPI: AAP Partnership for
Policy Implementation......Page 1344
Appendix 2: American Academy of Pediatrics Acronyms......Page 1346
Subject Index......Page 1350

Citation preview

  

Pediatric Clinical Practice Guidelines A Compendium of Evidence-based Research for Pediatric Practice 18th Edition

& Policies

Clinical practice guidelines have long provided physicians with an evidence-based decision-making tool for managing common pediatric conditions. Policies issued and endorsed by the American Academy of Pediatrics (AAP) represent the AAP position on child health care issues. More than 40 clinical practice guidelines and more than 500 policy statements, clinical reports, and tech­nical reports have been combined into this 18th edition of Pediatric Clinical Practice Guidelines & Policies book and eBook, giving you even easier access to the important clinical and policy information you need.

Organization of Pediatric Clinical Practice Guidelines & Policies, 18th Edition Section 1: Clinical Practice Guidelines From the American Academy of Pediatrics Section 2: Endorsed Clinical Practice Guidelines Section 3: Affirmation of Value Clinical Practice Guidelines Section 4: 2017 Policies From the American Academy of Pediatrics Section 5: Current Policies From the American Academy of Pediatrics Section 6: Endorsed Policies Appendix 1: PPI: AAP Partnership for Policy Implementation Appendix 2: American Academy of Pediatrics Acronyms

• Nonfebrile seizures • Otitis media • Palliative care • Radiology • Rhinoplasty—New! • Sedation and analgesia • Sinusitis • Sleep apnea • Status epilepticus • Telehealth—New! • Tobacco use and dependence • Turner syndrome—New! • Urinary tract infection • Vesicoureteral reflux Pediatric Clinical Practice Guidelines & Policies, 18th Edition, is the perfect practical reference book for p ­ rimary care ­physicians, nurses, and allied health pro­fessionals. To order other pediatric resources, visit shop.aap.org/ books.

& Policies, 18th Edition

Manual includes • Complete AAP clinical practice guidelines • Complete 2017 AAP policy statements and c­ linical and technical reports • Appendixes on the AAP Partnership for Policy Implementation and AAP acronyms • Quick Reference Tools, including coding tips, patient ­education handouts, and more • Six-section organization for ease of use Clinical practice guidelines included in this edition cover the following pediatric conditions: • Attention-deficit/hyperactivity disorder • Autism spectrum disorder • Brief resolved unexplained events • Bronchiolitis • Cardiovascular health • Cerebral palsy • Cerumen impaction—New! • Congenital adrenal hyperplasia • Congenital muscular dystrophy • Depression • Diabetes • Duchenne muscular dystrophy • Dysplasia of the hip • Emergency medical services • Endocarditis • Febrile seizures • Fluoride • Food allergy • Gastroenteritis • Hemorrhage • High blood pressure—New! • HIV • Hyperbilirubinemia • Immunocompromised host • Infantile spasms • Intravascular catheter-related ­infections • Jaundice • Migraine headache

eBook access included!

Pediatric Clinical Practice Guidelines

American Academy of Pediatrics

ISBN: 978-1-61002-148-7 ISSN: 1942-2024 MA0859

ISBN 978-1-61002-148-7

90000>

9 781610 021487

aap

A M E R I C A N AC A D E M Y O F P E D I AT R I C S

Am P er olic of ica y o Pe n A f th di ca e at d ric em s y

Pediatric

Clinical Practice

&

Guidelines

Policies

A Compendium of Evidence-based Research for Pediatric Practice 18th Edition

eBook access included!

Pediatric Clinical Practice Guidelines & Policies A Compendium of Evidence-based Research for Pediatric Practice 18th Edition

American Academy of Pediatrics 345 Park Blvd Itasca, IL 60143 www.aap.org

AMERICAN ACADEMY OF PEDIATRICS PUBLISHING STAFF Mark Grimes Vice President, Publishing Jennifer McDonald Senior Editor, Digital Publishing Leesa Levin-Doroba Production Manager, Practice Management Amanda Helmholz Medical Copy Editor Peg Mulcahy Manager, Art Direction and Production Sean Rogers Digital Content Specialist Mary Lou White Chief Product and Services Officer/SVP, Membership, Marketing, and Publishing Linda Smessaert Senior Marketing Manager, Professional Resources Mary Louise Carr Marketing Manager, Clinical Publications

The American Academy of Pediatrics is an organization of 66,000 primary care pediatricians, pediatric medical subspecialists, and pediatric surgical specialists dedicated to the health, safety, and well-being of infants, children, adolescents, and young adults. The recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. Products are mentioned for informational purposes only. Inclusion in this publication does not imply endorsement by the American Academy of Pediatrics. Every effort has been made to ensure that the drug selection and dosage set forth in this publication are in accordance with the current recommendations and practice at the time of publication. It is the responsibility of the health care professional to check the package insert of each drug for any change in indications and dosage and for added warnings and precautions. This publication has been developed by the American Academy of Pediatrics. The authors, editors, and contributors are expert authorities in the field of pediatrics. No commercial involvement of any kind has been solicited or accepted in the development of the content of this publication. © 2018 American Academy of Pediatrics All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means—electronic, mechanical, photocopying, recording, or otherwise—without prior written permission from the publisher (locate title at http://ebooks. aappublications.org and click on © Get Permissions; you may also fax the permissions editor at 847/434-8780 or e-mail [email protected]). First edition published 2001; 18th, 2018. Printed in the United States of America 9-5/1117 MA0859 ISBN: 978-1-61002-148-7 eBook: 978-1-61002-149-4 ISSN: 1942-2024

INTRODUCTION TO PEDIATRIC CLINICAL PRACTICE GUIDELINES & POLICIES: A COMPENDIUM OF EVIDENCE-BASED RESEARCH FOR PEDIATRIC PRACTICE Clinical practice guidelines have long provided physicians with evidence-based decision-making tools for managing common pediatric conditions. Policy statements issued and endorsed by the American Academy of Pediatrics (AAP) are developed to provide physicians with a quick reference guide to the AAP position on child health care issues. We have combined these 2 authoritative resources into 1 comprehensive manual/eBook resource to provide easy access to important clinical and policy information. This manual contains • Clinical practice guidelines from the AAP, plus related recommendation summaries, ICD-10-CM coding information, and AAP patient education handouts • Clinical practice guidelines endorsed by the AAP, including abstracts where applicable • Policy statements, clinical reports, and technical reports issued or endorsed through December 2017, including abstracts where applicable • Full text of all 2017 AAP policy statements, clinical reports, and technical reports The eBook, which is available via the code on the inside cover of this manual, builds on content of the manual and points to the full text of all AAP • Clinical practice guidelines • Policy statements • Clinical reports • Technical reports • Endorsed clinical practice guidelines and policies For easy reference within this publication, dates when AAP clinical practice guidelines, policy statements, clinical reports, and technical reports first appeared in the AAP journal Pediatrics are provided. In 2009, the online version of Pediatrics at http://pediatrics.aappublications.org became the official journal of record; therefore, date of online publication is given for policies from 2010 to present. Additional information about AAP policy can be found in a variety of professional publications such as Guidelines for Air and Ground Transport of Neonatal and Pediatric Patients, 4th Edition Pediatric Nutrition, 7th Edition Guidelines for Perinatal Care, 8th Edition Pediatric Environmental Health, 3rd Edition Care of the Young Athlete, 2nd Edition Red Book®, 31st Edition, and Red Book® Online (http://redbook.solutions.aap.org) Guidelines for To order these and other pediatric resources, please call 866/843-2271 or visit http://shop.aap.org/books.

Am Po er licy of ican of Pe A the di cad at ric em y s

INATAL PERIN CA R E Eighth Edition

All policy statements, clinical reports, and technical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time. Please check the American Academy of Pediatrics Web site at www.aap.org for up-to-date reaffirmations, revisions, and retirements.

AMERICAN ACADEMY OF PEDIATRICS The American Academy of Pediatrics (AAP) and its member pediatricians dedicate their efforts and resources to the health, safety, and well-being of infants, children, adolescents, and young adults. The AAP has approximately 66,000 members in the United States, Canada, and Latin America. Members include pediatricians, pediatric medical subspecialists, and pediatric surgical specialists. Core Values. We believe • In the inherent worth of all children; they are our most enduring and vulnerable legacy. • Children deserve optimal health and the highest quality health care. • Pediatricians, pediatric medical subspecialists, and pediatric surgical specialists are the best qualified to provide child health care. • Multidisciplinary teams including patients and families are integral to delivering the highest quality health care. The AAP is the organization to advance child health and well-being and the profession of pediatrics. Vision. Children have optimal health and well-being and are valued by society. American Academy of Pediatrics members practice the highest quality health care and experience professional satisfaction and personal well-being. Mission. The mission of the AAP is to attain optimal physical, mental, and social health and well-being for all infants, children, adolescents, and young adults. To accomplish this mission, the AAP shall support the professional needs of its members.

V

Table of Contents

SECTION 1 CLINICAL PRACTICE GUIDELINES FROM THE AMERICAN ACADEMY OF PEDIATRICS Foreword............................................................................................. 3 Attention-Deficit/Hyperactivity Disorder ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/ Hyperactivity Disorder in Children and Adolescents....... 5 See Appendix 1.

Attention-Deficit/Hyperactivity Disorder Clinical ­Practice Guideline Quick Reference Tools.........................................23 Brief Resolved Unexplained Events Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants................................................................ 47 See Appendix 1.



Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants: Executive Summary.......................... 81 See Appendix 1.

Brief Resolved Unexplained Events Clinical Practice Guideline Quick Reference Tools........................................ 85 Bronchiolitis The Diagnosis, Management, and Prevention of Bronchiolitis....................................................................... 89 See Appendix 1.

Bronchiolitis Clinical Practice Guideline Quick Reference Tools.................................................................... 121 Diabetes Management of Newly Diagnosed Type 2 Diabetes Mellitus (T2DM) in Children and Adolescents.............. 125 Diabetes Clinical Practice Guideline Quick Reference Tools.................................................................... 147 Dysplasia of the Hip Early Detection of Developmental Dysplasia of the Hip........ 151 Dysplasia of the Hip Clinical Practice Guideline Quick Reference Tools........................................................ 163 Febrile Seizures Febrile Seizures: Clinical Practice Guideline for the Long-term Management of the Child With Simple Febrile Seizures...................................................... 167 Febrile Seizures: Guideline for the Neurodiagnostic Evaluation of the Child With a Simple Febrile Seizure...................................................................... 175

Febrile Seizures Clinical Practice Guidelines Quick Reference Tools.................................................................... 183 High Blood Pressure Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents................................................................... 187 See Appendix 1.

High Blood Pressure Clinical Practice Guideline Quick Reference Tools.................................................................... 261 Hyperbilirubinemia Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation.............................. 265 Hyperbilirubinemia Clinical Practice Guideline Quick Reference Tools.................................................................... 289 Otitis Media The Diagnosis and Management of Acute Otitis Media......... 293 Otitis Media With Effusion........................................................... 331 Otitis Media Clinical Practice Guidelines Quick Reference Tools.................................................................... 351 Sinusitis Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis in Children Aged 1 to 18 Years.............................................. 361 See Appendix 1.

Sinusitis Clinical Practice Guideline Quick Reference Tools.................................................................... 383 Sleep Apnea Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome...................................................... 387 Sleep Apnea Clinical Practice Guideline Quick Reference Tools.................................................................... 399 Urinary Tract Infection Reaffirmation of AAP Clinical Practice Guideline: The Diagnosis and Management of the Initial Urinary Tract Infection in Febrile Infants and Young Children 2–24 Months of Age ............................. 403 Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months .................................................... 411 See Appendix 1.

Urinary Tract Infection Clinical Practice Guideline Quick Reference Tools........................................................ 427

VI

SECTION 2 ENDORSED CLINICAL PRACTICE GUIDELINES Autism Spectrum Disorder Screening and Diagnosis of Autism............................................ 433 Cardiovascular Health Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: Summary Report............. 433 Cerebral Palsy Diagnostic Assessment of the Child With Cerebral Palsy...................................................................... 433 Cerumen Impaction Cerumen Impaction....................................................................... 433 Congenital Adrenal Hyperplasia Congenital Adrenal Hyperplasia Due to Steroid 21-hydroxylase Deficiency: An Endocrine Society Clinical Practice Guideline................................... 433 Congenital Muscular Dystrophy Evidence-based Guideline Summary: Evaluation, ­ Diagnosis, and Management of Congenital ­ Muscular Dystrophy. Report of the Guideline Development Subcommittee of the American Academy of Neurology and the Practice Issues Review Panel of the American Association of ­Neuromuscular & Electrodiagnostic Medicine.............. 434

TABLE OF CONTENTS

Food Allergy Guidelines for the Diagnosis and Management of Food Allergy in the United States: Report of the NIAID-Sponsored Expert Panel................................. 436 Gastroenteritis Managing Acute Gastroenteritis Among Children: Oral Rehydration, Maintenance, and Nutritional Therapy............................................................ 436 Hemorrhage An Evidence-based Prehospital Guideline for External Hemorrhage Control........................................... 436 HIV Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-Exposed and HIV-Infected Children................................................ 436 Immunocompromised Host 2013 Infectious Diseases Society of America Clinical Practice Guidelines for the Immunization of the Immunocompromised Host............................................... 437 Infantile Spasms Evidence-based Guideline Update: Medical Treatment of Infantile Spasms.............................................................. 437 Intravascular Catheter-Related Infections Guidelines for the Prevention of Intravascular Catheter-Related Infections............................................... 438

Depression Guidelines for Adolescent Depression in Primary Care (GLAD-PC): I. Identification, Assessment, and Initial Management..................................................... 434 Guidelines for Adolescent Depression in Primary Care (GLAD-PC): II. Treatment and Ongoing Management......................................................................... 434

Jaundice Guideline for the Evaluation of Cholestatic Jaundice in Infants .............................................................................. 438

Duchenne Muscular Dystrophy Practice Guideline Update Summary: Corticosteroid Treatment of Duchenne Muscular Dystrophy................ 435

Palliative Care Clinical Practice Guidelines for Quality Palliative Care, Third Edition........................................................................ 438

Dysplasia of the Hip Guideline on Detection and Nonoperative Management of Pediatric Developmental Dysplasia of the Hip in Infants up to Six Months of Age: Evidence-based Clinical Practice Guideline............................................................... 435

Radiology Neuroimaging of the Neonate..................................................... 438

Emergency Medical Services National Model EMS Clinical Guidelines.................................. 435

Sedation and Analgesia Clinical Policy: Evidence-based Approach to Pharmacologic Agents Used in Pediatric Sedation and Analgesia in the Emergency Department................ 439

Endocarditis Prevention of Infective Endocarditis: Guidelines From the American Heart Association............................. 435 Fluoride Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States............. 436

Migraine Headache Pharmacological Treatment of Migraine Headache in Children and Adolescents.................................................. 438

Rhinoplasty Improving Nasal Form and Function after Rhinoplasty......... 439

Seizure Evaluating a First Nonfebrile Seizure in Children................... 439 Treatment of the Child With a First Unprovoked Seizure....... 439

PEDIATRIC CLINICAL PRACTICE GUIDELINES & POLICIES

VII

Status Epilepticus Diagnostic Assessment of the Child With Status Epilepticus (An Evidence-based Review)....................... 439 Telehealth Operating Procedures for Pediatric Telehealth......................... 440 Tobacco Use Treating Tobacco Use and Dependence: 2008 Update............. 440 Turner Syndrome Clinical Practice Guidelines for the Care of Girls and Women With Turner Syndrome: Proceedings From the 2016 Cincinnati International Turner Syndrome Meeting.............................................................. 442 Vesicoureteral Reflux Report on the Management of Primary Vesicoureteral Reflux in Children............................................................... 442 SECTION 3 AFFIRMATION OF VALUE CLINICAL PRACTICE  GUIDELINES Asthma Environmental Management of Pediatric Asthma: Guidelines for Health Care Providers.............................. 445 Palliative Care and Hospice Standards of Practice for Pediatric Palliative Care and Hospice......................................................................... 445 Sleep Apnea Practice Guidelines for the Perioperative Management of Patients with Obstructive Sleep Apnea....................... 445 Turner Syndrome Care of Girls and Women With Turner Syndrome: A Guideline of the Turner Syndrome Study Group.......... 445 SECTION 4 2017 POLICIES FROM THE AMERICAN ACADEMY OF PEDIATRICS Introduction.................................................................................... 2017 Recommendations for Preventive Pediatric Health Care.......................................................................... Adolescent and Young Adult Tattooing, Piercing, and Scarification.................................................................. The Adolescent’s Right to Confidential Care When Considering Abortion............................................. Age Limit of Pediatrics................................................................. The Breastfeeding-Friendly Pediatric Office Practice............... The Care of Children With Congenital Heart Disease in Their Primary Medical Home....................................... Care of the Adolescent After an Acute Sexual Assault............ The Child Witness in the Courtroom.......................................... Clinical Considerations Related to the Behavioral ­Manifestations of Child Maltreatment.............................

449 451 457 475 489 495 507 519 537 549

Clinical Tools to Assess Asthma Control in Children.............. 565 Consent by Proxy for Nonurgent Pediatric Care...................... 577 Cord Blood Banking for Potential Future Transplantation..... 589 Counseling Parents and Teens About Marijuana Use in the Era of Legalization of Marijuana........................... 601 Detention of Immigrant Children............................................... 609 Diagnosis, Treatment, and Prevention of Congenital Toxoplasmosis in the United States.................................. 625 Diagnosis of Pregnancy and Providing Options Counseling for the Adolescent Patient............................ 679 Disaster Preparedness in Neonatal Intensive Care Units........ 691 Donor Human Milk for the High-Risk Infant: Preparation, Safety, and Usage Options in the United States........................................................................ 705 Early Childhood Home Visiting.................................................. 713 Elimination of Perinatal Hepatitis B: Providing the First Vaccine Dose Within 24 Hours of Birth.................. 727 Epinephrine for First-aid Management of Anaphylaxis.......... 735 Expert Witness Participation in Civil and Criminal Proceedings......................................................... 747 Expert Witness Participation in Civil and Criminal Proceedings (Technical Report)........................ 753 Financing of Pediatric Home Health Care................................. 769 Fruit Juice in Infants, Children, and Adolescents: Current Recommendations................................................ 777 Global Human Trafficking and Child Victimization................ 787 Guidance on Completing a Written Allergy and Anaphylaxis Emergency Plan........................................... 801 Guidance on Forgoing Life-Sustaining Medical Treatment............................................................... 813 Guiding Principles for Team-Based Pediatric Care.................. 825 Infection Prevention and Control in Pediatric Ambulatory Settings........................................................... 835 Infectious Diseases Associated With Organized Sports and Outbreak Control............................................ 861 The Metabolic Syndrome in Children and Adolescents: Shifting the Focus to Cardiometabolic Risk Factor Clustering.......................... 887 The Need to Optimize Adolescent Immunization.................... 901 Needs of Kinship Care Families and Pediatric Practice.......... 919 A New Era in Quality Measurement: The Development and Application of Quality Measures.............................. 931 Nicotine and Tobacco as Substances of Abuse in Children and Adolescents............................................. 945 Nonemergency Acute Care: When It’s Not the Medical Home...................................................................... 961 Off-Label Use of Medical Devices in Children.......................... 973 Options Counseling for the Pregnant Adolescent Patient....... 979 Oral and Dental Aspects of Child Abuse and Neglect............ 987 Pain Assessment and Treatment in Children With Significant Impairment of the Central Nervous System................................................................... 997 Pediatric Integrative Medicine................................................... 1027 Practical Approaches to Optimize Adolescent Immunization................................................ 1051

VIII

TABLE OF CONTENTS

The Primary Care Pediatrician and the Care of Children With Cleft Lip and/or Cleft Palate................ 1067 See Appendix 1.

Principles of Child Health Care Financing.............................. Promotion of Healthy Weight-Control Practices in Young Athletes.............................................................. A Public Health Response to Opioid Use in Pregnancy........ Quality Early Education and Child Care From Birth to Kindergarten.................................................................. Recommendations for Prevention and Control of Influenza in Children, 2017–2018....................................

1083 1093 1109 1119 1127

See Appendix 1.

Recommended Childhood and Adolescent Immunization Schedule—United States, 2018 ............ Responsible Innovation in Children’s Surgical Care.............. Sexual and Reproductive Health Care Services in the Pediatric Setting..................................................... Shared Decision-Making and Children With Disabilities: Pathway to Consensus................................ Stigma Experienced by Children and Adolescents With Obesity .....................................................................

1149 1153 1165 1181 1193

SECTION 5 CURRENT POLICIES FROM THE AMERICAN ACADEMY OF PEDIATRICS 2017 Recommendations for Preventive Pediatric Health Care........................................................................ 1209 Abusive Head Trauma in Infants and Children...................... 1209 Access to Optimal Emergency Care for Children................... 1209 Achieving Quality Health Services for Adolescents ............. 1209 Addressing Early Childhood Emotional and Behavioral Problems ........................................................ 1209 Addressing Early Childhood Emotional and Behavioral Problems (Technical Report)........................ 1209 Admission and Discharge Guidelines for the Pediatric Patient Requiring Intermediate Care............. 1210 Adolescent and Young Adult Tattooing, Piercing, and Scarification................................................................ 1210 Adolescent Drug Testing Policies in Schools........................... 1210 Adolescent Drug Testing Policies in Schools (Technical Report)............................................................. 1210 Adolescent Pregnancy: Current Trends and Issues................ 1210 Adolescent Pregnancy: Current Trends and Issues— Addendum......................................................................... 1210 Adolescents and HIV Infection: The Pediatrician’s Role in Promoting Routine Testing................................ 1210 The Adolescent’s Right to Confidential Care When Considering Abortion....................................................... 1211 Advanced Practice in Neonatal Nursing................................. 1211 Age Limit of Pediatrics............................................................... 1211 Age Terminology During the Perinatal Period....................... 1211 Alcohol Use by Youth and Adolescents: A Pediatric Concern.......................................................... 1211 Allergy Testing in Childhood: Using AllergenSpecific IgE Tests (Clinical Report)................................. 1211

All-Terrain Vehicle Injury Prevention: Two-, Three-, and Four-Wheeled Unlicensed Motor Vehicles................................................................... Ambient Air Pollution: Health Hazards to Children............. Antenatal Counseling Regarding Resuscitation and Intensive Care Before 25 Weeks of Gestation................ Anterior Cruciate Ligament Injuries: Diagnosis, Treatment, and Prevention............................................... The Apgar Score .......................................................................... Apnea of Prematurity.................................................................. Application of the Resource-Based Relative Value Scale System to Pediatrics................................................ Assessment and Management of Inguinal Hernia in Infants............................................................................. Athletic Participation by Children and Adolescents Who Have Systemic Hypertension................................ Atopic Dermatitis: Skin-Directed Management...................... Attention-Deficit/Hyperactivity Disorder and Substance Abuse................................................................ Baseball and Softball................................................................... Best Practices for Improving Flow and Care of Pediatric Patients in the Emergency Department........ Bicycle Helmets............................................................................ Binge Drinking............................................................................. Bone Densitometry in Children and Adolescents................... Boxing Participation by Children and Adolescents................ Breastfeeding and the Use of Human Milk............................. The Breastfeeding-Friendly Pediatric Office Practice............. The Built Environment: Designing Communities to Promote Physical Activity in Children.......................... Calcium and Vitamin D Requirements of Enterally Fed Preterm Infants........................................................... Cardiovascular Monitoring and Stimulant Drugs for Attention-Deficit/Hyperactivity Disorder.............. Care of Adolescent Parents and Their Children..................... The Care of Children With Congenital Heart Disease in Their Primary Medical Home..................................... Care of the Adolescent After an Acute Sexual Assault.......... Caregiver-Fabricated Illness in a Child: A Manifestation of Child Maltreatment ....................... Cheerleading Injuries: Epidemiology and Recommendations for Prevention.................................. Chemical-Biological Terrorism and Its Impact on Children......................................................................... Chemical-Management Policy: Prioritizing Children’s Health.............................................................. Child Abuse, Confidentiality, and the Health Insurance Portability and Accountability Act............... Child Fatality Review.................................................................. Child Life Services....................................................................... Child Passenger Safety................................................................

1211 1212 1212 1212 1212 1212 1212 1213 1213 1213 1213 1213 1213 1213 1213 1214 1214 1214 1214 1215 1215 1215 1215 1215 1215 1216 1216 1216 1216 1216 1217 1217 1217

See Appendix 1.

Child Passenger Safety (Technical Report).............................. 1217 See Appendix 1.

PEDIATRIC CLINICAL PRACTICE GUIDELINES & POLICIES

Child Sex Trafficking and Commercial Sexual Exploitation: Health Care Needs of Victims................. The Child Witness in the Courtroom........................................ Children, Adolescents, and Advertising.................................. Children, Adolescents, and the Media..................................... Children, Adolescents, Obesity, and the Media...................... Children and Adolescents and Digital Media......................... Children’s Health Insurance Program (CHIP): Accomplishments, Challenges, and Policy Recommendations............................................................. Chronic Abdominal Pain in Children....................................... Chronic Abdominal Pain in Children (Technical Report)..... Circumcision Policy Statement.................................................. Climatic Heat Stress and Exercising Children and Adolescents................................................................. Clinical Considerations Related to the Behavioral Manifestations of Child Maltreatment........................... Clinical Genetic Evaluation of the Child With Mental Retardation or Developmental Delays........................... Clinical Practice Policy to Protect Children From Tobacco, Nicotine, and Tobacco Smoke......................... Clinical Tools to Assess Asthma Control in Children............ Cochlear Implants in Children: Surgical Site Infections and Prevention and Treatment of Acute Otitis Media and Meningitis............................ Codeine: Time to Say “No”........................................................ Collaborative Role of the Pediatrician in the Diagnosis and Management of Bipolar Disorder in Adolescents................................................... Communicating With Children and Families: From Everyday Interactions to Skill in Conveying Distressing Information............................... Community Pediatrics: Navigating the Intersection of Medicine, Public Health, and Social Determinants of Children’s Health................................ Comprehensive Evaluation of the Child With Intellectual Disability or Global Developmental Delays..................................................... Comprehensive Health Evaluation of the Newly Adopted Child................................................................... Condom Use by Adolescents..................................................... Conflicts Between Religious or Spiritual Beliefs and Pediatric Care: Informed Refusal, Exemptions, and Public Funding........................................................... Congenital Brain and Spinal Cord Malformations and Their Associated Cutaneous Markers.................... A Consensus Statement on Health Care Transitions for Young Adults With Special Health Care Needs......................................................................... Consent by Proxy for Nonurgent Pediatric Care.................... Consent for Emergency Medical Services for Children and Adolescents................................................ Consumption of Raw or Unpasteurized Milk and Milk Products by Pregnant Women and Children....... Contraception for Adolescents................................................... Contraception for Adolescents (Technical Report)................. Contraception for HIV-Infected Adolescents.......................... Controversies Concerning Vitamin K and the Newborn......

IX

1217 1218 1218 1218 1218 1218 1218 1219 1219 1219 1219 1220 1220 1220 1220 1220 1221 1221 1221 1221 1221 1222 1222 1222 1222 1222 1223 1223 1223 1223 1223 1223 1224

Cord Blood Banking for Potential Future Transplantation.................................................................. Corporal Punishment in Schools............................................... Counseling Families Who Choose Complementary and Alternative Medicine for Their Child With Chronic Illness or Disability.................................. Counseling Parents and Teens About Marijuana Use in the Era of Legalization of Marijuana......................... Countering Vaccine Hesitancy................................................... Creating Healthy Camp Experiences........................................ Critical Elements for the Pediatric Perioperative Anesthesia Environment.................................................. The Crucial Role of Recess in School........................................ Dealing With the Parent Whose Judgment Is Impaired by Alcohol or Drugs: Legal and Ethical Considerations...................................................... Death of a Child in the Emergency Department.................... Death of a Child in the Emergency Department (Technical Report)............................................................. Definition of a Pediatrician........................................................ Detention of Immigrant Children............................................. Developmental Dysplasia of the Hip Practice Guideline (Technical Report)........................................... Diagnosis, Treatment, and Prevention of Congenital Toxoplasmosis in the United States................................ Diagnosis and Management of an Initial UTI in Febrile Infants and Young Children............................................

1224 1224 1224 1224 1224 1225 1225 1225 1225 1225 1225 1225 1226 1226 1226 1227

See Appendix 1.

Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome.................................................... Diagnosis and Management of Infantile Hemangioma......... Diagnosis and Management of Infantile Hemangioma: Executive Summary.......................................................... Diagnosis and Prevention of Iron Deficiency and Iron-Deficiency Anemia in Infants and Young Children (0–3 Years of Age)............................................. Diagnosis of HIV-1 Infection in Children Younger Than 18 Months in the United States....................................... Diagnosis of Pregnancy and Providing Options Counseling for the Adolescent Patient.......................... Diagnostic Imaging of Child Abuse.......................................... Disaster Planning for Schools.................................................... Disaster Preparedness in Neonatal Intensive Care Units...... Disclosure of Adverse Events in Pediatrics ............................ Dispensing Medications at the Hospital Upon Discharge From an Emergency Department................. Distinguishing Sudden Infant Death Syndrome From Child Abuse Fatalities............................................ Donor Human Milk for the High-Risk Infant: Preparation, Safety, and Usage Options in the United States............................................................... Do-Not-Resuscitate Orders for Pediatric Patients Who Require Anesthesia and Surgery........................... Drinking Water From Private Wells and Risks to Children.......................................................................... Drinking Water From Private Wells and Risks to Children (Technical Report)........................................

1227 1227 1227 1228 1228 1228 1228 1228 1229 1229 1229 1229 1229 1230 1230 1230

X

Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science Into Lifelong Health ...............1230 Early Childhood Caries in Indigenous Communities.............1230 Early Childhood Home Visiting................................................ 1231 Early Intervention, IDEA Part C Services, and the Medical Home: Collaboration for Best Practice and Best Outcomes............................................................ 1231 Echocardiography in Infants and Children............................. 1231 Effects of Early Nutritional Interventions on the Development of Atopic Disease in Infants and Children: The Role of Maternal Dietary Restriction, Breastfeeding, Timing of Introduction of Complementary Foods, and Hydrolyzed Formulas............................................................................. 1231 Electronic Nicotine Delivery Systems....................................... 1231 Electronic Prescribing in Pediatrics: Toward Safer and More Effective Medication Management...................... 1232 Electronic Prescribing in Pediatrics: Toward Safer and More Effective Medication Management (Technical Report)............................................................. 1232 Electronic Prescribing Systems in Pediatrics: The Rationale and Functionality Requirements................... 1232 Electronic Prescribing Systems in Pediatrics: The Rationale and Functionality Requirements (Technical Report)............................................................. 1232 Elimination of Perinatal Hepatitis B: Providing the First Vaccine Dose Within 24 Hours of Birth.......... 1232 Emergency Contraception.......................................................... 1232 Emergency Contraception: Addendum.................................... 1233 Emergency Information Forms and Emergency Preparedness for Children With Special Health Care Needs............................................................ 1233 Endorsement of Health and Human Services Recommendation for Pulse Oximetry Screening for Critical Congenital Heart Disease.......... 1233 Enhancing Pediatric Workforce Diversity and Providing Culturally Effective Pediatric Care: Implications for Practice, Education, and Policy Making.................................................................... 1233 Ensuring the Health of Children in Disasters......................... 1233 Epidemiology and Diagnosis of Health Care– Associated Infections in the NICU................................. 1233 Epinephrine for First-aid Management of Anaphylaxis........ 1234 Equipment for Ground Ambulances........................................ 1234 Eradicating Polio: How the World’s Pediatricians Can Help Stop This Crippling Illness Forever............. 1234 Essential Contractual Language for Medical Necessity in Children.......................................................................... 1234 Establishing a Standard Protocol for the Voiding Cystourethrography.......................................................... 1235 Ethical and Policy Issues in Genetic Testing and Screening of Children....................................................... 1235 Ethical Considerations in Research With Socially Identifiable Populations................................................... 1235 Ethical Controversies in Organ Donation After Circulatory Death.............................................................. 1235 Evaluating Children With Fractures for Child Physical Abuse................................................................... 1235

TABLE OF CONTENTS

Evaluating for Suspected Child Abuse: Conditions That Predispose to Bleeding............................................ Evaluation and Management of Children and Adolescents With Acute Mental Health or Behavioral Problems. Part I: Common Clinical Challenges of Patients With Mental Health and/or Behavioral Emergencies..................................... Evaluation and Management of Children and Adolescents With Acute Mental Health or Behavioral Problems. Part I: Common Clinical Challenges of Patients With Mental Health and/or Behavioral Emergencies— Executive Summary.......................................................... Evaluation and Management of Children With Acute Mental Health or Behavioral Problems. Part II: Recognition of Clinically Challenging Mental Health Related Conditions Presenting With Medical or Uncertain Symptoms.......................... Evaluation and Management of Children With Acute Mental Health or Behavioral Problems. Part II: Recognition of Clinically Challenging Mental Health Related Conditions Presenting With Medical or Uncertain Symptoms— Executive Summary.......................................................... Evaluation and Management of the Infant Exposed to HIV-1 in the United States .......................................... Evaluation and Management of the Infant Exposed to HIV-1 in the United States—Addendum.................. Evaluation and Referral for Developmental Dysplasia of the Hip in Infants.......................................................... Evaluation and Referral of Children With Signs of Early Puberty..................................................................... Evaluation for Bleeding Disorders in Suspected Child Abuse........................................................................ The Evaluation of Children in the Primary Care  Setting When Sexual Abuse Is Suspected...................... The Evaluation of Sexual Behaviors in Children.................... The Evaluation of Suspected Child Physical Abuse............... Evidence for the Diagnosis and Treatment of Acute Uncomplicated Sinusitis in Children: A Systematic Review........................................................ An Evidence-Based Review of Important Issues Concerning Neonatal Hyperbilirubinemia................... Expert Witness Participation in Civil and Criminal Proceedings....................................................... Expert Witness Participation in Civil and Criminal Proceedings (Technical Report)...................... Exposure to Nontraditional Pets at Home and to Animals in Public Settings: Risks to Children.............. The Eye Examination in the Evaluation of Child Abuse....... Facilities and Equipment for the Care of Pediatric Patients in a Community Hospital................................. Falls From Heights: Windows, Roofs, and Balconies............. Families Affected by Parental Substance Use.......................... Fathers’ Roles in the Care and Development of Their Children: The Role of Pediatricians..................... The Female Athlete Triad............................................................ Fetal Alcohol Spectrum Disorders............................................. Fever and Antipyretic Use in Children....................................

1235

1236

1236

1237

1237 1237 1238 1238 1238 1238 1239 1239 1239 1239 1239 1240 1240 1240 1240 1240 1240 1240 1241 1241 1241 1241

PEDIATRIC CLINICAL PRACTICE GUIDELINES & POLICIES

Financing Graduate Medical Education to Meet the Needs of Children and the Future Pediatrician Workforce .................................................... Financing of Pediatric Home Health Care............................... Firearm-Related Injuries Affecting the Pediatric Population......................................................... Fireworks-Related Injuries to Children.................................... Fluoride Use in Caries Prevention in the Primary Care Setting........................................................................ Folic Acid for the Prevention of Neural Tube Defects........... Follow-up Management of Children With Tympanostomy Tubes....................................................... Forgoing Medically Provided Nutrition and Hydration in Children...................................................... Fruit Juice in Infants, Children, and Adolescents: Current Recommendations.............................................. The Future of Pediatrics: Mental Health Competencies for Pediatric Primary Care............................................... Gastroesophageal Reflux: Management Guidance for the Pediatrician............................................................ Generic Prescribing, Generic Substitution, and Therapeutic Substitution.................................................. Global Climate Change and Children’s Health...................... Global Climate Change and Children’s Health (Technical Report)............................................................. Global Human Trafficking and Child Victimization.............. Guidance for Effective Discipline.............................................. Guidance for the Administration of Medication in School.............................................................................. Guidance on Completing a Written Allergy and Anaphylaxis Emergency Plan......................................... Guidance on Forgoing Life-Sustaining Medical Treatment............................................................. Guidance on Management of Asymptomatic Neonates Born to Women With Active Genital Herpes Lesions.................................................... Guidelines for Care of Children in the Emergency Department................................................... Guidelines for Developing Admission and Discharge Policies for the Pediatric Intensive Care Unit............................................................................. Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016.................................................. Guidelines for Pediatric Cancer Centers.................................. Guidelines for the Determination of Brain Death in Infants and Children: An Update of the 1987 Task Force Recommendations................................ Guidelines for the Ethical Conduct of Studies to  Evaluate Drugs in Pediatric Populations...................... Guiding Principles for Managed Care Arrange­ments for the Health Care of Newborns, Infants, Children, Adolescents, and Young Adults ................... Guiding Principles for Pediatric Hospital Medicine Programs........................................................... Guiding Principles for Team-Based Pediatric Care................ Gynecologic Examination for Adolescents in the Pediatric Office Setting.....................................................

XI

1241 1242 1242 1242 1242 1242 1243 1243 1243 1243 1243 1244 1244 1244 1244 1244 1244 1245 1245 1245 1245 1246

1246 1246 1246 1247 1247 1247 1247 1247

Handoffs: Transitions of Care for Children in the Emergency Department .................................................. Head Lice...................................................................................... Health and Mental Health Needs of Children in US Military Families......................................................... Health Care for Youth in the Juvenile Justice System............ Health Care Issues for Children and Adolescents in Foster Care and Kinship Care......................................... Health Care Issues for Children and Adolescents in Foster Care and Kinship Care (Technical Report)........ Health Care of Youth Aging Out of Foster Care..................... Health Care Supervision for Children With Williams Syndrome........................................................... Health Equity and Children’s Rights........................................ Health Information Technology and the Medical Home....... Health Supervision for Children With Achondroplasia........ Health Supervision for Children With Down Syndrome......

1247 1248 1248 1248 1248 1248 1248 1249 1249 1249 1249 1249

See Appendix 1.

Health Supervision for Children With Fragile X Syndrome............................................................................ Health Supervision for Children With Marfan Syndrome............................................................................ Health Supervision for Children With Neurofibromatosis............................................................. Health Supervision for Children With Prader-Willi Syndrome............................................................................ Health Supervision for Children With Sickle Cell Disease........................................................................ Hearing Assessment in Infants and Children: Recommendations Beyond Neonatal Screening...........

1249 1250 1250 1250 1250 1250

See Appendix 1.

Helping Children and Families Deal With Divorce and Separation................................................................... High-Deductible Health Plans................................................... HIV Testing and Prophylaxis to Prevent Mother-toChild Transmission in the United States....................... Home, Hospital, and Other Non–School-based Instruction for Children and Adolescents Who Are Medically Unable to Attend School.............. Home Care of Children and Youth With Complex Health Care Needs and Technology Dependencies..................................................................... Honoring Do-Not-Attempt-Resuscitation Requests in Schools............................................................................ Hospital Discharge of the High-Risk Neonate........................ The Hospital Record of the Injured Child and the  Need for External Cause-of-Injury Codes .................... Hospital Stay for Healthy Term Newborn Infants................. Human Embryonic Stem Cell (hESC) and Human Embryo Research............................................................... Human Immunodeficiency Virus and Other Blood-borne Viral Pathogens in the Athletic Setting ................................................................. Hypothermia and Neonatal Encephalopathy.........................

1250 1250 1251 1251 1251 1251 1251 1252 1252 1252 1252 1252

XII

TABLE OF CONTENTS

Identification and Care of HIV-Exposed and HIV-Infected Infants, Children, and Adolescents in Foster Care .................................................................... 1252 Identification and Evaluation of Children With Autism Spectrum Disorders............................................ 1252 See Appendix 1.

Identification and Management of Eating Disorders in Children and Adolescents........................................... 1253 Identifying Infants and Young Children With Developmental Disorders in the Medical Home: An Algorithm for Developmental Surveillance and Screening ............................................. 1253 See Appendix 1.

Immersion in Water During Labor and Delivery................... Immunization for Streptococcus pneumoniae Infections in High-Risk Children...................................................... Immunization Information Systems ........................................ Immunizing Parents and Other Close Family Contacts in the Pediatric Office Setting.......................................... The Impact of Marijuana Policies on Youth: Clinical, Research, and Legal Update............................................ The Impact of Marijuana Policies on Youth: Clinical, Research, and Legal Update (Technical Report)........... The Impact of Social Media on Children, Adolescents, and Families....................................................................... The Importance of Play in Promoting Healthy Child Development and Maintaining Strong ParentChild Bond: Focus on Children in Poverty................... Incidental Findings on Brain and Spine Imaging in Children.......................................................................... Incorporating Recognition and Management of Perinatal and Postpartum Depression Into Pediatric Practice............................................................... Increasing Antiretroviral Drug Access for Children With HIV Infection............................................................ Increasing Immunization Coverage.......................................... The Individuals With Disabilities Education Act (IDEA) for Children With Special Educational Needs............................................................ Indoor Environmental Control Practices and Asthma Management....................................................... Infant Feeding and Transmission of Human Immunodeficiency Virus in the United States.............. Infant Methemoglobinemia: The Role of Dietary Nitrate in Food and Water............................................... Infection Prevention and Control in Pediatric Ambulatory Settings......................................................... Infectious Complications With the Use of Biologic Response Modifiers in Infants and Children................ Infectious Diseases Associated With Organized Sports and Outbreak Control....................................................... Influenza Immunization for All Health Care Personnel: Keep It Mandatory........................................ Informed Consent in Decision-Making in Pediatric Practice .............................................................. Informed Consent in Decision-Making in Pediatric Practice (Technical Report)..............................................

1253 1253 1254 1254 1254 1254 1254 1254 1255 1255 1255 1255 1256 1256 1256

Injuries Associated With Infant Walkers.................................. Injuries in Youth Soccer............................................................... Injury Risk of Nonpowder Guns............................................... In-line Skating Injuries in Children and Adolescents............ Institutional Ethics Committees................................................. Instrument-Based Pediatric Vision Screening Policy Statement................................................................ Insufficient Sleep in Adolescents and Young Adults: An Update on Causes and Consequences..................................................................... Insurance Coverage of Mental Health and Substance Abuse Services for Children and Adolescents: A Consensus Statement.................................................... Intensive Training and Sports Specialization in Young Athletes .................................................................. Interferon-γ Release Assays for Diagnosis of Tuberculosis Infection and Disease in Children........... Intimate Partner Violence: The Role of the Pediatrician........ Iodine Deficiency, Pollutant Chemicals, and the Thyroid: New Information on an Old Problem............ Lactose Intolerance in Infants, Children, and Adolescents........................................................................ “Late-Preterm” Infants: A Population at Risk......................... Lawn Mower-Related Injuries to Children.............................. Lawn Mower-Related Injuries to Children (Technical Report)............................................................. Learning Disabilities, Dyslexia, and Vision............................. Learning Disabilities, Dyslexia, and Vision (Technical Report)............................................................. Levels of Neonatal Care.............................................................. The Lifelong Effects of Early Childhood Adversity and Toxic Stress................................................................. Literacy Promotion: An Essential Component of Primary Care Pediatric Practice...................................... Long-term Follow-up Care for Pediatric Cancer Survivors............................................................................. Maintaining and Improving the Oral Health of Young Children.................................................................. Male Adolescent Sexual and Reproductive Health Care....... Male Circumcision....................................................................... Maltreatment of Children With Disabilities............................. Management of Children With Autism Spectrum Disorders.............................................................................

1257 1258 1258 1258 1258 1258 1258 1259 1259 1259 1259 1259 1259 1260 1260 1260 1260 1260 1260 1260 1261 1261 1261 1261 1262 1262 1263

See Appendix 1.

1256 1256 1257 1257 1257 1257 1257

Management of Dental Trauma in a Primary Care Setting........................................................................ Management of Food Allergy in the School Setting............... Management of Neonates With Suspected or Proven Early-Onset Bacterial Sepsis............................................ Management of Pediatric Trauma ............................................ Management of Type 2 Diabetes Mellitus in Children and Adolescents.................................................................

1263 1263 1263 1263 1263

See Appendix 1.

Maternal Phenylketonuria.......................................................... 1264 Maternal-Fetal Intervention and Fetal Care Centers.............. 1264

PEDIATRIC CLINICAL PRACTICE GUIDELINES & POLICIES

Media and Young Minds ........................................................... Media Education.......................................................................... Media Use in School-Aged Children and Adolescents.......... Mediators and Adverse Effects of Child Poverty in the United States............................................................... Medicaid Policy Statement......................................................... Medical Conditions Affecting Sports Participation................ Medical Countermeasures for Children in Public Health Emergencies, Disasters, or Terrorism ............... Medical Emergencies Occurring at School.............................. The Medical Home...................................................................... Medical Staff Appointment and Delineation of Pediatric Privileges in Hospitals..................................... Medical Versus Nonmedical Immunization Exemptions for Child Care and School Attendance ........................................................................ Medication-Assisted Treatment of Adolescents With Opioid Use Disorders ...................................................... Menstrual Management for Adolescents With Disabilities.......................................................................... The Metabolic Syndrome in Children and Adolescents: Shifting the Focus to Cardiometabolic Risk Factor Clustering............................................................... Metric Units and the Preferred Dosing of Orally Administered Liquid Medications................................. Mind-Body Therapies in Children and Youth......................... Minors as Living Solid-Organ Donors..................................... Model Contractual Language for Medical Necessity for Children........................................................................ Motor Delays: Early Identification and Evaluation................ The Need to Optimize Adolescent Immunization.................. Needs of Kinship Care Families and Pediatric Practice........ Neonatal Drug Withdrawal........................................................ A New Era in Quality Measurement: The Development and Application of Quality Measures............................ Newborn Screening Expands: Recommendations for Pediatricians and Medical Homes—Implications for the System....................................................................

XIII

1264 1264 1265 1265 1265 1265 1265 1266 1266 1266 1266 1266 1266 1267 1267 1267 1267 1267 1267 1268 1268 1268 1268 1268

See Appendix 1.

Newborn Screening for Biliary Atresia..................................... Nicotine and Tobacco as Substances of Abuse in Children and Adolescents................................................ Nondiscrimination in Pediatric Health Care........................... Nonemergency Acute Care: When It’s Not the Medical Home.................................................................... Noninitiation or Withdrawal of Intensive Care for High-Risk Newborns........................................................ Noninvasive Respiratory Support............................................. Nonoral Feeding for Children and Youth With Developmental or Acquired Disabilities....................... Nontherapeutic Use of Antimicrobial Agents in Animal Agriculture: Implications for Pediatrics............................................................................ Office-Based Care for Lesbian, Gay, Bisexual, Transgender, and Questioning Youth.............................

1269 1269 1269 1269 1269 1269 1270 1270 1270

Office-Based Care for Lesbian, Gay, Bisexual, Transgender, and Questioning Youth (Technical Report)............................................................. Office-Based Counseling for Unintentional Injury Prevention........................................................................... Off-Label Use of Drugs in Children.......................................... Off-Label Use of Medical Devices in Children........................ Ophthalmologic Examinations in Children With Juvenile Rheumatoid Arthritis ....................................... Optimizing Bone Health in Children and Adolescents......... Options Counseling for the Pregnant Adolescent Patient................................................................................. Oral and Dental Aspects of Child Abuse and Neglect.......... Oral Health Care for Children With Developmental Disabilities.......................................................................... Organic Foods: Health and Environmental Advantages and Disadvantages..................................... Organized Sports for Children and Preadolescents............... Out-of-Home Placement for Children and Adolescents With Disabilities.......................................... Out-of-Home Placement for Children and Adolescents With Disabilities—Addendum: Care Options for Children and Adolescents With Disabilities and Medical Complexity................... Out-of-School Suspension and Expulsion................................ Overcrowding Crisis in Our Nation’s Emergency Departments: Is Our Safety Net Unraveling?............... Overuse Injuries, Overtraining, and Burnout in Child and Adolescent Athletes........................................ Oxygen Targeting in Extremely Low Birth Weight Infants................................................................................. Pain Assessment and Treatment in Children With  Significant Impairment of the Central Nervous System................................................................. Parental Leave for Residents and Pediatric Training Programs............................................................. Parental Presence During Treatment of Ebola or Other Highly Consequential Infection........................... Parent-Provider-Community Partnerships: Optimizing Outcomes for Children With Disabilities................................................................ Patent Ductus Arteriosus in Preterm Infants........................... Patient- and Family-Centered Care and the Pediatrician’s Role............................................................. Patient- and Family-Centered Care and the Role of the Emergency Physician Providing Care to a Child in the Emergency Department...................... Patient- and Family-Centered Care Coordination: A Framework for Integrating Care for Children and Youth Across Multiple Systems............................... Patient- and Family-Centered Care of Children in the Emergency Department............................................. Patient Safety in the Pediatric Emergency Care Setting........ Pedestrian Safety.......................................................................... Pediatric and Adolescent Mental Health Emergencies in the Emergency Medical Services System.................. Pediatric Anthrax Clinical Management.................................. Pediatric Anthrax Clinical Management: Executive Summary..........................................................

1270 1270 1271 1271 1271 1271 1271 1271 1272 1272 1272 1272

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XIV

Pediatric Aspects of Inpatient Health Information Technology Systems.......................................................... Pediatric Fellowship Training.................................................... Pediatric Integrative Medicine................................................... Pediatric Mental Health Emergencies in the Emergency Medical Services System ............................ Pediatric Observation Units....................................................... Pediatric Organ Donation and Transplantation...................... Pediatric Palliative Care and Hospice Care Commitments, Guidelines, and Recommendations............................................................. Pediatric Primary Health Care................................................... Pediatric Sudden Cardiac Arrest............................................... The Pediatrician and Childhood Bereavement....................... The Pediatrician Workforce: Current Status and Future Prospects................................................................ Pediatrician Workforce Policy Statement................................. Pediatrician-Family-Patient Relationships: Managing the Boundaries................................................................... The Pediatrician’s Role in Child Maltreatment Prevention........................................................................... The Pediatrician’s Role in Family Support and Family Support Programs............................................................. The Pediatrician’s Role in Optimizing School Readiness .............................................................. The Pediatrician’s Role in Supporting Adoptive Families............................................................. The Pediatrician’s Role in the Evaluation and Preparation of Pediatric Patients Undergoing Anesthesia.................................................... The Pediatrician’s Role in the Prevention of Missing Children............................................................... Personal Watercraft Use by Children and Adolescents ........ Pesticide Exposure in Children.................................................. Pesticide Exposure in Children (Technical Report)................ Phototherapy to Prevent Severe Neonatal Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation....................................... Physician Health and Wellness.................................................. Physician Refusal to Provide Information or Treatment on the Basis of Claims of Conscience.......... Physicians’ Roles in Coordinating Care of Hospitalized Children...................................................... Planned Home Birth.................................................................... Point-of-Care Ultrasonography by Pediatric Emergency Medicine Physicians.................................... Point-of-Care Ultrasonography by Pediatric Emergency Medicine Physicians (Technical Report)....... Postdischarge Follow-up of Infants With Congenital Diaphragmatic Hernia...................................................... Postnatal Corticosteroids to Prevent or Treat  Bronchopulmonary Dysplasia......................................... Postnatal Glucose Homeostasis in Late-Preterm and Term Infants....................................................................... Poverty and Child Health in the United States ..................... Practical Approaches to Optimize Adolescent Immunization.....................................................................

TABLE OF CONTENTS

1276 1277 1277 1277 1277 1277 1277 1278 1278 1278 1278 1278 1279 1279 1279 1279 1279 1279 1280 1280 1280 1280 1280 1281 1281 1281 1281 1281 1282 1282 1282 1282 1282 1282

Premedication for Nonemergency Endotracheal Intubation in the Neonate................................................ Prenatal Substance Abuse: Short- and Long-term Effects on the Exposed Fetus........................................... The Prenatal Visit......................................................................... Preparation for Emergencies in the Offices of Pediatricians and Pediatric Primary Care Providers................................................................... Preparing for Pediatric Emergencies: Drugs to Consider..... Prescribing Assistive-Technology Systems: Focus on Children With Impaired Communication..................... Prescribing Therapy Services for Children With Motor Disabilities.............................................................. Preservation of Fertility in Pediatric and Adolescent Patients With Cancer........................................................ Preventing and Treating Homesickness................................... Preventing Obesity and Eating Disorders in Adolescents........................................................................ Prevention and Management of Procedural Pain in the Neonate: An Update ................................................. Prevention of Agricultural Injuries Among Children and Adolescents................................................................. Prevention of Childhood Lead Toxicity .................................. Prevention of Choking Among Children................................. Prevention of Drowning............................................................. Prevention of Drowning (Technical Report)............................ Prevention of Sexual Harassment in the Workplace and Educational Settings ................................................. The Prevention of Unintentional Injury Among American Indian and Alaska Native Children: A Subject Review............................................................... The Primary Care Pediatrician and the Care of Children With Cleft Lip and/or Cleft Palate................ Principles of Child Health Care Financing.............................. Principles of Pediatric Patient Safety: Reducing Harm Due to Medical Care.............................................. Probiotics and Prebiotics in Pediatrics..................................... Procedures for the Evaluation of the Visual System by Pediatricians................................................... Professional Liability Insurance and Medicolegal Education for Pediatric Residents and Fellows............ Professionalism in Pediatrics..................................................... Professionalism in Pediatrics: Statement of Principles.......... Promoting Education, Mentorship, and Support for Pediatric Research....................................................... Promoting Food Security for All Children............................... Promoting Optimal Development: Screening for  Behavioral and Emotional Problems.............................. Promoting the Participation of Children With Disabilities in Sports, Recreation, and Physical Activities............................................................. Promoting the Well-Being of Children Whose Parents Are Gay or Lesbian........................................................... Promoting the Well-Being of Children Whose Parents Are Gay or Lesbian (Technical Report).......................... Promotion of Healthy Weight-Control Practices in Young Athletes...................................................................

1283 1283 1283 1283 1283 1283 1284 1284 1284 1284 1284 1284 1284 1285 1285 1285 1285 1285 1285 1286 1286 1286 1287 1287 1287 1287 1287 1287 1287 1288 1288 1288 1288

PEDIATRIC CLINICAL PRACTICE GUIDELINES & POLICIES

Protecting Children From Sexual Abuse by Health Care Providers................................................................... Protecting Children From Tobacco, Nicotine, and Tobacco Smoke................................................................... Protective Eyewear for Young Athletes.................................... Providing a Primary Care Medical Home for Children and Youth With Cerebral Palsy....................................... Providing a Primary Care Medical Home for Children and Youth With Spina Bifida........................................... Providing Care for Children and Adolescents Facing Homelessness and Housing Insecurity.......................... Providing Care for Immigrant, Migrant, and Border Children................................................................. Providing Psychosocial Support to Children and Families in the Aftermath of Disasters and Crises........................................................................... Provision of Educationally Related Services for Children and Adolescents With Chronic Diseases and Disabling Conditions................................ Psychological Maltreatment....................................................... Psychosocial Implications of Disaster or Terrorism on Children: A Guide for the Pediatrician.................... Psychosocial Support for Youth Living With HIV.................. A Public Health Response to Opioid Use in Pregnancy........ Public Policy to Protect Children From Tobacco, Nicotine, and Tobacco Smoke......................................... Quality Early Education and Child Care From Birth to Kindergarten.................................................................. Race, Ethnicity, and Socioeconomic Status in Research on Child Health................................................ Racial and Ethnic Disparities in the Health and Health Care of Children................................................... Radiation Disasters and Children ............................................ Radiation Risk to Children From Computed Tomography....................................................................... Recognition and Management of Iatrogenically Induced Opioid Dependence and Withdrawal in Children.......................................................................... Recognition and Management of Medical Complexity......... Recognizing and Responding to Medical Neglect.................. Recommendations for Prevention and Control of Influenza in Children, 2017–2018....................................

XV

1288 1289 1289 1289 1289 1289 1289 1289 1290 1290 1290 1290 1291 1291 1291 1291 1291 1292 1292 1292 1292 1293 1293

See Appendix 1.

Recommendations for Serogroup B Meningococcal Vaccine for Persons 10 Years and Older........................ Recommended Childhood and Adolescent Immunization Schedule—United States, 2018.............. Reducing Injury Risk From Body Checking in Boys’ Youth Ice Hockey.............................................................. Reducing the Number of Deaths and Injuries From Residential Fires ............................................................... Referral to Pediatric Surgical Specialists.................................. Reimbursement for Foods for Special Dietary Use ............... Relief of Pain and Anxiety in Pediatric Patients in Emergency Medical Systems........................................... Rescue Medicine for Epilepsy in Education Settings............. Respiratory Support in Preterm Infants at Birth.....................

1293 1293 1293 1294 1294 1294 1294 1294 1294

Responding to Parental Refusals of Immunization of Children.......................................................................... Responsible Innovation in Children’s Surgical Care.............. Returning to Learning Following a Concussion..................... Ritual Genital Cutting of Female Minors................................. Role of Pediatricians in Advocating Life Support Training Courses for Parents and the Public................ Role of Pediatricians in Advocating Life Support Training Courses for Parents and the Public (Technical Report)............................................................. Role of Pulse Oximetry in Examining Newborns for Congenital Heart Disease: A Scientific Statement from the AHA and AAP................................ The Role of the Pediatrician in Primary Prevention of Obesity............................................................................ The Role of the Pediatrician in Rural Emergency Medical Services for Children......................................... Role of the Pediatrician in Youth Violence Prevention.......... Role of the School Nurse in Providing School Health Services ................................................................. Role of the School Physician...................................................... Safe Sleep and Skin-to-Skin Care in the Neonatal  Period for Healthy Term Newborns............................... Safe Transportation of Newborns at Hospital Discharge...... Safe Transportation of Preterm and Low Birth Weight Infants at Hospital Discharge.......................................... School Bus Transportation of Children With Special Health Care Needs ........................................................... School Health Assessments ....................................................... School Readiness.......................................................................... School Start Times for Adolescents........................................... School Transportation Safety...................................................... School-Based Health Centers and Pediatric Practice............. Scope of Health Care Benefits for Children From Birth Through Age 26................................................................. Scope of Practice Issues in the Delivery of Pediatric Health Care........................................................................ Screening Examination of Premature Infants for  Retinopathy of Prematurity............................................. Screening for Nonviral Sexually Transmitted Infections in Adolescents and Young Adults.................................. Screening for Retinopathy in the Pediatric Patient With Type 1 Diabetes Mellitus........................................ Secondhand and Prenatal Tobacco Smoke Exposure............. Selecting Appropriate Toys for Young Children: The Pediatrician’s Role..................................................... Sensory Integration Therapies for Children With Developmental and Behavioral Disorders.................... Sexual and Reproductive Health Care Services in the Pediatric Setting.......................................................... Sexuality Education for Children and Adolescents................ Sexuality of Children and Adolescents With Developmental Disabilities.............................................. Shared Decision-Making and Children With Disabilities: Pathways to Consensus.............................. Shopping Cart–Related Injuries to Children .......................... Shopping Cart–Related Injuries to Children (Technical Report) ............................................................

1294 1295 1295 1295 1295 1295 1295 1296 1296 1296 1296 1296 1296 1297 1297 1297 1297 1297 1297 1297 1298 1298 1298 1298 1298 1298 1299 1299 1299 1299 1299 1300 1300 1300 1300

XVI

TABLE OF CONTENTS

SIDS and Other Sleep-Related Infant Deaths: Updated 2016 Recommendations for a Safe Infant Sleeping Environment ......................................... SIDS and Other Sleep-Related Infant Deaths: Evidence Base for 2016 Updated Recommendations for a Safe Infant Sleeping Environment...................................................... Skateboard and Scooter Injuries................................................ Skin-to-Skin Care for Term and Preterm Infants in the Neonatal ICU............................................................... Snacks, Sweetened Beverages, Added Sugars, and Schools......................................................................... Snowmobiling Hazards............................................................... Special Requirements of Electronic Health Record Systems in Pediatrics........................................................ Spectrum of Noninfectious Health Effects From Molds........ Spectrum of Noninfectious Health Effects From Molds (Technical Report)............................................................. Sport-Related Concussion in Children and Adolescents....... Sports Drinks and Energy Drinks for Children and Adolescents: Are They Appropriate?............................. Sports Specialization and Intensive Training in Young Athletes................................................................... Standard Terminology for Fetal, Infant, and Perinatal Deaths................................................................. Standardization of Inpatient Handoff Communication......... Standards for Health Information Technology to Ensure Adolescent Privacy.............................................. Standards for Pediatric Cancer Centers................................... Stigma Experienced by Children and Adolescents With Obesity...................................................................... Strategies for Prevention of Health Care–Associated Infections in the NICU..................................................... Strength Training by Children and Adolescents..................... Substance Use Screening, Brief Intervention, and Referral to Treatment........................................................ Substance Use Screening, Brief Intervention, and Referral to Treatment (Clinical Report).......................... Suicide and Suicide Attempts in Adolescents......................... Supplemental Security Income (SSI) for Children and Youth With Disabilities............................................. Supporting the Family After the Death of a Child................. Supporting the Grieving Child and Family............................. Supporting the Health Care Transition From Adolescence to Adulthood in the Medical Home........

1300

1301 1301 1301 1301 1301 1301 1302 1302 1302 1302 1302 1303 1303 1303 1303 1303 1303 1303 1304 1304 1304 1304 1304 1304 1305

See Appendix 1.

Surfactant Replacement Therapy for Preterm and Term Neonates With Respiratory Distress.................... Tackling in Youth Football ......................................................... The Teen Driver ........................................................................... Telemedicine for Evaluation of Retinopathy of Prematurity........................................................................ Telemedicine: Pediatric Applications........................................ Testing for Drugs of Abuse in Children and Adolescents........................................................................ Tobacco Use: A Pediatric Disease..............................................

1305 1305 1305 1305 1305 1306 1306

Toward Transparent Clinical Policies....................................... Trampoline Safety in Childhood and Adolescence................ The Transfer of Drugs and Therapeutics Into Human Breast Milk: An Update on Selected Topics................................................................... Transitioning HIV-Infected Youth Into Adult Health Care........................................................................ Transporting Children With Special Health Care Needs....... The Treatment of Neurologically Impaired Children Using Patterning ............................................................... Ultraviolet Radiation: A Hazard to Children and Adolescents................................................................ Ultraviolet Radiation: A Hazard to Children and Adolescents (Technical Report)....................................... Umbilical Cord Care in the Newborn Infant........................... Underinsurance of Adolescents: Recommendations for Improved Coverage of Preventive, Reproductive, and Behavioral Health Care Services...................................................................... Understanding the Behavioral and Emotional Consequences of Child Abuse......................................... Update of Newborn Screening and Therapy for Congenital Hypothyroidism............................................ Updated Guidance for Palivizumab Prophylaxis Among Infants and Young Children at Increased Risk of Hospitalization for Respiratory Syncytial Virus Infection ...........................

1306 1306 1306 1307 1307 1307 1307 1307 1308

1308 1308 1308

1308

See Appendix 1.

Updated Guidance for Palivizumab Prophylaxis Among Infants and Young Children at Increased Risk of Hospitalization for Respiratory Syncytial Virus Infection (Technical Report)............................................................. 1309 See Appendix 1.

Updated Recommendations on the Use of Meningococcal Vaccines................................................... The Use and Misuse of Fruit Juice in Pediatrics..................... Use of Chaperones During the Physical Examination of the Pediatric Patient..................................................... The Use of Complementary and Alternative Medicine in Pediatrics........................................................................ Use of Inhaled Nitric Oxide....................................................... Use of Inhaled Nitric Oxide in Preterm Infants...................... Use of Performance-Enhancing Substances............................. Use of Soy Protein-Based Formulas in Infant Feeding.......... The Use of Systemic and Topical Fluoroquinolones.............. The Use of Telemedicine to Address Access and Physician Workforce Shortages....................................... Ventricular Fibrillation and the Use of Automated External Defibrillators on Children................................ Virtual Violence ........................................................................... Visual System Assessment in Infants, Children, and Young Adults by Pediatricians........................................ WIC Program................................................................................

1309 1309 1309 1309 1309 1309 1310 1310 1310 1310 1310 1311 1311 1311

PEDIATRIC CLINICAL PRACTICE GUIDELINES & POLICIES

Withholding or Termination of Resuscitation in Pediatric Out-of-Hospital Traumatic Cardiopulmonary Arrest.................................................. 1311 Year 2007 Position Statement: Principles and Guidelines for Early Hearing Detection and Intervention Programs ............................................. 1311 Youth Participation and Injury Risk in Martial Arts.............. 1311 SECTION 6 ENDORSED POLICIES 2015 SPCTPD/ACC/AAP/AHA Training Guidelines for Pediatric Cardiology Fellowship Programs (Revision of the 2005 Training Guidelines for Pediatric Cardiology Fellowship Programs)................. 1315 Advanced Practice Registered Nurse: Role, Preparation, and Scope of Practice................................. 1315 Antenatal Corticosteroid Therapy for Fetal Maturation.........1315 Appropriate Use Criteria for Initial Transthoracic Echocardiography in Outpatient Pediatric Cardiology.......................................................................... 1315 Best Practice for Infant Surgery: A Position Statement From the American Pediatric Surgical Association...... 1316 Cardiovascular Risk Reduction in High-Risk Pediatric Populations........................................................ 1316 Children’s Surgery Verification Pilot Draft Documents........ 1316 Collaboration in Practice: Implementing Team-Based Care .............................................................. 1316 Confidentiality Protections for Adolescents and Young Adults in the Health Care Billing and Insurance Claims Process ................................................ 1316 Consensus Communication on Early Peanut Introduction and the Prevention of Peanut Allergy in High-risk Infants............................................ 1316 Consensus Statement: Definitions for Consistent Emergency Department Metrics..................................... 1317 Consensus Statement on Management of Intersex Disorders............................................................. 1317 Defining Pediatric Malnutrition: A Paradigm Shift Toward Etiology-Related Definitions............................. 1317 Delayed Umbilical Cord Clamping After Birth...................... 1317 Diabetes Care for Emerging Adults: Recommendations for Transition From Pediatric to Adult Diabetes Care Systems...................................................................... 1317 Diagnosis, Treatment, and Long-Term Management of Kawasaki Disease: A Statement for Health Professionals....................................................................... 1317 Dietary Recommendations for Children and Adolescents: A Guide for Practitioners.......................... 1317 Dietary Reference Intakes for Calcium and Vitamin D......... 1318 Emergency Equipment and Supplies in the School Setting..................................................................... 1318 Enhancing the Work of the HHS National Vaccine Program in Global Immunizations................................. 1318 Ethical Consideration for Including Women as Research Participants........................................................ 1318 Evidence Report: Genetic and Metabolic Testing on Children With Global Developmental Delay.......... 1318 Evidence-Based Management of Sickle Cell Disease: Expert Panel Report, 2014................................................ 1318

XVII

Executing Juvenile Offenders: A Fundamental Failure of Society............................................................... Faculty Competencies for Global Health................................. Genetic Basis for Congenital Heart Defects: Current Knowledge.......................................................... Gifts to Physicians From Industry............................................ Guidelines for Field Triage of Injured Patients....................... Guidelines for Referral of Children and Adolescents to Pediatric Rheumatologists........................................... Helping the Student with Diabetes Succeed: A Guide for School Personnel......................................... Importance and Implementation of Training in Cardiopulmonary Resuscitation and Automated External Defibrillation in Schools.............. Inter-Association Consensus Statement on Best Practices for Sports Medicine Management for Secondary Schools and Colleges.............................. Long-term Cardiovascular Toxicity in Children, Adolescents, and Young Adults Who Receive Cancer Therapy: Pathophysiology, Course, Monitoring, Management, Prevention, and Research Directions; A Scientific Statement From the American Heart Association.......................... The Management of Hypotension in the Very-LowBirth-Weight Infant: Guideline for Practice.................. Meeting of the Strategic Advisory Group of Experts on Immunization, April 2012–Conclusions and Recommendations..................................................... Menstruation in Girls and Adolescents: Using the Menstrual Cycle as a Vital Sign ..................................... Multilingual Children: Beyond Myths and Toward Best Practices...................................................................... National Adoption Center: Open Records............................... Neonatal Encephalopathy and Neurologic Outcome, Second Edition................................................................... Neurodevelopmental Outcomes in Children With Congenital Heart Disease: Evaluation and Management; A Scientific Statement From the American Heart Association..................................... The Neurologist’s Role in Supporting Transition to Adult Health Care ....................................................... Noninherited Risk Factors and Congenital Cardiovascular Defects: Current Knowledge............... Orthoptists as Physician Extenders .......................................... A Practical Guide for Primary Care Physicians: Instrument-Based Vision Screening in Children.......... Prevention and Control of Meningococcal Disease: Recommendations of the Advisory Committee on Immunization Practices (ACIP) ................................ Protecting Adolescents: Ensuring Access to Care and Reporting Sexual Activity and Abuse.................... Recommended Amount of Sleep for Pediatric Populations: A Consensus Statement of the American Academy of Sleep Medicine.......................... Report of the National Consensus ­Conference on Family Presence during Pediatric Cardio­pulmonary Resuscitation and  Procedures..........................................................................

1318 1318 1318 1318 1318 1318 1319 1319 1319

1319 1319 1319 1319 1319 1319 1320

1320 1320 1320 1320 1320 1321 1321 1321

1321

XVIII

Response to Cardiac Arrest and Selected LifeThreatening Medical Emergencies: The Medical Emergency Response Plan for Schools. A Statement for Healthcare Providers, Policymakers, School Administrators, and Community Leaders......................................................... Screening for Idiopathic Scoliosis in Adolescents— Position Statement............................................................. Skiing and Snowboarding Injury Prevention.......................... Supplement to the JCIH 2007 Position Statement: Principles and Guidelines for Early Intervention After Confirmation That a Child Is Deaf or Hard of Hearing................................................................ Systematic Review and Evidence-Based Guidelines for the Management of Patients With Positional Plagiocephaly ................................................. Timing of Umbilical Cord Clamping After Birth.................... Weighing All Patients in Kilograms..........................................

TABLE OF CONTENTS

APPENDIX 1 PPI: AAP PARTNERSHIP FOR POLICY IMPLEMENTATION...................................................................1325 1321 1322 1322

1322 1323 1323 1323

APPENDIX 2 AMERICAN ACADEMY OF PEDIATRICS ACRONYMS.................................................................................1327 Subject Index............................................................................... 1331

1

Section 1

Clinical Practice Guidelines From the American Academy of Pediatrics



• Clinical Practice Guidelines

EVIDENCE-BASED DECISION-MAKING TOOLS FOR MANAGING COMMON PEDIATRIC CONDITIONS

• Quick Reference Tools

TOOLS FOR IMPLEMENTING AMERICAN ACADEMY OF PEDIATRICS GUIDELINES IN YOUR PRACTICE AND AT THE POINT OF CARE

3

FOREWORD To promote the practice of evidence-based medicine, the American Academy of Pediatrics (AAP) p ­ rovides physicians with evidence-based guidelines for managing common pediatric conditions. The AAP has an established organizational process and methodology for the development of these clinical practice guidelines. The evidence-based approach to developing clinical practice guidelines requires systematically defining the problem and identifying interventions and health outcomes. Extensive literature reviews and data syntheses provide the basis for guideline recommendations. Clinical practice guidelines also undergo a thorough peer-review process prior to publication and are periodically reviewed to ensure that they are based on the most current data available. American Academy of Pediatrics clinical practice guidelines are designed to provide physicians with an analytic framework for evaluating and treating common pediatric conditions and are not intended as an exclusive course of treatment or standard of care. When using AAP clinical practice guidelines, physicians should continue to consider other sources of information as well as variations in individual circumstances. The AAP recognizes circumstances in which there is a lack of definitive data and relies on expert consensus in cases in which data do not exist. American Academy of Pediatrics clinical practice guidelines allow for flexibility and adaptability at the local level and should not replace sound clinical judgment. This manual contains clinical practice guidelines, technical reports, and technical report summaries developed and published by the AAP. Each one contains a summary of data reviewed, results of data analysis, complete evidence tables, and a bibliography of articles included in the review. This manual also contains abstracts and introductions for evidence-based clinical practice guidelines from other organizations that the AAP has endorsed. The AAP is committed to systematically evaluating these documents and disseminating appropriate documents to its membership. Clinical practice guidelines will continually be added to this compendium as they are released or updated. We encourage you to look forward to these future guidelines. Additionally, this edition includes the full text of all policy statements, clinical reports, and technical reports published in 2017 by the AAP as well as abstracts of all active AAP and endorsed policy statements and reports. Policy statements, where possible, should include the quality of evidence and strength of recommendations using a generally acceptable grading system. Both intellectual transparency and financial transparency are essential and should appear in all clinical practice guidelines, as well as policy statements, clinical reports, and technical reports. The companion eBook points to all active AAP and endorsed policy statements and reports published prior to 2017. If you have any questions about current or future clinical practice guidelines, please contact Kymika Okechukwu, senior manager of evidence-based medicine initiatives at the AAP, at 630/626-6317 or via e-mail at [email protected] aap.org. To order copies of patient education resources that accompany each guideline, please call the AAP at 866/843-2271 or visit http://shop.aap.org/books. Wayne H. Franklin, MD, MPH, MMM, FAAP Chairperson, Council on Quality Improvement and Patient Safety

5

ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents •  Clinical Practice Guideline – PPI: AAP Partnership for Policy Implementation See Appendix 1 for more information.

FROM THE AMERICAN ACADEMY OF PEDIATRICS 7 Guidance for the Clinician in Rendering Pediatric Care

CLINICAL PRACTICE GUIDELINE

ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/ Hyperactivity Disorder in Children and Adolescents SUBCOMMITTEE ON ATTENTION-DEFICIT/HYPERACTIVITY DISORDER, STEERING COMMITTEE ON QUALITY IMPROVEMENT AND MANAGEMENT KEY WORDS attention-deficit/hyperactivity disorder, children, adolescents, preschool, behavioral therapy, medication ABBREVIATIONS AAP—American Academy of Pediatrics ADHD—attention-deficit/hyperactivity disorder DSM-PC—Diagnostic and Statistical Manual for Primary Care CDC—Centers for Disease Control and Prevention FDA—Food and Drug Administration DSM-IV—Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition MTA—Multimodal Therapy of ADHD This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication. The recommendations in this report do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

www.pediatrics.org/cgi/doi/10.1542/peds.2011-2654 doi:10.1542/peds.2011-2654 All clinical practice guidelines from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time. PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2011 by the American Academy of Pediatrics

PEDIATRICS Volume 128, Number 5, November 2011

abstract

+

Attention-deficit/hyperactivity disorder (ADHD) is the most common neurobehavioral disorder of childhood and can profoundly affect the academic achievement, well-being, and social interactions of children; the American Academy of Pediatrics first published clinical recommendations for the diagnosis and evaluation of ADHD in children in 2000; recommendations for treatment followed in 2001. Pediatrics 2011;128: 1007–1022 Summary of key action statements: 1. The primary care clinician should initiate an evaluation for ADHD for any child 4 through 18 years of age who presents with academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity (quality of evidence B/strong recommendation). 2. To make a diagnosis of ADHD, the primary care clinician should determine that Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria have been met (including documentation of impairment in more than 1 major setting); information should be obtained primarily from reports from parents or guardians, teachers, and other school and mental health clinicians involved in the child’s care. The primary care clinician should also rule out any alternative cause (quality of evidence B/strong recommendation). 3. In the evaluation of a child for ADHD, the primary care clinician should include assessment for other conditions that might coexist with ADHD, including emotional or behavioral (eg, anxiety, depressive, oppositional defiant, and conduct disorders), developmental (eg, learning and language disorders or other neurodevelopmental disorders), and physical (eg, tics, sleep apnea) conditions (quality of evidence B/strong recommendation). 4. The primary care clinician should recognize ADHD as a chronic condition and, therefore, consider children and adolescents with ADHD as children and youth with special health care needs. Management of children and youth with special health care needs should follow the principles of the chronic care model and the medical home (quality of evidence B/strong recommendation). 1007

8

SECTION 1/CLINICAL PRACTICE GUIDELINES

5. Recommendations for treatment of children and youth with ADHD vary depending on the patient’s age: a. For preschool-aged children (4–5 years of age), the primary care clinician should prescribe evidence-based parent- and/or teacher-administered behavior therapy as the first line of treatment (quality of evidence A/strong recommendation) and may prescribe methylphenidate if the behavior interventions do not provide significant improvement and there is moderate-tosevere continuing disturbance in the child’s function. In areas where evidence-based behavioral treatments are not available, the clinician needs to weigh the risks of starting medication at an early age against the harm of delaying diagnosis and treatment (quality of evidence B/recommendation). b. For elementary school–aged children (6–11 years of age), the primary care clinician should prescribe US Food and Drug Administration–approved medications for ADHD (quality of evidence A/strong recommendation) and/or evidence-based parentand/or teacher-administered behavior therapy as treatment for ADHD, preferably both (quality of evidence B/strong recommendation). The evidence is particularly strong for stimulant medications and sufficient but less strong for atomoxetine, extended-release guanfacine, and extended-release clonidine (in that order) (quality of evidence A/strong recommendation). The school environment, program, or placement is a part of any treatment plan. c. For adolescents (12–18 years of age), the primary care clinician 1008

FROM THE AMERICAN ACADEMY OF PEDIATRICS

should prescribe Food and Drug Administration–approved medications for ADHD with the assent of the adolescent (quality of evidence A/strong recommendation) and may prescribe behavior therapy as treatment for ADHD (quality of evidence C/recommendation), preferably both. 6. The primary care clinician should titrate doses of medication for ADHD to achieve maximum benefit with minimum adverse effects (quality of evidence B/strong recommendation).

INTRODUCTION This document updates and replaces 2 previously published clinical guidelines from the American Academy of Pediatrics (AAP) on the diagnosis and treatment of attention-deficit/hyperactivity disorder (ADHD) in children: “Clinical Practice Guideline: Diagnosis and Evaluation of the Child With Attention-Deficit/Hyperactivity Disorder” 1 (2000) and “Clinical Practice Guideline: Treatment of the School-aged Child With Attention-Deficit/Hyperactivity Disorder” (2001).2 Since these guidelines were published, new information and evidence regarding the diagnosis and treatment of ADHD has become available. Surveys conducted before and after the publication of the previous guidelines have also provided insight into pediatricians’ attitudes and practices regarding ADHD. On the basis of an increased understanding regarding ADHD and the challenges it raises for children and families and as a source for clinicians seeking to diagnose and treat children, this guideline pays particular attention to a number of areas. Expanded Age Range The previous guidelines addressed diagnosis and treatment of ADHD in chil-

dren 6 through 12 years of age. There is now emerging evidence to expand the age range of the recommendations to include preschool-aged children and adolescents. This guideline addresses the diagnosis and treatment of ADHD in children 4 through 18 years of age, and attention is brought to special circumstances or concerns in particular age groups when appropriate. Expanded Scope Behavioral interventions might help families of children with hyperactive/ impulsive behaviors that do not meet full diagnostic criteria for ADHD. Guidance regarding the diagnosis of problem-level concerns in children based on the Diagnostic and Statistical Manual for Primary Care (DSM-PC), Child and Adolescent Version,3 as well as suggestions for treatment and care of children and families with problemlevel concerns, are provided here. The current DSM-PC was published in 1996 and, therefore, is not consistent with intervening changes to International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). Although this version of the DSM-PC should not be used as a definitive source for diagnostic codes related to ADHD and comorbid conditions, it certainly may continue to be used as a resource for enriching the understanding of ADHD manifestations. The DSM-PC will be revised when both the DSM-V and ICD-10 are available for use. A Process of Care for Diagnosis and Treatment This guideline and process-of-care algorithm (see Supplemental Fig 2 and Supplemental Appendix) recognizes evaluation, diagnosis, and treatment as a continuous process and provides recommendations for both the guideline and the algorithm in this single publication. In addition to the formal recommendations for assessment, diagnosis, and treatment, this guideline

FROM THE AMERICAN ACADEMY OF PEDIATRICS

ADHD: DIAGNOSIS AND EVALUATION OF ATTENTION-DEFICIT/HYPERACTIVITY DISORDER IN CHILDREN AND ADOLESCENTS

provides a single algorithm to guide the clinical process.

are beyond the scope of this guideline but are important to consider.

Integration With the Task Force on Mental Health

METHODOLOGY

This guideline fits into the broader mission of the AAP Task Force on Mental Health and its efforts to provide a base from which primary care providers can develop alliances with families, work to prevent mental health conditions and identify them early, and collaborate with mental health clinicians. The diagnosis and management of ADHD in children and youth has been particularly challenging for primary care clinicians because of the limited payment provided for what requires more time than most of the other conditions they typically address. The procedures recommended in this guideline necessitate spending more time with patients and families, developing a system of contacts with school and other personnel, and providing continuous, coordinated care, all of which is time demanding. In addition, relegating mental health conditions exclusively to mental health clinicians also is not a viable solution for many clinicians, because in many areas access to mental health clinicians to whom they can refer patients is limited. Access in many areas is also limited to psychologists when further assessment of cognitive issues is required and not available through the education system because of restrictions from third-party payers in paying for the evaluations on the basis of them being educational and not health related. Cultural differences in the diagnosis and treatment of ADHD are an important issue, as they are for all pediatric conditions. Because the diagnosis and treatment of ADHD depends to a great extent on family and teacher perceptions, these issues might be even more prominent an issue for ADHD. Specific cultural issues PEDIATRICS Volume 128, Number 5, November 2011

As with the 2 previously published clinical guidelines, the AAP collaborated with several organizations to develop a working subcommittee that represented a wide range of primary care and subspecialty groups. The subcommittee included primary care pediatricians, developmental-behavioral pediatricians, and representatives from the American Academy of Child and Adolescent Psychiatry, the Child Neurology Society, the Society for Pediatric Psychology, the National Association of School Psychologists, the Society for Developmental and Behavioral Pediatrics, the American Academy of Family Physicians, and Children and Adults With Attention-Deficit/Hyperactivity Disorder (CHADD), as well as an epidemiologist from the Centers for Disease Control and Prevention (CDC). This group met over a 2-year period, during which it reviewed the changes in practice that have occurred and issues that have been identified since the previous guidelines were published. Delay in completing the process led to further conference calls and extended the years of literature reviewed in order to remain as current as possible. The AAP funded the development of this guideline; potential financial conflicts of the participants were identified and taken into consideration in the deliberations. The guideline will be reviewed and/or revised in 5 years unless new evidence emerges that warrants revision sooner. The subcommittee developed a series of research questions to direct an extensive evidence-based review in partnership with the CDC and the University of Oklahoma Health Sciences Center. The diagnostic review was conducted by the CDC, and the evidence was evaluated in a combined effort of

the AAP, CDC, and University of Oklahoma Health Sciences Center staff. The treatment-related evidence relied on a recent evidence review by the Agency for Healthcare Research and Quality and was supplemented by evidence identified through the CDC review. The diagnostic issues were focused on 5 areas: 1. ADHD prevalence—specifically: (a) What percentage of the general US population aged 21 years or younger has ADHD? (b) What percentage of patients presenting at pediatricians’ or family physicians’ offices in the United States meet diagnostic criteria for ADHD? 2. Co-occurring mental disorders— of people with ADHD, what percentage has 1 or more of the following co-occurring conditions: sleep disorders, learning disabilities, depression, anxiety, conduct disorder, and oppositional defiant disorder? 3. What are the functional impairments of children and youth diagnosed with ADHD? Specifically, in what domains and to what degree do youth with ADHD demonstrate impairments in functional domains, including peer relations, academic performance, adaptive skills, and family functioning? 4. Do behavior rating scales remain the standard of care in assessing the diagnostic criteria for ADHD? 5. What is the prevalence of abnormal findings on selected medical screening tests commonly recommended as standard components of an evaluation of a child with suspected ADHD? How accurate are these tests in the diagnosis of ADHD compared with a reference standard (ie, what are the psychometric properties of these tests)? The treatment issues were focused on 3 areas: 1. What new information is available 1009

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regarding the long-term efficacy and safety of medications approved by the US Food and Drug Administration (FDA) for the treatment of ADHD (stimulants and nonstimulants), and specifically, what information is available about the efficacy and safety of these medications in preschool-aged and adolescent patients? 2. What evidence is available about the long-term efficacy and safety of psychosocial interventions (behavioral modification) for the treatment of ADHD for children, and specifically, what information is available about the efficacy and safety of these interventions in preschool-aged and adolescent patients? 3. Are there any additional therapies that reach the level of consideration as evidence based? Evidence-Review Process for Diagnosis A multilevel, systematic approach was taken to identify the literature that built the evidence base for both diagnosis and treatment. To increase the likelihood that relevant articles were included in the final evidence base, the reviewers first conducted a scoping review of the literature by systematically searching literature using relevant key words and then summarized the primary findings of articles that met standard inclusion criteria. The reviewers then created evidence tables that were reviewed by contentarea experts who were best able to identify articles that might have been missed through the scoping review. Articles that were missed were reviewed carefully to determine where the abstraction methodology failed, and adjustments to the search strategy were made as required (see technical report to be published). Finally, although published literature reviews did not contribute directly to the evidence 1010

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base, the articles included in review articles were cross-referenced with the final evidence tables to ensure that all relevant articles were included in the final evidence tables. For the scoping review, articles were abstracted in a stratified fashion from 3 article-retrieval systems that provided access to articles in the domains of medicine, psychology, and education: PubMed (www.ncbi.nlm.nih.gov/ sites/entrez), PsycINFO (www.apa.org/ pubs/databases/psycinfo/index.aspx), and ERIC (www.eric.ed.gov). Englishlanguage, peer-reviewed articles published between 1998 and 2009 were queried in the 3 search engines. Key words were selected with the intent of including all possible articles that might have been relevant to 1 or more of the questions of interest (see the technical report to be published). The primary abstraction included the following terms: “attention deficit hyperactivity disorder” or “attention deficit disorder” or “hyperkinesis” and “child.” A second, independent abstraction was conducted to identify articles related to medical screening tests for ADHD. For this abstraction, the same search terms were used as in the previous procedure along with the additional condition term “behavioral problems” to allow for the inclusion of studies of youth that sought to diagnose ADHD by using medical screening tests. Abstractions were conducted in parallel fashion across each of the 3 databases; the results from each abstraction (complete reference, abstract, and key words) were exported and compiled into a common reference database using EndNote 10.0.4 References were subsequently and systematically deduplicated by using the software’s deduplication procedure. References for books, chapters, and theses were also deleted from the library. Once a deduplicated library was developed, the semifinal

database of 8267 references was reviewed for inclusion on the basis of inclusion criteria listed in the technical report. Included articles were then pulled in their entirety, the inclusion criteria were reconfirmed, and then the study findings were summarized in evidence tables. The articles included in relevant review articles were revisited to ensure their inclusion in the final evidence base. The evidence tables were then presented to the committee for expert review. Evidence-Review Process for Treatment In addition to this systematic review, for treatment we used the review from the Agency for Healthcare Research and Quality (AHRQ) Effective Healthcare Program “Attention Deficit Hyperactivity Disorder: Effectiveness of Treatment in At-Risk Preschoolers; Long-term Effectiveness in All Ages; and Variability in Prevalence, Diagnosis, and Treatment.”5 This review addressed a number of key questions for the committee, including the efficacy of medications and behavioral interventions for preschoolers, children, and adolescents. Evidence identified through the systematic evidence review for diagnosis was also used as a secondary data source to supplement the evidence presented in the AHRQ report. The draft practice guidelines were developed by consensus of the committee regarding the evidence. It was decided to create 2 separate components. The guideline recommendations were based on clear characterization of the evidence. The second component is a practice-of-care algorithm (see Supplemental Fig 2) that provides considerably more detail about how to implement the guidelines but is, necessarily, based less on available evidence and more on consensus of the committee members. When data were lacking, particularly in the

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ADHD: DIAGNOSIS AND EVALUATION OF ATTENTION-DEFICIT/HYPERACTIVITY DISORDER IN CHILDREN AND ADOLESCENTS

oped and has been used in the revision of the AAP ADHD toolkit. Implementation: Preparing the Practice

FIGURE 1

Integrating evidence-quality appraisal with an assessment of the anticipated balance between benefits and harms if a policy is conducted leads to designation of a policy as a strong recommendation, recommendation, option, or no recommendation. The evidence is discussed in more detail in a technical report that will follow in a later publication. RCT indicates randomized controlled trial; Rec, recommendation.

process-of-care algorithmic portion of the guidelines, a combination of evidence and expert consensus was used. Action statements labeled “strong recommendation” or “recommendation” were based on high- to moderatequality scientific evidence and a preponderance of benefit over harm.6 Option-level action statements were based on lesser-quality or limited data and expert consensus or highquality evidence with a balance between benefits and harms. These clinical options are interventions that a reasonable health care provider might or might not wish to implement in his or her practice. The quality of evidence supporting each recommendation and the strength of each recommendation were assessed by the committee member most experienced in epidemiology and graded according to AAP policy (Fig 1).6 The guidelines and process-of-care algorithm underwent extensive peer review by committees, sections, councils, and task forces within the AAP; numerous outside organizations; and other individuals identified by the subcommittee. Liaisons to the subcommittee also were invited to distribute the draft to entities within their organizations. The rePEDIATRICS Volume 128, Number 5, November 2011

sulting comments were compiled and reviewed by the chairperson, and relevant changes were incorporated into the draft, which was then reviewed by the full committee.

ABOUT THIS GUIDELINE Key Action Statements In light of the concerns highlighted previously and informed by the available evidence, the AAP has developed 6 action statements for the evaluation, diagnosis, and treatment of ADHD in children. These action statements provide for consistent and quality care for children and families with concerns about or symptoms that suggest attention disorders or problems. Context This guideline is intended to be integrated with the broader algorithms developed as part of the mission of the AAP Task Force on Mental Health.7 Implementation: A Process-of-Care Algorithm The AAP recognizes the challenge of instituting practice changes and adopting new recommendations for care. To address the need, a processof-care algorithm has been devel-

Full implementation of the action statements described in this guideline and the process-of-care algorithm might require changes in office procedures and/or preparatory efforts to identify community resources. The section titled “Preparing the Practice” in the process-of-care algorithm and further information can be found in the supplement to the Task Force on Mental Health report.7 It is important to document all aspects of the diagnostic and treatment procedures in the patients’ records. Use of rating scales for the diagnosis of ADHD and assessment for comorbid conditions and as a method for monitoring treatment as described in the process algorithm (see Supplemental Fig 2), as well as information provided to parents such as management plans, can help facilitate a clinician’s accurate documentation of his or her process. Note The AAP acknowledges that some primary care clinicians might not be confident of their ability to successfully diagnose and treat ADHD in a child because of the child’s age, coexisting conditions, or other concerns. At any point at which a clinician feels that he or she is not adequately trained or is uncertain about making a diagnosis or continuing with treatment, a referral to a pediatric or mental health subspecialist should be made. If a diagnosis of ADHD or other condition is made by a subspecialist, the primary care clinician should develop a management strategy with the subspecialist that ensures that the child will continue to receive appropriate care consistent with a medical home model wherein the pediatrician part1011

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ners with parents so that both health and mental health needs are integrated.

● Role of patient preferences: Success

● Harms/risks/costs: The DSM-IV sys-

with treatment depends on patient and family preference, which has to be taken into account.

tem does not specifically provide for developmental-level differences and might lead to some misdiagnoses.

KEY ACTION STATEMENTS FOR THE EVALUATION, DIAGNOSIS, TREATMENT, AND MONITORING OF ADHD IN CHILDREN AND ADOLESCENTS

● Exclusions: None.

Action statement 1: The primary care clinician should initiate an evaluation for ADHD for any child 4 through 18 years of age who presents with academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity (quality of evidence B/strong recommendation). Evidence Profile ● Aggregate evidence quality: B. ● Benefits: In a considerable number of

children, ADHD goes undiagnosed. Primary care clinicians’ systematic identification of children with these problems will likely decrease the rate of undiagnosed and untreated ADHD in children. ● Harms/risks/costs: Children in whom

ADHD is inappropriately diagnosed might be labeled inappropriately, or another condition might be missed, and they might receive treatments that will not benefit them. ● Benefits-harms assessment: The high

prevalence of ADHD and limited mental health resources require primary care pediatricians to play a significant role in the care of their patients with ADHD so that children with this condition receive the appropriate diagnosis and treatment. Treatments available have shown good evidence of efficacy, and lack of treatment results in a risk for impaired outcomes. ● Value judgments: The committee con-

sidered the requirements for establishing the diagnosis, the prevalence of ADHD, and the efficacy and adverse effects of treatment as well as the longterm outcomes. 1012

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● Intentional vagueness: The limits be-

tween what can be handled by a primary care clinician and what should be referred to a subspecialist because of the varying degrees of skills among primary care clinicians. ● Strength: strong recommendation.

The basis for this recommendation is essentially unchanged from that in the previous guideline. ADHD is the most common neurobehavioral disorder in children and occurs in approximately 8% of children and youth8–10; the number of children with this condition is far greater than can be managed by the mental health system. There is now increased evidence that appropriate diagnosis can be provided for preschool-aged children11 (4 –5 years of age) and for adolescents.12 Action statement 2: To make a diagnosis of ADHD, the primary care clinician should determine that Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV-TR) criteria have been met (including documentation of impairment in more than 1 major setting), and information should be obtained primarily from reports from parents or guardians, teachers, and other school and mental health clinicians involved in the child’s care. The primary care clinician should also rule out any alternative cause (quality of evidence B/strong recommendation). Evidence Profile ● Aggregate evidence quality: B. ● Benefits: The use of DSM-IV criteria has

lead to more uniform categorization of the condition across professional disciplines.

● Benefits-harms assessment: The ben-

efits far outweigh the harm. ● Value judgments: The committee took

into consideration the importance of coordination between pediatric and mental health services. ● Role of patient preferences: Although

there is some stigma associated with mental disorder diagnoses resulting in some families preferring other diagnoses, the need for better clarity in diagnoses was felt to outweigh this preference. ● Exclusions: None. ● Intentional vagueness: None. ● Strength: strong recommendation.

As with the findings in the previous guideline, the DSM-IV criteria continue to be the criteria best supported by evidence and consensus. Developed through several iterations by the American Psychiatric Association, the DSM-IV criteria were created through use of consensus and an expanding research foundation.13 The DSM-IV system is used by professionals in psychiatry, psychology, health care systems, and primary care. Use of DSM-IV criteria, in addition to having the best evidence to date for criteria for ADHD, also affords the best method for communication across clinicians and is established with third-party payers. The criteria are under review for the development of the DSM-V, but these changes will not be available until at least 1 year after the publication of this current guideline. The diagnostic criteria have not changed since the previous guideline and are presented in Supplemental Table 2. An anticipated change in the DSM-V is increasing the age limit for when ADHD needs to have first presented from 7 to 12 years.14

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ADHD: DIAGNOSIS AND EVALUATION OF ATTENTION-DEFICIT/HYPERACTIVITY DISORDER IN CHILDREN AND ADOLESCENTS

Special Circumstances: Preschoolaged Children (4 –5 Years Old) There is evidence that the diagnostic criteria for ADHD can be applied to preschool-aged children; however, the subtypes detailed in the DSM-IV might not be valid for this population.15–21 A review of the literature, including the multisite study of the efficacy of methylphenidate in preschool-aged children, revealed that the criteria could appropriately identify children with the condition.11 However, there are added challenges in determining the presence of key symptoms. Preschoolaged children are not likely to have a separate observer if they do not attend a preschool or child care program, and even if they do attend, staff in those programs might be less qualified than certified teachers to provide accurate observations. Here, too, focused checklists can help physicians in the diagnostic evaluation, although only the Conners Comprehensive Behavior Rating Scales and the ADHD Rating Scale IV are DSM-IV– based scales that have been validated in preschoolaged children.22 When there are concerns about the availability or quality of nonparent observations of a child’s behavior, physicians may recommend that parents complete a parent-training program before confirming an ADHD diagnosis for preschool-aged children and consider placement in a qualified preschool program if they have not done so already. Information can be obtained from parents and teachers through the use of validated DSM-IV– based ADHD rating scales. The parenttraining program must include helping parents develop age-appropriate developmental expectations and specific management skills for problem behaviors. The clinician may obtain reports from the parenting class instructor about the parents’ ability to manage their children, and if the children are PEDIATRICS Volume 128, Number 5, November 2011

in programs in which they are directly observed, instructors can report information about the core symptoms and function of the child directly. Qualified preschool programs include programs such as Head Start or other public prekindergarten programs. Preschool-aged children who display significant emotional or behavioral concerns might also qualify for Early Childhood Special Education services through their local school districts, and the evaluators for these programs and/or Early Childhood Special Education teachers might be excellent reporters of core symptoms. Special Circumstances: Adolescents Obtaining teacher reports for adolescents might be more challenging, because many adolescents will have multiple teachers. Likewise, parents might have less opportunity to observe their adolescent’s behaviors than they had when their children were younger. Adolescents’ reports of their own behaviors often differ from those of other observers, because they tend to minimize their own problematic behaviors.23–25 Adolescents are less likely to exhibit overt hyperactive behavior. Despite the difficulties, clinicians need to try to obtain (with agreement from the adolescent) information from at least 2 teachers as well as information from other sources such as coaches, school guidance counselors, or leaders of community activities in which the adolescent participates. In addition, it is unusual for adolescents with behavioral/attention problems not to have been previously given a diagnosis of ADHD. Therefore, it is important to establish the younger manifestations of the condition that were missed and to strongly consider substance use, depression, and anxiety as alternative or co-occurring diagnoses. Adolescents with ADHD, especially when untreated, are at greater risk of substance abuse.26 In addition, the risks of

mood and anxiety disorders and risky sexual behaviors increase during adolescence.12 Special Circumstances: Inattention or Hyperactivity/Impulsivity (Problem Level) Teachers, parents, and child health professionals typically encounter children with behaviors relating to activity level, impulsivity, and inattention who might not fully meet DSM-IV criteria. The DSM-PC3 provides a guide to the more common behaviors seen in pediatrics. The manual describes common variations in behavior as well as more problematic behaviors at levels of less impairment than those specified in the DSM-IV. The behavioral descriptions of the DSM-PC have not yet been tested in community studies to determine the prevalence or severity of developmental variations and problems in the areas of inattention, hyperactivity, or impulsivity. They do, however, provide guidance to clinicians regarding elements of treatment for children with problems with mild-to-moderate inattention, hyperactivity, or impulsivity. The DSM-PC also considers environmental influences on a child’s behavior and provides information on differential diagnosis with a developmental perspective. Action statement 3: In the evaluation of a child for ADHD, the primary care clinician should include assessment for other conditions that might coexist with ADHD, including emotional or behavioral (eg, anxiety, depressive, oppositional defiant, and conduct disorders), developmental (eg, learning and language disorders or other neurodevelopmental disorders), and physical (eg, tics, sleep apnea) conditions (quality of evidence B/strong recommendation). 1013

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Evidence Profile ● Aggregate evidence quality: B. ● Benefits: Identifying coexisting condi-

tions is important for developing the most appropriate treatment plan. ● Harms/risks/costs: The major risk is mis-

diagnosing the conditions and providing inappropriate care. ● Benefits-harms assessment: There is a

preponderance of benefit over harm. ● Value judgments: The committee mem-

bers took into consideration the common occurrence of coexisting conditions and the importance of addressing them in making this recommendation. ● Role of patient preferences: None. ● Exclusions: None. ● Intentional vagueness: None. ● Strength: strong recommendation.

A variety of other behavioral, developmental, and physical conditions can coexist in children who are evaluated for ADHD. These conditions include, but are not limited to, learning problems, language disorder, disruptive behavior, anxiety, mood disorders, tic disorders, seizures, developmental coordination disorder, or sleep disorders.23,24,27–38 In some cases, the presence of a coexisting condition will alter the treatment of ADHD. The primary care clinician might benefit from additional support and guidance or might need to refer a child with ADHD and coexisting conditions, such as severe mood or anxiety disorders, to subspecialists for assessment and management. The subspecialists could include child psychiatrists, developmentalbehavioral pediatricians, neurodevelopmental disability physicians, child neurologists, or child or school psychologists. Given the likelihood that another condition exists, primary care clinicians should conduct assessments that determine or at least identify the risk of coexisting conditions. Through its Task Force on Mental 1014

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Health, the AAP has developed algorithms and a toolkit39 for assessing and treating (or comanaging) the most common developmental disorders and mental health concerns in children. These resources might be useful in assessing children who are being evaluated for ADHD. Payment for evaluation and treatment must cover the fixed and variable costs of providing the services, as noted in the AAP policy statement “Scope of Health Care Benefits for Children From Birth Through Age 26.40 Special Circumstances: Adolescents Clinicians should assess adolescent patients with newly diagnosed ADHD for symptoms and signs of substance abuse; when these signs and symptoms are found, evaluation and treatment for addiction should precede treatment for ADHD, if possible, or careful treatment for ADHD can begin if necessary.25 Action statement 4: The primary care clinician should recognize ADHD as a chronic condition and, therefore, consider children and adolescents with ADHD as children and youth with special health care needs. Management of children and youth with special health care needs should follow the principles of the chronic care model and the medical home (quality of evidence B/strong recommendation). Evidence Profile ● Aggregate evidence quality: B. ● Benefits: The recommendation de-

scribes the coordinated services most appropriate for managing the condition. ● Harms/risks/costs: Providing the ser-

vices might be more costly. ● Benefits-harms assessment: There is a

preponderance of benefit over harm. ● Value judgments: The committee mem-

bers considered the value of medical

home services when deciding to make this recommendation. ● Role of patient preferences: Family

preference in how these services are provided is an important consideration. ● Exclusions: None. ● Intentional vagueness: None. ● Strength: strong recommendation.

As in the previous guideline, this recommendation is based on the evidence that ADHD continues to cause symptoms and dysfunction in many children who have the condition over long periods of time, even into adulthood, and that the treatments available address symptoms and function but are usually not curative. Although the chronic illness model has not been specifically studied in children and youth with ADHD, it has been effective for other chronic conditions such as asthma,23 and the medical home model has been accepted as the preferred standard of care.41 The management process is also helped by encouraging strong family-school partnerships.42 Longitudinal studies have found that, frequently, treatments are not sustained despite the fact that longterm outcomes for children with ADHD indicate that they are at greater risk of significant problems if they discontinue treatment.43 Because a number of parents of children with ADHD also have ADHD, extra support might be necessary to help those parents provide medication on a consistent basis and institute a consistent behavioral program. The medical home and chronic illness approach is provided in the process algorithm (Supplemental Fig 2). An important process in ongoing care is bidirectional communication with teachers and other school and mental health clinicians involved in the child’s care as well as with parents and patients.

FROM THE AMERICAN ACADEMY OF PEDIATRICS

ADHD: DIAGNOSIS AND EVALUATION OF ATTENTION-DEFICIT/HYPERACTIVITY DISORDER IN CHILDREN AND ADOLESCENTS

Special Circumstances: Inattention or Hyperactivity/Impulsivity (Problem Level)

bers included the effects of untreated ADHD when deciding to make this recommendation.

Children with inattention or hyperactivity/impulsivity at the problem level (DSM-PC) and their families might also benefit from the same chronic illness and medical home principles.

● Role of patient preferences: Family

Action statement 5: Recommendations for treatment of children and youth with ADHD vary depending on the patient’s age. Action statement 5a: For preschoolaged children (4–5 years of age), the primary care clinician should prescribe evidence-based parentand/or teacher-administered behavior therapy as the first line of treatment (quality of evidence A/strong recommendation) and may prescribe methylphenidate if the behavior interventions do not provide significant improvement and there is moderate-to-severe continuing disturbance in the child’s function. In areas in which evidence-based behavioral treatments are not available, the clinician needs to weigh the risks of starting medication at an early age against the harm of delaying diagnosis and treatment (quality of evidence B/recommendation). Evidence Profile ● Aggregate evidence quality: A for be-

havior; B for methylphenidate. ● Benefits: Both behavior therapy and

methylphenidate have been demonstrated to reduce behaviors associated with ADHD and improve function. ● Harms/risks/costs: Both therapies in-

crease the cost of care, and behavior therapy requires a higher level of family involvement, whereas methylphenidate has some potential adverse effects. ● Benefits-harms assessment: Given the

preference is essential in determining the treatment plan.

● Role of patient preferences: Family

preference, including patient preference, is essential in determining the treatment plan.

● Exclusions: None.

● Exclusions: None.

● Intentional vagueness: None.

● Intentional vagueness: None.

● Strength: strong recommendation.

● Strength: strong recommendation.

Action statement 5b: For elementary school-aged children (6–11 years of age), the primary care clinician should prescribe FDAapproved medications for ADHD (quality of evidence A/strong recommendation) and/or evidencebased parent- and/or teacheradministered behavior therapy as treatment for ADHD, preferably both (quality of evidence B/strong recommendation). The evidence is particularly strong for stimulant medications and sufficient but less strong for atomoxetine, extendedrelease guanfacine, and extendedrelease clonidine (in that order) (quality of evidence A/strong recommendation). The school environment, program, or placement is a part of any treatment plan.

Action statement 5c: For adolescents (12–18 years of age), the primary care clinician should prescribe FDA-approved medications for ADHD with the assent of the adolescent (quality of evidence A/strong recommendation) and may prescribe behavior therapy as treatment for ADHD (quality of evidence C/recommendation), preferably both. Evidence Profile ● Aggregate evidence quality: A for

medications; C for behavior therapy. ● Benefits: Both behavior therapy and

FDA-approved medications have been demonstrated to reduce behaviors associated with ADHD and improve function. ● Harms/risks/costs: Both therapies in-

treatment with FDA-approved medications; B for behavior therapy.

crease the cost of care, and behavior therapy requires a higher level of family involvement, whereas FDA-approved medications have some potential adverse effects.

● Benefits: Both behavior therapy and

● Benefits-harms assessment: Given the

Evidence Profile ● Aggregate evidence quality: A for

FDA-approved medications have been demonstrated to reduce behaviors associated with ADHD and improve function. ● Harms/risks/costs: Both therapies in-

crease the cost of care, and behavior therapy requires a higher level of family involvement, whereas FDA-approved medications have some potential adverse effects. ● Benefits-harms assessment: Given the

risks of untreated ADHD, the benefits outweigh the risks.

risks of untreated ADHD, the benefits outweigh the risks.

● Value judgments: The committee mem-

● Value judgments: The committee mem-

bers included the effects of untreated

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ADHD when deciding to make this recommendation.

risks of untreated ADHD, the benefits outweigh the risks. ● Value judgments: The committee mem-

bers included the effects of untreated ADHD when deciding to make this recommendation. ● Role of patient preferences: Family

preference, including patient preference, is essential in determining the treatment plan. ● Exclusions: None. ● Intentional vagueness: None. ● Strength: strong recommendation/

recommendation. 1015

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Medication Similar to the recommendations from the previous guideline, stimulant medications are highly effective for most children in reducing core symptoms of ADHD.44 One selective norepinephrinereuptake inhibitor (atomoxetine45,46) and 2 selective 2-adrenergic agonists (extended-release guanfacine47,48 and extended-release clonidine49) have also demonstrated efficacy in reducing core symptoms. Because norepinephrine-reuptake inhibitors and 2-adrenergic agonists are newer, the evidence base that supports them—although adequate for FDA approval—is considerably smaller than that for stimulants. None of them have been approved for use in preschool-aged children. Compared with stimulant medications that have an effect size [effect size  (treatment mean  control mean)/control SD] of approximately 1.0,50 the effects of the nonstimulants are slightly weaker; atomoxetine has an effect size of approximately 0.7, and extended-release guanfacine and extended-release clonidine also have effect sizes of approximately 0.7. The accompanying process-of-care algorithm provides a list of the currently available FDA-approved medications for ADHD (Supplemental Table 3). Characteristics of each medication are provided to help guide the clinician’s choice in prescribing medication. As was identified in the previous guideline, the most common stimulant adverse effects are appetite loss, abdominal pain, headaches, and sleep disturbance. The results of the Multimodal Therapy of ADHD (MTA) study revealed a more persistent effect of stimulants on decreasing growth velocity than have most previous studies, particularly when children were on higher and more consistently administered doses. The effects diminished by the third year of treatment, but no com1016

FROM THE AMERICAN ACADEMY OF PEDIATRICS

pensatory rebound effects were found.51 However, diminished growth was in the range of 1 to 2 cm. An uncommon additional significant adverse effect of stimulants is the occurrence of hallucinations and other psychotic symptoms.52 Although concerns have been raised about the rare occurrence of sudden cardiac death among children using stimulant medications,53 sudden death in children on stimulant medication is extremely rare, and evidence is conflicting as to whether stimulant medications increase the risk of sudden death.54–56 It is important to expand the history to include specific cardiac symptoms, Wolf-Parkinson-White syndrome, sudden death in the family, hypertrophic cardiomyopathy, and long QT syndrome. Preschool-aged children might experience increased mood lability and dysphoria.57 For the nonstimulant atomoxetine, the adverse effects include initial somnolence and gastrointestinal tract symptoms, particularly if the dosage is increased too rapidly; decrease in appetite; increase in suicidal thoughts (less common); and hepatitis (rare). For the nonstimulant 2adrenergic agonists extended-release guanfacine and extended-release clonidine, adverse effects include somnolence and dry mouth. Only 2 medications have evidence to support their use as adjunctive therapy with stimulant medications sufficient to achieve FDA approval: extended-release guanfacine26 and extended-release clonidine. Other medications have been used in combination off-label, but there is currently only anecdotal evidence for their safety or efficacy, so their use cannot be recommended at this time.

ate ADHD treatment in preschool-aged children (ages 4 –5 years) with behavioral therapy alone first.57 These circumstances include: ● The multisite study of methylpheni-

date57 was limited to preschoolaged children who had moderateto-severe dysfunction. ● The study also found that many chil-

dren (ages 4 –5 years) experience improvements in symptoms with behavior therapy alone, and the overall evidence for behavior therapy in preschool-aged children is strong. ● Behavioral programs for children 4

to 5 years of age typically run in the form of group parent-training programs and, although not always compensated by health insurance, have a lower cost. The process algorithm (see Supplemental pages s1516) contains criteria for the clinician to use in assessing the quality of the behavioral therapy. In addition, programs such as Head Start and Children and Adults With Attention Deficit Hyperactivity Disorder (CHADD) (www.chadd.org) might provide some behavioral supports. Many young children with ADHD might still require medication to achieve maximum improvement, and medication is not contraindicated for children 4 through 5 years of age. However, only 1 multisite study has carefully assessed medication use in preschoolaged children. Other considerations in the recommendation about treating children 4 to 5 years of age with stimulant medications include: ● The study was limited to preschool-

aged children who had moderateto-severe dysfunction. ● Research has found that a number

Special Circumstances: Preschoolaged Children A number of special circumstances support the recommendation to initi-

of young children (4 –5 years of age) experience improvements in symptoms with behavior therapy alone. ● There are concerns about the possi-

FROM THE AMERICAN ACADEMY OF PEDIATRICS

ADHD: DIAGNOSIS AND EVALUATION OF ATTENTION-DEFICIT/HYPERACTIVITY DISORDER IN CHILDREN AND ADOLESCENTS

ble effects on growth during this rapid growth period of preschoolaged children. ● There has been limited information

about and experience with the effects of stimulant medication in children between the ages of 4 and 5 years. Here, the criteria for enrollment (and, therefore, medication use) included measures of severity that distinguished treated children from the larger group of preschool-aged children with ADHD. Thus, before initiating medications, the physician should assess the severity of the child’s ADHD. Given current data, only those preschool-aged children with ADHD who have moderate-to-severe dysfunction should be considered for medication. Criteria for this level of severity, based on the multisite-study results,57 are (1) symptoms that have persisted for at least 9 months, (2) dysfunction that is manifested in both the home and other settings such as preschool or child care, and (3) dysfunction that has not responded adequately to behavior therapy. The decision to consider initiating medication at this age depends in part on the clinician’s assessment of the estimated developmental impairment, safety risks, or consequences for school or social participation that could ensue if medications are not initiated. It is often helpful to consult with a mental health specialist who has had specific experience with preschool-aged children if possible. Dextroamphetamine is the only medication approved by the FDA for use in children younger than 6 years of age. This approval, however, was based on less stringent criteria in force when the medication was approved rather than on empirical evidence of its safety and efficacy in this age group. Most of the evidence for the safety and efficacy of treating preschool-aged children with stimulant medications has been PEDIATRICS Volume 128, Number 5, November 2011

from methylphenidate.57 Methylphenidate evidence consists of 1 multisite study of 165 children and 10 other smaller single-site studies that included from 11 to 59 children (total of 269 children); 7 of the 10 single-site studies found significant efficacy. It must be noted that although there is moderate evidence that methylphenidate is safe and efficacious in preschool-aged children, its use in this age group remains off-label. Although the use of dextroamphetamine is onlabel, the insufficient evidence for its safety and efficacy in this age group does not make it possible to recommend at this time. If children do not experience adequate symptom improvement with behavior therapy, medication can be prescribed, as described previously. Evidence suggests that the rate of metabolizing stimulant medication is slower in children 4 through 5 years of age, so they should be given a lower dose to start, and the dose can be increased in smaller increments. Maximum doses have not been adequately studied.57 Special Circumstances: Adolescents As noted previously, before beginning medication treatment for adolescents with newly diagnosed ADHD, clinicians should assess these patients for symptoms of substance abuse. When substance use is identified, assessment when off the abusive substances should precede treatment for ADHD (see the Task Force on Mental Health report7). Diversion of ADHD medication (use for other than its intended medical purposes) is also a special concern among adolescents58; clinicians should monitor symptoms and prescription-refill requests for signs of misuse or diversion of ADHD medication and consider prescribing medications with no abuse potential, such as atomoxetine (Strattera [Ely Lilly Co, Indianapolis, IN]) and

extended-release guanfacine (Intuniv [Shire US Inc, Wayne, PA]) or extended-release clonidine (Kapvay [Shionogi Inc, Florham Park, NJ]) (which are not stimulants) or stimulant medications with less abuse potential, such as lisdexamfetamine (Vyvanse [Shire US Inc]), dermal methylphenidate (Daytrana [Noven Therapeutics, LLC, Miami, FL]), or OROS methylphenidate (Concerta [Janssen Pharmaceuticals, Inc, Titusville, NJ]). Because lisdexamfetamine is dextroamphetamine, which contains an additional lysine molecule, it is only activated after ingestion, when it is metabolized by erythrocyte cells to dexamphetamine. The other preparations make extraction of the stimulant medication more difficult. Given the inherent risks of driving by adolescents with ADHD, special concern should be taken to provide medication coverage for symptom control while driving. Longer-acting or late-afternoon, short-acting medications might be helpful in this regard.59 Special Circumstances: Inattention or Hyperactivity/Impulsivity (Problem Level) Medication is not appropriate for children whose symptoms do not meet DSM-IV criteria for diagnosis of ADHD, although behavior therapy does not require a specific diagnosis, and many of the efficacy studies have included children without specific mental behavioral disorders. Behavior Therapy Behavior therapy represents a broad set of specific interventions that have a common goal of modifying the physical and social environment to alter or change behavior. Behavior therapy usually is implemented by training parents in specific techniques that improve their abilities to modify and 1017

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TABLE 1 Evidence-Based Behavioral Treatments for ADHD Intervention Type

Description

Typical Outcome(s)

Median Effect Sizea

Behavioral parent training (BPT)

Behavior-modification principles provided to parents for implementation in home settings

0.55

Behavioral classroom management

Behavior-modification principles provided to teachers for implementation in classroom settings Interventions focused on peer interactions/relationships; these are often groupbased interventions provided weekly and include clinic-based social-skills training used either alone or concurrently with behavioral parent training and/or medication

Improved compliance with parental commands; improved parental understanding of behavioral principles; high levels of parental satisfaction with treatment Improved attention to instruction; improved compliance with classroom rules; decreased disruptive behavior; improved work productivity Office-based interventions have produced minimal effects; interventions have been of questionable social validity; some studies of BPI combined with clinic-based BPT found positive effects on parent ratings of ADHD symptoms; no differences on social functioning or parent ratings of social behavior have been revealed

Behavioral peer interventions (BPI)b

0.61

Effect size  (treatment median  control median)/control SD. The effect size for behavioral peer interventions is not reported, because the effect sizes for these studies represent outcomes associated with combined interventions. A lower effect size means that they have less of an effect. The effect sizes found are considered moderate. Adapted from Pelham W, Fabiano GA. J Clin Child Adolesc Psychol. 2008;37(1):184 –214.

a

b

shape their child’s behavior and to improve the child’s ability to regulate his or her own behavior. The training involves techniques to more effectively provide rewards when their child demonstrates the desired behavior (eg, positive reinforcement), learn what behaviors can be reduced or eliminated by using planned ignoring as an active strategy (or using praising and ignoring in combination), or provide appropriate consequences or punishments when their child fails to meet the goals (eg, punishment). There is a need to consistently apply rewards and consequences as tasks are achieved and then to gradually increase the expectations for each task as they are mastered to shape behaviors. Although behavior therapy shares a set of principles, individual programs introduce different techniques and strategies to achieve the same ends. Table 1 lists the major behavioral intervention approaches that have been demonstrated to be evidence based for the management of ADHD in 3 different types of settings. The table is based on 22 studies, each completed between 1997 and 2006. Evidence for the effectiveness of behavior therapy in children with ADHD is 1018

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derived from a variety of studies60–62 and an Agency for Healthcare Research and Quality review.5 The diversity of interventions and outcome measures makes meta-analysis of the effects of behavior therapy alone or in association with medications challenging. The long-term positive effects of behavior therapy have yet to be determined. Ongoing adherence to a behavior program might be important; therefore, implementing a chronic care model for child health might contribute to the long-term effects.63 Study results have indicated positive effects of behavior therapy when combined with medications. Most studies that compared behavior therapy to stimulants found a much stronger effect on ADHD core symptoms from stimulants than from behavior therapy. The MTA study found that combined treatment (behavior therapy and stimulant medication) was not significantly more efficacious than treatment with medication alone for the core symptoms of ADHD after correction for multiple tests in the primary analysis.64 However, a secondary analysis of a combined measure of parent and teacher ratings of ADHD symptoms revealed a significant advantage

for the combination with a small effect size of d  0.26.65 However, the same study also found that the combined treatment compared with medication alone did offer greater improvements on academic and conduct measures when ADHD coexisted with anxiety and when children lived in low socioeconomic environments. In addition, parents and teachers of children who were receiving combined therapy were significantly more satisfied with the treatment plan. Finally, the combination of medication management and behavior therapy allowed for the use of lower dosages of stimulants, which possibly reduced the risk of adverse effects.66 School Programming and Supports Behavior therapy programs coordinating efforts at school as well as home might enhance the effects. School programs can provide classroom adaptations, such as preferred seating, modified work assignments, and test modifications (to the location at which it is administered and time allotted for taking the test), as well as behavior plans as part of a 504 Rehabilitation Act Plan or special education Individualized Education Program (IEP) under the “other health impairment” designation as part of the Individuals With

FROM THE AMERICAN ACADEMY OF PEDIATRICS

ADHD: DIAGNOSIS AND EVALUATION OF ATTENTION-DEFICIT/HYPERACTIVITY DISORDER IN CHILDREN AND ADOLESCENTS

Disability Education Act (IDEA).67 It is helpful for clinicians to be aware of the eligibility criteria in their state and school district to advise families of their options. Youths documented to have ADHD can also get permission to take college-readiness tests in an untimed manner by following appropriate documentation guidelines.68 The effect of coexisting conditions on ADHD treatment is variable. In some cases, treatment of the ADHD resolves the coexisting condition. For example, treatment of ADHD might resolve oppositional defiant disorder or anxiety.68 However, sometimes the co-occurring condition might require treatment that is in addition to the treatment for ADHD. Some coexisting conditions can be treated in the primary care setting, but others will require referral and comanagement with a subspecialist. Action statement 6: Primary care clinicians should titrate doses of medication for ADHD to achieve maximum benefit with minimum adverse effects (quality of evidence B/strong recommendation). Evidence Profile ● Aggregate evidence quality: B. ● Benefits: The optimal dose of medica-

tion is required to reduce core symptoms to or as close to the levels of children without ADHD. ● Harms/risks/costs: Higher levels of

medication increase the chances of adverse effects. ● Benefits-harms assessment: The im-

portance of adequately treating ADHD outweighs the risk of adverse effects. ● Value judgments: The committee mem-

bers included the effects of untreated ADHD when deciding to make this recommendation. ● Role of patient preferences: The fam-

ilies’ preferences and comfort need to be taken into consideration in developing a titration plan. ● Exclusions: None.

PEDIATRICS Volume 128, Number 5, November 2011

● Intentional vagueness: None. ● Strength: strong recommendation.

The findings from the MTA study suggested that more than 70% of children and youth with ADHD respond to one of the stimulant medications at an optimal dose when a systematic trial is used.65 Children in the MTA who were treated in the community with care as usual from whomever they chose or to whom they had access received lower doses of stimulants with less frequent monitoring and had less optimal results.65 Because stimulants might produce positive but suboptimal effects at a low dose in some children and youth, titration to maximum doses that control symptoms without adverse effects is recommended instead of titration strictly on a milligram-per-kilogram basis. Education of parents is an important component in the chronic illness model to ensure their cooperation in efforts to reach appropriate titration (remembering that the parents themselves might be challenged significantly by ADHD).69,70 The primary care clinician should alert parents and children that changing medication dose and occasionally changing a medication might be necessary for optimal medication management, that the process might require a few months to achieve optimal success, and that medication efficacy should be systematically monitored at regular intervals. Because stimulant medication effects are seen immediately, trials of different doses of stimulants can be accomplished in a relatively short time period. Stimulant medications can be effectively titrated on a 3- to 7-day basis.65 It is important to note that by the 3-year follow-up of 14-month MTA interventions (optimal medications management, optimal behavioral management, the combination of the 2, or community treatment), all differences among the initial 4

groups were no longer present. After the initial 14-month intervention, the children no longer received the careful monthly monitoring provided by the study and went back to receiving care from their community providers. Their medications and doses varied, and a number of them were no longer taking medication. In children still on medication, the growth deceleration was only seen for the first 2 years and was in the range of 1 to 2 cm.

CONCLUSION Evidence continues to be fairly clear with regard to the legitimacy of the diagnosis of ADHD and the appropriate diagnostic criteria and procedures required to establish a diagnosis, identify co-occurring conditions, and treat effectively with both behavioral and pharmacologic interventions. However, the steps required to sustain appropriate treatments and achieve successful long-term outcomes still remain a challenge. To provide more detailed information about how the recommendations of this guideline can be accomplished, a more detailed but less strongly evidencebased algorithm is provided as a companion article.

AREAS FOR FUTURE RESEARCH Some specific research topics pertinent to the diagnosis and treatment of ADHD or developmental variations or problems in children and adolescents in primary care to be explored include: ● identification or development of

reliable instruments suitable to use in primary care to assess the nature or degree of functional impairment in children/adolescents with ADHD and monitor improvement over time; ● study of medications and other

therapies used clinically but not approved by the FDA for ADHD, such as 1019

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electroencephalographic biofeedback;

some aspects of severity, disability, or impairment; and

● determination of the optimal schedule

● long-term outcomes of children first

for monitoring children/adolescents with ADHD, including factors for adjusting that schedule according to age, symptom severity, and progress reports;

identified with ADHD as preschoolaged children.

● evaluation of the effectiveness of

various school-based interventions; ● comparisons of medication use and

effectiveness in different ages, including both harms and benefits; ● development of methods to involve

parents and children/adolescents in their own care and improve adherence to both behavior and medication treatments; ● standardized and documented tools

that will help primary care providers in identifying coexisting conditions; ● development and determination of ef-

fective electronic and Web-based systems to help gather information to diagnose and monitor children with ADHD; ● improved systems of communica-

tion with schools and mental health professionals, as well as other community agencies, to provide effective collaborative care; ● evidence for optimal monitoring by

SUBCOMMITTEE ON ATTENTION DEFICIT HYPERACTIVITY DISORDER (OVERSIGHT BY THE STEERING COMMITTEE ON QUALITY IMPROVEMENT AND MANAGEMENT, 2005–2011) WRITING COMMITTEE Mark Wolraich, MD, Chair – (periodic consultant to Shire, Eli Lilly, Shinogi, and Next Wave Pharmaceuticals) Lawrence Brown, MD – (neurologist; AAP Section on Neurology; Child Neurology Society) (Safety Monitoring Board for Best Pharmaceuticals for Children Act for National Institutes of Health) Ronald T. Brown, PhD – (child psychologist; Society for Pediatric Psychology) (no conflicts) George DuPaul, PhD – (school psychologist; National Association of School Psychologists) (participated in clinical trial on Vyvanse effects on college students with ADHD, funded by Shire; published 2 books on ADHD and receives royalties) Marian Earls, MD – (general pediatrician with QI expertise, developmental and behavioral pediatrician) (no conflicts) Heidi M. Feldman, MD, PhD – (developmental and behavioral pediatrician; Society for Developmental and Behavioral Pediatricians) (no conflicts)

Theodore G. Ganiats, MD – (family physician; American Academy of Family Physicians) (no conflicts) Beth Kaplanek, RN, BSN – (parent advocate, Children and Adults With Attention Deficit Hyperactivity Disorder [CHADD]) (no conflicts) Bruce Meyer, MD – (general pediatrician) (no conflicts) James Perrin, MD – (general pediatrician; AAP Mental Health Task Force, AAP Council on Children With Disabilities) (consultant to Pfizer not related to ADHD) Karen Pierce, MD – (child psychiatrist; American Academy of Child and Adolescent Psychiatry) (no conflicts) Michael Reiff, MD – (developmental and behavioral pediatrician; AAP Section on Developmental and Behavioral Pediatrics) (no conflicts) Martin T. Stein, MD – (developmental and behavioral pediatrician; AAP Section on Developmental and Behavioral Pediatrics) (no conflicts) Susanna Visser, MS – (epidemiologist) (no conflicts)

CONSULTANT Melissa Capers, MA, MFA – (medical writer) (no conflicts)

STAFF Caryn Davidson, MA

ACKNOWLEDGMENTS This guideline was developed with support from the Partnership for Policy Implementation (PPI) initiative. Physicians trained in medical informatics were involved with formatting the algorithm and helping to keep the key action statements actionable, decidable, and executable.

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51. Swanson J, Elliott GR, Greenhill LL, et al. Effects of stimulant medication on growth rates across 3 years in the MTA follow-up. J Am Acad Child Adolesc Psychiatry. 2007; 46(8):1015–1027 52. Mosholder AD, Gelperin K, Hammad TA, Phelan K, Johann-Liang R. Hallucinations and other psychotic symptoms associated with the use of attention-deficit/hyperactivity disorder drugs in children. Pediatrics. 2009;123(2):611– 616 53. Avigan M. Review of AERS Data From Marketed Safety Experience During Stimulant Therapy: Death, Sudden Death, Cardiovascular SAEs (Including Stroke). Silver Spring, MD: Food and Drug Administration, Center for Drug Evaluation and Research; 2004. Report No. D030403 54. Perrin JM, Friedman RA, Knilans TK, et al; American Academy of Pediatrics, Black Box Working Group, Section on Cardiology and Cardiac Surgery. Cardiovascular monitoring and stimulant drugs for attentiondeficit/hyperactivity disorder. Pediatrics. 2008;122(2):451– 453 55. McCarthy S, Cranswick N, Potts L, Taylor E, Wong IC. Mortality associated with attention-deficit hyperactivity disorder (ADHD) drug treatment: a retrospective cohort study of children, adolescents and young adults using the general practice research database. Drug Saf. 2009;32(11): 1089–1110 56. Gould MS, Walsh BT, Munfakh JL, et al. Sudden death and use of stimulant medications in youths. Am J Psychiatry. 2009;166(9):992–1001 57. Greenhill L, Kollins S, Abikoff H, McCracken J, Riddle M, Swanson J. Efficacy and safety of immediate-release methylphenidate treatment for preschoolers with ADHD. J Am Acad Child Adolesc Psychiatry. 2006;45(11): 1284 –1293 58. Low K, Gendaszek AE. Illicit use of psychostimulants among college students: a preliminary study. Psychol Health Med. 2002; 7(3):283–287 59. Cox D, Merkel RL, Moore M, Thorndike F, Muller C, Kovatchev B. Relative benefits of stimulant therapy with OROS methylphenidate versus mixed amphetamine salts extended release in improving the driving performance of adolescent drivers with attention-deficit/hyperactivity disorder. Pediatrics. 2006;118(3). Available at:

www.pediatrics.org/cgi/content/full/118/ 3/e704 60. Pelham W, Wheeler T, Chronis A. Empirically supported psychological treatments for attention deficit hyperactivity disorder. J Clin Child Psychol. 1998;27(2):190 –205 61. Sonuga-Barke E, Daley D, Thompson M, LaverBradburyC,WeeksA.Parent-basedtherapiesfor preschool attention-deficit/hyperactivity disorder: a randomized, controlled trial with a community sample. J Am Acad Child Adolesc Psychiatry. 2001;40(4):402–408 62. Pelham W, Fabiano GA. Evidence-based psychosocial treatments for attention-deficit/ hyperactivity disorder. J Clin Child Adolesc Psychol. 2008;37(1):184 –214 63. Van Cleave J, Leslie LK. Approaching ADHD as a chronic condition: implications for long-term adherence. J Psychosoc Nurs Ment Health Serv. 2008;46(8):28 –36 64. A 14-month randomized clinical trial of treatment strategies for attention-deficit/ hyperactivity disorder. The MTA Cooperative Group. Multimodal Treatment Study of Children With ADHD. Arch Gen Psychiatry. 1999;56(12):1073–1086 65. Jensen P, Hinshaw SP, Swanson JM, et al. Findings from the NIMH multimodal treatment study of ADHD (MTA): implications and applications for primary care providers. J Dev Behav Pediatr. 2001;22(1):60 –73 66. Pelham WE, Gnagy EM. Psychosocial and combined treatments for ADHD. Ment Retard Dev Disabil Res Rev. 1999;5(3):225–236 67. DavilaRR,WilliamsML,MacDonaldJT.Memorandum on clarification of policy to address the needs of children with attention deficit disorders within general and/or special education. In: Parker HCThe ADD Hyperactivity Handbook for Schools. Plantation, FL: Impact Publications Inc; 1991:261–268 68. The College Board. Services for Students With Disabilities (SSD). Available at: www. collegeboard.com/ssd/student. Accessed July 8, 2011 69. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. JAMA 2002;288:1775–1779 70. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, Part 2. JAMA 2002;288:1909 –1914

ADHD: DIAGNOSIS AND EVALUATION OF ATTENTION-DEFICIT/HYPERACTIVITY DISORDER IN CHILDREN AND ADOLESCENTS 23 23

Attention-Deficit/Hyperactivity Disorder Clinical Practice Guideline Quick Reference Tools • Action Statement Summary —— ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents • ICD-10-CM Coding Quick Reference for ADHD • Bonus Features —— ADHD Coding Fact Sheet for Primary Care Physicians —— Continuum Model for ADHD • AAP Patient Education Handouts —— Understanding ADHD: Information for Parents About Attention-Deficit/Hyperactivity Disorder —— Medicines for ADHD: Questions From Teens Who Have ADHD —— What Is ADHD? Questions From Teens

Action Statement Summary ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents Key Action Statement 1 The primary care clinician should initiate an evaluation for ADHD for any child 4 through 18 years of age who presents with academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity (quality of evidence B/strong recommendation). Key Action Statement 2 To make a diagnosis of ADHD, the primary care clinician should determine that Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV-TR) criteria have been met (including documentation of impairment in more than 1 major setting), and information should be obtained primarily from reports from parents or guardians, teachers, and other school and mental health clinicians involved in the child’s care. The primary care clinician should also rule out any alternative cause (quality of evidence B/strong recommendation). Key Action Statement 3 In the evaluation of a child for ADHD, the primary care clinician should include assessment for other conditions that might coexist with ADHD, including emotional or behavioral (eg, anxiety, depressive, oppositional defiant, and conduct disorders), developmental (eg, learning and language disorders or other neurodevelopmental disorders), and physical (eg, tics, sleep apnea) conditions (quality of evidence B/strong recommendation). Key Action Statement 4 The primary care clinician should recognize ADHD as a chronic condition and, therefore, consider children and adolescents with ADHD as children and youth with special health care needs. Management of children and youth with special health care needs should follow the ­principles of the chronic care model and the medical home (quality of evidence B/strong recommendation). Key Action Statement 5 Recommendations for treatment of children and youth with ADHD vary depending on the patient’s age.

Key Action Statement 5a For preschool-aged children (4–5 years of age), the primary care clinician should prescribe evidence-based parent and/or teacheradministered behavior therapy as the first line of treatment (quality of evidence A/strong recommendation) and may prescribe methylphenidate if the behavior interventions do not provide significant improvement and there is moderate-to-severe continuing disturbance in the child’s function. In areas in which evidence-based behavioral treatments are not available, the clinician needs to weigh the risks of starting medication at an early age against the harm of delaying diagnosis and treatment (quality of evidence B/recommendation). Key Action Statement 5b For elementary school-aged children (6–11 years of age), the primary care clinician should prescribe FDA-approved medications for ADHD (quality of evidence A/strong recommendation) and/or evidence based parent- and/or teacher-administered behavior therapy as treatment for ADHD, preferably both (quality of evidence B/strong recommendation). The evidence is particularly strong for stimulant medications and sufficient but less strong for atomoxetine, extended-release guanfacine, and extendedrelease clonidine (in that order) (quality of evidence A/strong recommendation). The school environment, program, or placement is a part of any treatment plan. Key Action Statement 5c For adolescents (12–18 years of age), the primary care clinician should prescribe FDA-approved medications for ADHD with the assent of the adolescent (quality of evidence A/strong recommendation) and may prescribe behavior therapy as treatment for ADHD (quality of evidence C/recommendation), preferably both. Key Action Statement 6 Primary care clinicians should titrate doses of medication for ADHD to achieve maximum benefit with minimum adverse effects (quality of evidence B/strong recommendation).

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SECTION 1/CLINICAL PRACTICE GUIDELINES

Coding Quick Reference for ADHD ICD-10-CM F90.0 Attention-deficit hyperactivity disorder, predominantly inattentive type F90.1 Attention-deficit hyperactivity disorder, predominantly hyperactive type

ADHD CLINICAL PRACTICE GUIDELINE QUICK REFERENCE TOOLS

25

ADHD Coding Fact Sheet for Primary Care Physicians Current Procedural Terminology (CPT®) (­Procedure) Codes Initial assessment usually involves a lot of time in determining the differential diagnosis, a diagnostic plan, and potential treatment options. Therefore, most pediatricians will report either an office or an outpatient evaluation and management (E/M) code using time as the key factor or a consultation code for the initial assessment.

Physician E/M Services *99201

Office or other outpatient visit, newa patient; self limited or minor problem, 10 min. *99202 low to moderate severity problem, 20 min. *99203 moderate severity problem, 30 min. *99204 moderate to high severity problem, 45 min. *99205 high severity problem, 60 min. *99211 Office or other outpatient visit, established patient; minimal problem, 5 min. *99212 self limited or minor problem, 10 min. *99213 low to moderate severity problem, 15 min. *99214 moderate severity problem, 25 min. *99215 moderate to high severity problem, 40 min. *99241 Office or other outpatient consultation,b–d new or established patient; self-limited or minor problem, 15 min. *99242 low severity problem, 30 min. *99243 moderate severity problem, 45 min. *99244 moderate to high severity problem, 60 min. *99245 moderate to high severity problem, 80 min. *+99354 Prolonged physician services in office or other outpatient setting, with direct patient contact; first hour (use in conjunction with time-based codes 99201– 99215, 99241–99245, 99301–99350, 90837) *+99355 each additional 30 min. (use in conjunction with 99354) • Used when a physician provides prolonged services beyond the usual service (ie, beyond the typical time). • Time spent does not have to be continuous. • Prolonged service of less than 15 minutes beyond the first hour or less than 15 minutes beyond the final 30 minutes is not reported separately. • If reporting E/M service according to time and not key factors (history, examination, and medical decision-making), the physician must reach the typical time in the highest code in the code set being reported (eg, 99205, 99215, 99245) before face-to-face prolonged services can be reported. • Refer to CPT for clinical staff prolonged services. A new patient is one who has not received any professional services (face-to-face services) rendered by physicians and other qualified health care professionals who may report E/M services using 1 or more specific CPT codes from the physician/qualified health care professional, or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past 3 years. b Use of these codes (99241–99245) requires the following actions: 1. Written or verbal request for consultation is documented in the medical record. 2. Consultant’s opinion and any services ordered or performed are documented in the medical record. 3. Consultant’s opinion and any services that are performed are prepared in a written report, which is sent to the requesting physician or other appropriate source. c Patients/parents may not initiate a consultation. d For more information on consultation code changes for 2010, see www.aap.org/en-us/ professional-resources/practice-transformation/getting-paid/Coding-at-the-AAP/ Pages/ADHD-Coding-Fact-Sheet.aspx. a

+ Codes are add-on codes, meaning they are reported separately in addition to the ­appropriate code for the service provided. * Indicates a CPT-approved telemedicine service. CPT ® copyright 2017 American Medical Association. All rights reserved.

Reporting E/M Services Using “Time” • When counseling or coordination of care dominates (>50%) the physician/patient or family encounter (face-to-face time in the ­office or other outpatient setting or floor/unit time in the hospital or nursing facility), time shall be considered the key or controlling factor to qualify for a particular level of E/M services. • This includes time spent with parties who have assumed responsibility for the care of the patient or decision-making, whether or not they are family members (eg, foster parents, person acting in loco parentis, legal guardian). The extent of counseling or coor­ dination of care must be documented in the medical record. • For coding purposes, face-to-face time for these services is defined as only that time that the physician spends face-to-face with the patient or family. This includes the time in which the physician performs such tasks as obtaining a history, performing an examination, and counseling the patient. • When codes are ranked in sequential typical times (eg, officebased E/M services, consultation codes) and the actual time is between 2 typical times, the code with the typical time closest to the actual time is used. —— Example: A physician sees an established patient in the office to discuss the current attention-deficit/hyperactivity disorder (ADHD) medication the patient was placed on. The total face-to-face time was 22 minutes, of which 15 minutes was spent in counseling the mom and patient. Because more than 50% of the total time was spent in counseling, the physician would report the E/M service according to time. The physician would report 99214 instead of 99213 because the total face-to-face time was closer to 99214 (25 minutes) than 99213 (15 minutes).

ADHD Follow-up During a Routine Preventive Medicine Service • A good time to follow up with a patient regarding his or her ADHD could be during a preventive medicine service. • If the follow-up requires little additional work on behalf of the physician, it should be reported under the preventive medicine service, rather than as a separate service. • If the follow-up work requires an additional E/M service in addition to the preventive medicine service, it should be reported as a separate service. • Chronic conditions should be reported only if they are separately addressed. • When reporting a preventive medicine service in addition to an office-based E/M service and the services are significant and separately identifiable, modifier 25 will be required on the officebased E/M service. —— Example: A 12-year-old established patient presents for his routine preventive medicine service and, while he and Mom are there, Mom asks about changing his ADHD medication because of some side effects he is experiencing. The physician completes the routine preventive medicine check and then addresses the mom’s concerns in a separate service. The additional E/M service takes 15 minutes, of which the physician spends about 10 minutes in counseling and coordinating care; therefore, the E/M service is reported according to time. ~~ Code 99394 and 99213-25 account for both E/M services and link each to the appropriate International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) code. ~~ Modifier 25 is required on the problem-oriented office visit code (eg, 99213) when it is significant and separately identifiable from another service.

26

SECTION 1/CLINICAL PRACTICE GUIDELINES

Physician Non–face-to-face Services 99339

99340 99358 +99359 99367

99441

99442 99443 99444

 are Plan Oversight—Individual physician superC vision of a patient (patient not present) in home, domiciliary or rest home (e.g., assisted living facility) requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including telephone calls) for purposes of assessment or care decisions with health care professional(s), family member(s), surrogate decision maker(s) (e.g., legal guardian) and/or key caregiver(s) involved in patient’s care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 15–29 minutes 30 minutes or more Prolonged physician services without direct patient contact; first hour each additional 30 min. (+ use in conjunction with 99358) Medical team conference by physician with interdisciplinary team of health care professionals, patient and/or family not present, 30 minutes or more Telephone evaluation and management to patient, parent or guardian not originating from a related E/M service within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5–10 minutes of medical discussion 11–20 minutes of medical discussion 21–30 minutes of medical discussion Online E/M service provided by a physician or other qualified health care professional to an established patient, guardian or health care provider not originating from a related E/M service provided within the previous 7 days, using the internet or similar electronic communications network

Care Management Services Codes are selected according to the amount of time spent by clinical staff providing care coordination activities. CPT clearly defines which activities are care coordination activities. To report chronic care management codes, you must 1. Provide 24/7 access to physicians or other qualified health care professionals or clinical staff. 2. Use a standardized methodology to identify patients who require chronic complex care coordination services. 3. Have an internal care coordination process/function whereby a patient identified as meeting the requirements for these services starts receiving them in a timely manner. 4. Use a form and format in the medical record that is standardized within the practice. 5. Be able to engage and educate patients and caregivers, as well as coordinate care among all service professionals, as appropriate for each patient.

+ Codes are add-on codes, meaning they are reported separately in addition to the ­appropriate code for the service provided. * Indicates a CPT-approved telemedicine service. CPT ® copyright 2017 American Medical Association. All rights reserved.

99490

 hronic care management services, at least 20 minC utes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements: • multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; • chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; • comprehensive care plan established, implemented, revised, or monitored. Chronic care management services are provided when medical needs or psychosocial needs (or both types of needs) of the patient require establishing, implementing, revising, or monitoring the care plan. If 20 minutes is not met within a calendar month, you do not report chronic care management. Refer to CPT for more information.

Psychiatry +90785

Interactive complexity (Use in conjunction with codes for diagnostic psychiatric evaluation [90791, 90792], psychotherapy [90832, 90834, 90837], psychotherapy when performed with an evaluation and management service [90833, 90836, 90838, 99201–99255, 99304–99337, 99341–99350], and group psychotherapy [90853])

Psychiatric Diagnostic or Evaluative Interview ­Procedures 90791 90792

 sychiatric diagnostic interview examination P ­evaluation Psychiatric diagnostic evaluation with medical ­services

Psychotherapy *90832 Psychotherapy, 30 min with patient; *+90833 with medical E/M (Use in conjunction with 99201– 99255, 99304–99337, 99341–99350) *90834 Psychotherapy, 45 min with patient; *+90836 with medical E/M services (Use in conjunction with 99201–99255, 99304–99337, 99341–99350) *90837 Psychotherapy, 60 min with patient; *+90838 with medical E/M services (Use in conjunction with 99201–99255, 99304–99337, 99341–99350) +90785 Interactive complexity (Use in conjunction with codes for diagnostic psychiatric evaluation [90791, 90792], psychotherapy [90832, 90834, 90837], psychotherapy when performed with an evaluation and management service [90833, 90836, 90838, 99201–99255, 99304–99337, 99341–99350], and group psychotherapy [90853]) • Refers to specific communication factors that complicate the delivery of a psychiatric procedure. Common factors include more difficult communication with discordant or emotional family members and engagement of young and verbally undeveloped or impaired patients. Typical encounters include —— Patients who have other individuals legally responsible for their care —— Patients who request others to be present or involved in their care such as translators, interpreters, or additional family members

ADHD CLINICAL PRACTICE GUIDELINE QUICK REFERENCE TOOLS

—— Patients who require the involvement of other third parties such as child welfare agencies, schools, or probation officers *90846 Family psychotherapy (without patient present), 50 min *90847 Family psychotherapy (conjoint psychotherapy) (with patient present), 50 min

Other Psychiatric Services/Procedures 90863

90887

90889

 harmacologic management, including prescription P and review of medication, when performed with psychotherapy services (Use in conjunction with 90832, 90834, 90837) • For pharmacologic management with psychotherapy services performed by a physician or other qualified health care professional who may report E/M codes, use the appropriate E/M codes (99201–99255, 99281–99285, 99304–99337, 99341–99350) and the appropriate psychotherapy with E/M service (90833, 90836, 90838). • Note code 90862 was deleted. Interpretation or explanation of results of psychiatric, other medical exams, or other accumulated data to family or other responsible persons, or advising them how to assist patient Preparation of reports on patient’s psychiatric status, history, treatment, or progress (other than for legal or consultative purposes) for other physicians, agencies, or insurance carriers

27

*96116

96127

97127

Nonphysician Provider (NPP) Services 99366

99368

96120

Psychological Testing 96101

96102

96103

96110 96111

 sychological testing (includes psychodiagnostic P assessment of emotionality, intellectual abilities, personality and psychopathology, e.g., MMPI, Rorschach, WAIS), per hour of the psychologist’s or physician’s time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g., MMPI, Rorschach, WAIS), with qualified health care professional interpretation and report, administered by technician, per hour of technician time, face-to-face Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g., MMPI, Rorschach, WAIS), administered by a computer, with qualified health care professional interpretation and report Developmental screening, with scoring and documentation, per standardized instrument (Do not use for ADHD screens or assessments) Developmental testing (includes assessment of motor, language, social, adaptive and/or cognitive functioning by standardized instruments) with interpretation and report

*96150

*96151 *96152

*96153 *96154 96155

CPT ® copyright 2017 American Medical Association. All rights reserved.

 edical team conference with interdisciplinary team M of health care professionals, face-to-face with patient and/or family, 30 minutes or more, participation by a nonphysician qualified health care professional Medical team conference with interdisciplinary team of health care professionals, patient and/or family not present, 30 minutes or more, participation by a nonphysician qualified health care professional Neuropsychological testing (eg, Wisconsin Card Sorting Test), administered by a computer, with qualified health care professional interpretation and report Health and behavior assessment performed by nonphysician provider (health-focused clinical interviews, behavior observations) to identify psychological, behavioral, emotional, cognitive or social factors important to management of physical health problems, 15 min., initial assessment re-assessment Health and behavior intervention performed by nonphysician provider to improve patient’s health and well-being using cognitive, behavioral, social, and/or psychophysiological procedures designed to ameliorate specific disease-related problems, individual, 15 min. group (2 or more patients) family (with the patient present) family (without the patient present)

Non–face-to-face Services: NPP 98966

98967 98968 + Codes are add-on codes, meaning they are reported separately in addition to the ­appropriate code for the service provided. * Indicates a CPT-approved telemedicine service.

 eurobehavioral status exam (clinical assessment of N thinking, reasoning and judgment, eg, acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities), per hour of the psychologist’s or physician’s time, both face-to-face time with the patient and time interpreting test results and preparing the report Brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument Therapeutic interventions that focus on cognitive function (eg, attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (eg, managing time or schedules, initiating, organizing and sequencing tasks), direct (one-on-one) patient contact

 elephone assessment and management service T provided by a qualified nonphysician health care professional to an established patient, parent or guardian not originating from a related assessment and management service provided within the previous seven days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 5–10 minutes of medical discussion 11–20 minutes of medical discussion 21–30 minutes of medical discussion

28

98969

SECTION 1/CLINICAL PRACTICE GUIDELINES

 nline assessment and management service provided O by a qualified nonphysician health care professional to an established patient or guardian not originating from a related assessment and management service provided within the previous seven days nor using the internet or similar electronic communications network

Miscellaneous Services 99071

 ducational supplies, such as books, tapes, or pamE phlets, provided by the physician for the patient’s education at cost to the physician

Clinical Staff 99484

99492

 are management services for behavioral health C conditions, at least 20 minutes of clinical staff time, directed by a physician or other qualified health care professional, per calendar month, with the following required elements: • initial assessment or follow-up monitoring, including the use of applicable validated rating scales; • behavioral health care planning in relation to behavioral/ psychiatric health problems, including revision for patients who are not progressing or whose status changes; • facilitating and coordinating treatment such as psychotherapy, pharmacotherapy, counseling and/ or psychiatric consultation; and • continuity of care with a designated member of the care team. • Do not report in conjunction with psychiatric collaborative care management codes (99492, 99493, 99494) for the same calendar month. Initial psychiatric collaborative care management, first 70 minutes in the first calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional, with the following required elements: • outreach to and engagement in treatment of a patient directed by the treating physician or other qualified health care professional; • initial assessment of the patient, including administration of validated rating scales, with the development of an individualized treatment plan; • review by the psychiatric consultant with modifications of the plan if recommended; • entering patient in a registry and tracking patient follow-up and progress using the registry, with appropriate documentation, and participation in weekly caseload consultation with the psychiatric consultant; and • provision of brief interventions using evidencebased techniques such as behavioral activation, motivational interviewing, and other focused ­treatment strategies.

99493

 ubsequent psychiatric collaborative care manageS ment, first 60 minutes in a subsequent month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional, with the following required elements: • tracking patient follow-up and progress using the registry, with appropriate documentation; • participation in weekly caseload consultation with the psychiatric consultant; • ongoing collaboration with and coordination of the patient’s mental health care with the treating physician or other qualified health care professional and any other treating mental health providers; • additional review of progress and recommendations for changes in treatment, as indicated, including medications, based on recommendations provided by the psychiatric consultant; • provision of brief interventions using evidencebased techniques such as behavioral activation, motivational interviewing, and other focused treatment strategies; • monitoring of patient outcomes using validated rating scales; and • relapse prevention planning with patients as they achieve remission of symptoms and/or other treatment goals and are prepared for discharge from active treatment. +99494 Initial or subsequent psychiatric collaborative care management, each additional 30 minutes in a calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional (Use 99494 in conjunction with 99492, 99493)

ICD-10-CM Codes • Use as many diagnosis codes that apply to document the patient’s complexity and report the patient’s symptoms or adverse environmental circumstances (or both). • Once a definitive diagnosis is established, report any appropriate definitive diagnosis codes as the primary codes, plus any other symptoms that the patient is exhibiting as secondary diagnoses that are not part of the usual disease course or are considered incidental. • ICD-10-CM codes are only valid on or after October 1, 2015.

Depressive Disorders F34.1 F39 F30.8

Anxiety Disorders F06.4 F40.10 F40.11 F40.8

+ Codes are add-on codes, meaning they are reported separately in addition to the appropriate code for the service provided. * Indicates a CPT-approved telemedicine service.

CPT ® copyright 2017 American Medical Association. All rights reserved.

 ysthymic disorder (depressive personality disorder, D dysthymia neurotic depression) Mood (affective) disorder, unspecified Other manic episode

F40.9 F41.1 F41.9

 nxiety disorder due to known physiological A ­conditions Social phobia, unspecified Social phobia, generalized Phobic anxiety disorders, other (phobic anxiety disorder of childhood) Phobic anxiety disorder, unspecified Generalized anxiety disorder Anxiety disorder, unspecified

ADHD CLINICAL PRACTICE GUIDELINE QUICK REFERENCE TOOLS

Feeding and Eating Disorders/Elimination Disorders F50.89 F50.9 F98.0 F98.1 F98.3

Eating disorders, other Eating disorder, unspecified Enuresis not due to a substance or known physiological condition Encopresis not due to a substance or known physiological condition Pica (infancy or childhood)

Impulse Disorders F63.9

Impulse disorder, unspecified

29

F91.9 F93.0 F93.8 F93.9 F94.9 F95.0 F95.1 F95.2 F95.9 F98.8

Trauma- and Stressor-Related Disorders F43.20 F43.21 F43.22 F43.23 F43.24

Adjustment disorder, unspecified Adjustment disorder with depressed mood Adjustment disorder with anxiety Adjustment disorder with mixed anxiety and depressed mood Adjustment disorder with disturbance of conduct

Neurodevelopmental/Other Developmental ­Disorders F70 F71 F72 F73 F79 F80.0 F80.1 F80.2 F80.4 F80.81 F80.82 F80.89 F80.9 F81.0 F81.2 F81.89 F82 F84.0 F88 F89 F81.9

Mild intellectual disabilities Moderate intellectual disabilities Severe intellectual disabilities Profound intellectual disabilities Unspecified intellectual disabilities Phonological (speech) disorder (speech-sound ­disorder) Expressive language disorder Mixed receptive-expressive language disorder Speech and language developmental delay due to hearing loss (code also hearing loss) Stuttering Social pragmatic communication disorder Other developmental disorders of speech and ­language Developmental disorder of speech and language, unspecified Specific reading disorder Mathematics disorder Other developmental disorders of scholastic skills Developmental coordination disorder Autistic disorder (Autism spectrum disorder) Specified delays in development; other Unspecified delay in development Developmental disorder of scholastic skills, ­unspecified

Behavioral/Emotional Disorders F90.0 F90.1 F90.8 F90.9 F91.1 F91.2 F91.3

Attention-deficit hyperactivity disorder, predominantly inattentive type Attention-deficit hyperactivity disorder, predominantly hyperactive type Attention-deficit hyperactivity disorder, other type Attention-deficit hyperactivity disorder, unspecified type Conduct disorder, childhood-onset type Conduct disorder, adolescent-onset type Oppositional defiant disorder

+ Codes are add-on codes, meaning they are reported separately in addition to the appropriate code for the service provided. * Indicates a CPT-approved telemedicine service.

CPT ® copyright 2017 American Medical Association. All rights reserved.

Conduct disorder, unspecified Separation anxiety disorder Other childhood emotional disorders (relationship problems) Childhood emotional disorder, unspecified Childhood disorder of social functioning, unspecified Transient tic disorder Chronic motor or vocal tic disorder Tourette’s disorder Tic disorder, unspecified Other specified behavioral and emotional disorders with onset usually occurring in childhood and adolescence (nail-biting, nose-picking, thumb-sucking)

Other F07.81 F07.89

Postconcussional syndrome P  ersonality and behavioral disorders due to known physiological condition, other F07.9 Personality and behavioral disorder due to known physiological condition, unspecified  ain disorder exclusively related to psychological F45.41 P ­factors F48.8 Nonpsychotic mental disorders, other (neurasthenia) F48.9 Nonpsychotic mental disorders, unspecified F51.01 Primary insomnia F51.02 Adjustment insomnia F51.03 Paradoxical insomnia F51.04 Psychophysiologic insomnia F51.05 I nsomnia due to other mental disorder (Code also associated mental disorder) F51.09 I nsomnia, other (not due to a substance or known physiological condition) F51.3 Sleepwalking [somnambulism] F51.4 Sleep terrors [night terrors] F51.8 Other sleep disorders F93.8 Childhood emotional disorders, other R46.89 Other symptoms and signs involving appearance and behavior

Substance-Related and Addictive Disorders If a provider documents multiple patterns of use, only 1 should be reported. Use the following hierarchy: use–abuse–­dependence (eg, if use and dependence are documented, only code for ­dependence). When a minus symbol (-) is included in codes F10–F17, a last character is required. Be sure to include the last character from the following list: 0 anxiety disorder 2 sleep disorder 8 other disorder 9 unspecified disorder

Alcohol F10.10

A  lcohol abuse, uncomplicated (alcohol use disorder, mild) F10.14 Alcohol abuse with alcohol-induced mood disorder F10.159 A  lcohol abuse with alcohol-induced psychotic disorder, unspecified F10.18- Alcohol abuse with alcohol-induced F10.19 A  lcohol abuse with unspecified alcohol-induced disorder F10.20 Alcohol dependence, uncomplicated F10.21 Alcohol dependence, in remission

30

F10.24 F10.259 F10.28- F10.29 F10.94 F10.959 F10.98- F10.99

SECTION 1/CLINICAL PRACTICE GUIDELINES

 lcohol dependence with alcohol-induced mood A disorder Alcohol dependence with alcohol-induced psychotic disorder, unspecified Alcohol dependence with alcohol-induced Alcohol dependence with unspecified alcoholinduced disorder Alcohol use, unspecified with alcohol-induced mood disorder Alcohol use, unspecified with alcohol-induced psychotic disorder, unspecified Alcohol use, unspecified with alcohol-induced Alcohol use, unspecified with unspecified alcoholinduced disorder

Cannabis F12.10

 annabis abuse, uncomplicated (cannabis use disorC der, mild) F12.18- Cannabis abuse with cannabis-induced F12.19 Cannabis abuse with unspecified cannabis-induced disorder F12.20 Cannabis dependence, uncomplicated F12.21 Cannabis dependence, in remission F12.28- Cannabis dependence with cannabis-induced F12.29 Cannabis dependence with unspecified cannabisinduced disorder F12.90 Cannabis use, unspecified, uncomplicated F12.98- Cannabis use, unspecified with F12.99 Cannabis use, unspecified with unspecified cannabisinduced disorder

Sedatives F13.10

 edative, hypnotic or anxiolytic abuse, uncompliS cated (sedative, hypnotic, or anxiolytic use disorder, mild) F13.129 Sedative, hypnotic or anxiolytic abuse with intoxication, unspecified F13.14 Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced mood disorder F13.18- Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced F13.21 Sedative, hypnotic or anxiolytic dependence, in remission F13.90 Sedative, hypnotic or anxiolytic use, unspecified, uncomplicated F13.94 Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic or anxiolytic-induced mood ­disorder F13.98- Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic or anxiolytic-induced F13.99 Sedative, hypnotic or anxiolytic use, unspecified with unspecified sedative, hypnotic or anxiolytic-induced disorder

Stimulants (eg, caffeine, amphetamines) F15.10 F15.14

Other stimulant (amphetamine-related disorders or caffeine) abuse, uncomplicated (amphetamine, other or unspecified type substance use disorder, mild) Other stimulant (amphetamine-related disorders or caffeine) abuse with stimulant-induced mood ­disorder

+ Codes are add-on codes, meaning they are reported separately in addition to the ­appropriate code for the service provided. * Indicates a CPT-approved telemedicine service. CPT ® copyright 2017 American Medical Association. All rights reserved.

F15.18- O  ther stimulant (amphetamine-related disorders or caffeine) abuse with stimulant-induced F15.19 O  ther stimulant (amphetamine-related disorders or caffeine) abuse with unspecified stimulant-induced disorder F15.20 O  ther stimulant (amphetamine-related disorders or caffeine) dependence, uncomplicated F15.21 O  ther stimulant (amphetamine-related disorders or caffeine) dependence, in remission F15.24 O  ther stimulant (amphetamine-related disorders or caffeine) dependence with stimulant-induced mood disorder F15.28- Other stimulant (amphetamine-related disorders or caffeine) dependence with stimulant-induced  ther stimulant (amphetamine-related disorders or F15.29 O caffeine) dependence with unspecified stimulantinduced disorder F15.90 O  ther stimulant (amphetamine-related disorders or caffeine) use, unspecified, uncomplicated F15.94 O  ther stimulant (amphetamine-related disorders or caffeine) use, unspecified with stimulant-induced mood disorder F15.98- Other stimulant (amphetamine-related disorders or caffeine) use, unspecified with stimulant-induced F15.99 O  ther stimulant (amphetamine-related disorders or caffeine) use, unspecified with unspecified stimulantinduced disorder

Nicotine (eg, cigarettes) F17.200 N  icotine dependence, unspecified, uncomplicated (tobacco use disorder, mild, moderate or severe) F17.201 Nicotine dependence, unspecified, in remission F17.203 Nicotine dependence, unspecified, with withdrawal F17.20- Nicotine dependence, unspecified, with F17.210 Nicotine dependence, cigarettes, uncomplicated F17.211 Nicotine dependence, cigarettes, in remission F17.213 Nicotine dependence, cigarettes, with withdrawal F17.218- Nicotine dependence, cigarettes, with

Symptoms, Signs, and Ill-defined Conditions Use these codes in absence of a definitive mental diagnosis or when the sign or symptom is not part of the disease course or is considered incidental. G47.9 Sleep disorder, unspecified H90.0 Conductive hearing loss, bilateral H90.11 C  onductive hearing loss, unilateral, right ear, with unrestricted hearing on the contralateral side H90.12 C  onductive hearing loss, unilateral, left ear, with unrestricted hearing on the contralateral side H90.A1- Conductive hearing loss, unilateral, with restricted hearing on the contralateral side H90.A2- Sensorineural hearing loss, unilateral, with restricted hearing on the contralateral side H90.A3- Mixed conductive and sensorineural hearing loss, unilateral, with restricted hearing on the contralateral side (Codes under category H90 require a 6th digit: 1– right ear, 2–left ear) K11.7 Disturbance of salivary secretions K59.00 Constipation, unspecified N39.44 Nocturnal enuresis R10.0 Acute abdomen pain R11.11 Vomiting without nausea R11.2 Nausea with vomiting, unspecified

ADHD CLINICAL PRACTICE GUIDELINE QUICK REFERENCE TOOLS

R19.7 Diarrhea, unspecified R21 Rash, NOS R25.0 Abnormal head movements R25.1 Tremor, unspecified R25.3 Twitching, NOS R25.8 Other abnormal involuntary movements R25.9 Unspecified abnormal involuntary movements R27.8 Other lack of coordination (excludes ataxia) R27.9 Unspecified lack of coordination R41.83 Borderline intellectual functioning Dizziness R42 R48.0 Alexia/dyslexia, NOS Headache R51 R62.0 Delayed milestone in childhood R62.52 Short stature (child) R63.3 Feeding difficulties R63.4 Abnormal weight loss R63.5 Abnormal weight gain R68.2 Dry mouth, unspecified T56.0X1A Toxic effect of lead and its compounds, accidental (unintentional), initial encounter

Z Codes Z codes represent reasons for encounters. Categories Z00–Z99 are provided for occasions when circumstances other than a disease, an injury, or an external cause classifiable to categories A00–Y89 are recorded as diagnoses or problems. This can arise in 2 main ways. 1. When a person who may or may not be sick encounters the health services for some specific purpose, such as to receive limited care or service for a current condition, to donate an organ or tissue, to receive prophylactic vaccination (immunization), or to discuss a problem that is, in itself, not a disease or an injury 2. When some circumstance or problem is present that influences the person’s health status but is not, in itself, a current illness or injury Z13.89 Encounter for screening for other disorder Z55.0 Illiteracy and low-level literacy Z55.2 Failed school examinations Z55.3 Underachievement in school Z55.4 Educational maladjustment and discord with teachers and classmates Z55.8 Other problems related to education and literacy Z55.9 Problems related to education and literacy, ­unspecified ( Z55 codes exclude those conditions reported with F80–F89) Z60.4 Social exclusion and rejection Z60.8 Other problems related to social environment

+ Codes are add-on codes, meaning they are reported separately in addition to the ­appropriate code for the service provided. * Indicates a CPT-approved telemedicine service. CPT ® copyright 2017 American Medical Association. All rights reserved.

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Z60.9 Z62.0 Z62.21 Z62.6 Z62.810 Z62.811 Z62.820 Z62.821 Z62.822 Z63.72 Z63.8 Z65.3 Z71.89 Z71.9 Z72.0 Z77.011 Z79.899 Z81.0 Z81.8 Z83.2 Z86.2 Z86.39 Z86.59 Z86.69 Z87.09 Z87.19 Z87.798 Z87.820 Z91.128 Z91.138 Z91.14 Z91.19 Z91.411

Problem related to social environment, unspecified Inadequate parental supervision and control Foster care status (child welfare) Inappropriate (excessive) parental pressure Personal history of physical and sexual abuse in childhood Personal history of psychological abuse in childhood Parent-biological child conflict Parent-adopted child conflict Parent-foster child conflict Alcoholism and drug addiction in family O  ther specified problems related to primary support group Problems related to legal circumstances Counseling, other specified Counseling, unspecified Tobacco use Contact with and (suspected) exposure to lead Other long term (current) drug therapy Family history of intellectual disabilities (conditions classifiable to F70–F79) Family history of other mental and behavioral ­disorders F  amily history of diseases of the blood and bloodforming organs (anemia) (conditions classifiable to D50–D89) Personal history of diseases of the blood and bloodforming organs P  ersonal history of other endocrine, nutritional, and metabolic disease P  ersonal history of other mental and behavioral ­disorders P  ersonal history of other diseases of the nervous system and sense organs P  ersonal history of other diseases of the respiratory system P  ersonal history of other diseases of the digestive system P  ersonal history of other (corrected) congenital ­malformations Personal history of traumatic brain injury Patient’s intentional underdosing of medication regimen for other reason (report drug code) Patient’s unintentional underdosing of medication regimen for other reason (report drug code) P  atient’s other noncompliance with medication regimen P  atient’s noncompliance with other medical treatment and regimen Personal history of adult psychological abuse

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SECTION 1/CLINICAL PRACTICE GUIDELINES

Continuum Model for ADHD The following continuum model from Coding for Pediatrics 2018 has been devised to express the various levels of service for ADHD. This model demonstrates the cumulative effect of the key criteria for each level of service using a single diagnosis as the common denominator. It also shows the importance of other variables, such as patient age, duration and severity of illness, social contexts, and comorbid conditions, that often have key roles in pediatric cases.

Quick Reference for Codes Used in Continuum for ADHD—Established Patientsa E/M Code Level

History

Examination

MDM

Time

99211b

NA

NA

NA

5 min

99212

Problem-focused

Problem-focused

Straightforward

10 min

99213

Expanded problemfocused

Expanded problemfocused

Low

15 min

99214

Detailed

Detailed

Moderate

25 min

99215

Comprehensive

Comprehensive

High

40 min

Abbreviations: ADHD, attention-deficit/hyperactivity disorder; E/M, evaluation and management; MDM, medical decision-making; NA, not applicable. a Use of a code level requires that you meet or exceed 2 of the 3 key components on the basis of medical necessity. b Low level E/M service that may not require the presence of a physician.

Adapted from American Academy of Pediatrics. Coding for Pediatrics 2018: A Manual for Pediatric Documentation and Payment. 23rd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2018. CPT® copyright 2017 American Medical Association. All rights reserved.

Chapter 7: Evaluation and Management Services in the Office, Outpatient, Home, or Nursing Facility Setting

Medical Decision-making

99211a Nurse visit to follow up growth or blood pressure prior to renewing prescription for psychoactive drugs

1. Chief complaint 2. Brief HPI, existing medications, and desired/undesired effects

1. Weight, blood pressure 2. Overall appearance

1. Refill existing prescription.

99212 Follow-up visit to recheck prior weight loss in patient with established ADHD otherwise stable on stimulant medication

Problem focused 1. Chief complaint 2. Brief HPI, existing medications, and desired/undesired effects

Problem focused 1. Weight, blood pressure 2. Overall appearance

Straightforward 1. Refill existing prescription.

99213 (Typical time: 15 min) 3- to 6-month follow-up of child with ADHD who is presently doing well using medication and without other problems OR May be reported based on time if more than 50% of the faceto-face encounter is spent in counseling and/or coordination of care

Expanded problem focused 1. Reason for the visit 2. Review of medications 3. Effect of medication on appetite, mood, sleep 4. Quality of schoolwork (eg, review report cards) 5. Absence of tics 6. Problem-pertinent ROS

Expanded problem focused 1. General multisystem examination or single organ system examination with special reference to neurologic examination

Low complexity 1. Review rating scale results and feedback materials from teacher. 2. Discuss 6-month treatment plan with adjustment of medication. 3. Plan for further monitoring.

99214 (Typical time: 25 min) Follow-up evaluation of an established patient with ADHD with failure to improve on medication and/or weight loss OR May be reported based on time if more than 50% of the faceto-face encounter is spent in counseling and/or coordination of care

Detailed All data implicit in 99213 expanded plus pertinent review of PFSH and extended ROS, including gastrointestinal and psychiatric

Detailed 1. General multisystem examination or detailed single organ system examination of neurologic system

Moderate complexity 1. Review rating scale results and feedback materials from teacher. 2. Discussion of possible interventions, including, but not limited to a. Educational intervention b. Alteration in medications c. Obtaining drug levels d. Psychiatric intervention e. Behavioral modification program

CHAPTER 7: EVALUATION AND MANAGEMENT SERVICES

Physical Examination

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History

208

CPT Code Vignette

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CPT copyright 2017 American Medical Association. All rights reserved.

Continuum Model for Attention-Deficit/Hyperactivity Disorder ®

33

34

CPT® Code Vignette

History

Physical Examination

Medical Decision-making

99215 (Typical time: 40 min) Initial evaluation of an established patient experiencing difficulty in classroom, home, or social situation and suspected of having ADHD This could be billed as a consultation if the established patient is referred by school for opinion or advice (not transfer of care) and the criteria for reporting a consultation are met. May be reported based on time if more than 50% of the faceto-face encounter is spent in counseling and/or coordination of care

Comprehensive 1. Chief complaint 2. History of the problem, extended 3. Complete PFSH 4. Complete ROS

Comprehensive 1. General multisystem examination with special attention to neurologic examination and mental health status

High complexity Review of Vanderbilt scales, school record, any other formal evaluations completed to date; discussion of differential diagnoses; possible interventions including, but not limited to 1. Educational interventions 2. Initiation of medications 3. Obtaining drug levels or ruling out substance abuse, if appropriate 4. Laboratory tests as indicated (eg, complete blood cell count and iron studies, serum lead levels) 5. Psychological and/or psychiatric interventions 6. Behavioral modification program 7. Consideration of neurology consultation 8. Coordination of care services with school, family, and other providers

Abbreviations: ADHD, attention-deficit/hyperactivity disorder; CPT, Current Procedural Terminology; HPI, history of present illness; PFSH, past, family, and social history; ROS, review of systems. There are no required key components for code 99211; however, the nurse must document his or her history, physical examination, and assessment to support medical necessity.

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Chapter 7: Evaluation and Management Services in the Office, Outpatient, Home, or Nursing Facility Setting

a

CONTINUUM MODELS fOR OTITIS MEDIA, ATTENTION-DEfICIT/HyPERACTIVITy DISORDER, AND ASTHMA

CPT copyright 2017 American Medical Association. All rights reserved.

Continuum Model for Attention-Deficit/Hyperactivity Disorder (continued )

ADHD CLINICAL PRACTICE GUIDELINE QUICK REFERENCE TOOLS

35

Understanding ADHD: Information for Parents About Attention-Deficit/Hyperactivity Disorder Almost all children have times when their behavior veers out of control. However, for some children, these kinds of behaviors are more than an occasional problem. Children with attention-deficit/hyperactivity disorder (ADHD) have behavioral problems that are so frequent and severe that they interfere with their ability to live normal lives. An impulsive nature may put them in actual physical danger. They may speed about in constant motion, make noise nonstop, refuse to wait their turn, and crash into everything around them. At other times, they may drift as if in a daydream, unable to pay attention or finish what they start. Those who have trouble paying attention usually have trouble learning.

Table 1. Symptoms of ADHD Symptom

How a Child With This Symptom May Behave

Inattention

Often has a hard time paying attention, daydreams Often does not seem to listen Is easily distracted from work or play Often does not seem to care about details, makes careless mistakes

Left untreated, ADHD in some children will continue to cause serious, lifelong problems, such as poor grades in school, run-ins with the law, failed relationships, and the inability to keep a job. Children with ADHD often have trouble getting along with siblings and other children at school, at home, and in other settings. They may be labeled “bad kids” or “space cadets.” If your child has ADHD, effective treatment is available. Your child’s doctor can offer a long-term treatment plan to help your child lead a happy and healthy life. As a parent, you have a very important role in this treatment. Here is more information from the American Academy of Pediatrics about ADHD and how you can help your child.

Frequently does not follow through on instructions or finish tasks Is disorganized Frequently loses a lot of important things Often forgets things Frequently avoids doing things that require ongoing mental effort Hyperactivity

NOTE: To make reading this publication easier, the pronoun he is used to describe a child or teen.

Cannot stay seated Frequently squirms and fidgets Talks too much

What is ADHD? ADHD is a condition of the brain that makes it difficult for children to control their behavior. It is one of the most common chronic conditions of childhood. It affects 6% to 12% of school-aged children. ADHD is diagnosed about 3 times more often in boys than in girls. The condition affects behavior in specific ways. See section, What are the symptoms of ADHD?

What are the symptoms of ADHD? ADHD includes 3 groups of behavioral symptoms: inattention, hyperactivity, and impulsivity. See Table 1.

Are there different types of ADHD? Children with ADHD may have one or more of the symptoms listed in Table 1. The symptoms are usually classified as the following types of ADHD: • Inattentive only (formerly known as attention-deficit disorder [ADD]) — Children with this form of ADHD are not overly active. Because they do not disrupt the classroom or other activities, their symptoms may not be noticed. Among girls with ADHD, this form is more common. • Hyperactive/impulsive — Children with this type of ADHD have both hyperactive and impulsive behavior, but they can pay attention. They are the least common group and are often younger.

Is in constant motion, as if “driven by a motor”

Often runs, jumps, and climbs when this is not permitted Cannot play quietly Impulsivity

Frequently acts and speaks without thinking May run into the street without looking for traffic first Frequently has trouble taking turns Cannot wait for things Often calls out answers before the question is complete Frequently interrupts others

• Combined inattentive/hyperactive/impulsive — Children with this type of ADHD have behaviors from all 3 symptoms. It is the type most people think of when they think of ADHD.

How can I tell if my child has ADHD? Remember, it is common for all children to show some of these symptoms from time to time. Your child may be reacting to stress at school or at home. He may be bored or going through a difficult stage of life. It does not mean he has ADHD. Sometimes a teacher is the first to notice inattention, hyperactivity, and/or impulsivity and will inform the parents.

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SECTION 1/CLINICAL PRACTICE GUIDELINES

Keep Safety in Mind If your child shows any symptoms of ADHD, it is very important that you pay close attention to safety. A child with ADHD may not always be aware of dangers and can get hurt easily. Be especially careful around • Traffic • Firearms • Swimming pools • Tools and equipment, such as lawn mowers • Poisonous chemicals, cleaning supplies, or medicines

Maybe questions from your child’s doctor raised the issue. At well-child visits, your child’s doctor may ask

with parents and siblings, building relationships with friends, or having the ability to function in groups such as sports teams. In addition to looking at your child’s behavior, your child’s doctor will conduct a physical and neurological examination. A full medical history will be needed to put your child’s behavior in context and screen for other conditions that may affect his behavior. Your child’s doctor will also talk with your child about how he acts and feels. Your child’s doctor may refer your child to a pediatric subspecialist or mental health clinician if there are concerns in any of the following areas: • Intellectual disability (previously called mental retardation) • Developmental disorder, such as speech or motor disorders or a learning disability • Chronic illness being treated with a medication that may interfere with learning • Trouble seeing and/or hearing

• How is your child doing in school?

• History of abuse

• Are there any problems with learning that you or your child’s teachers have seen?

• Major anxiety or major depression

• Is your child happy in school? • Is your child having problems completing class work or homework? • Are you concerned with any behavioral problems in school, at home, or when your child is playing with friends? Your answers to these questions may lead to further evaluation for ADHD. If your child has shown symptoms of ADHD on a regular basis for more than 6 months, discuss this with his doctor.

How is ADHD diagnosed? Your child’s doctor will determine whether he has ADHD by using standard guidelines developed by the American Academy of Pediatrics specifically for children 4 to 18 years of age. It is difficult to diagnose ADHD in children younger than 4 years. This is because younger children change very rapidly. It is also more difficult to diagnose ADHD once a child becomes a teen. There is no single test for ADHD. The process requires several steps and involves gathering information from multiple sources. You, your child, your child’s school, and other caregivers should be involved in assessing your child’s behavior. Children with ADHD show signs of inattention, hyperactivity, and/or impulsivity in specific ways. (See the behaviors listed in Table 1.) Your child’s doctor will look at how your child’s behavior compares to that of other children his age, based on the information reported about your child by you, his teacher, and any other caregivers who spend time with your child, such as coaches or child care workers.

• Severe aggression • Possible seizure disorder • Possible sleep disorder

How can parents help with the diagnosis? As a parent, you will provide crucial information about your child’s behavior and how it affects his life at home, in school, and in other social settings. Your child’s doctor will want to know what symptoms your child is experiencing, how long the symptoms have occurred, and how the behavior affects your child and your family. You may need to fill in checklists or rating scales about your child’s behavior. In addition, sharing your family history can offer important clues about your child’s condition.

How will my child’s school be involved? For an accurate diagnosis, your child’s doctor will need to get information about your child directly from his classroom teacher or another school professional. Children at least 4 years and older spend many of their waking hours at preschool or school. Teachers provide valuable insights. Your child’s teacher may write a report or discuss the following topics with your child’s doctor: • Your child’s behavior in the classroom • Your child’s learning patterns • How long the symptoms have been a problem • How the symptoms are affecting your child’s progress at school • Ways the classroom program is being adapted to help your child

Here are guidelines used to confirm a diagnosis of ADHD.

• Whether other conditions may be affecting the symptoms

• Some symptoms occur in 2 or more settings, such as home, school, and social situations, and cause some impairment.

In addition, your child’s doctor may want to see report cards, standardized tests, and samples of your child’s schoolwork.

• In a child 4 to 17 years of age, 6 or more symptoms must be identified.

How will others who care for my child be involved?

• In a teen 17 years and older, 5 or more symptoms must be identified. • Symptoms significantly impair your child’s ability to function in some daily activities, such as doing schoolwork, maintaining relationships

Other caregivers may also provide important information about your child’s behavior. Former teachers, religious and scout leaders, or coaches may have valuable input. If your child is homeschooled,

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ADHD CLINICAL PRACTICE GUIDELINE QUICK REFERENCE TOOLS

it is especially important to assess his behavior in settings outside of the home. Your child may not behave the same way at home as he does in other settings. Direct information about the way your child acts in more than one setting is required. It is important to consider other possible causes of your child’s symptoms in these settings.

37

language. A speech-and-language clinician can detect it by observing how a child uses language in his day-to-day activities.

Are there other tests for ADHD? You may have heard theories about other tests for ADHD. There are no other proven diagnostic tests at this time.

In some cases, other mental health care professionals, such as child psychologists or psychiatrists, may also need to be involved in gathering information for the diagnosis.

Many theories have been presented, but studies have shown that the following evaluations add little value in diagnosing the disorder:

What are coexisting conditions?

• Computerized continuous performance tests

As part of the diagnosis, your child’s doctor will look for other conditions that cause the same types of symptoms as ADHD. Your child may simply have a different condition or ADHD combined with another condition (a coexisting condition). Most children with a diagnosis of ADHD have at least one additional condition.

• Brain imaging studies, such as computed tomography (CT) scans and magnetic resonance imaging (MRI)

Common coexisting conditions include • Learning disabilities — Learning disabilities are conditions that make it difficult for a child to master specific skills, such as reading or math. ADHD is not a learning disability. However, ADHD can make it hard for a child to do well in school. Diagnosing learning disabilities requires conducting evaluations, such as IQ and academic achievement tests, and it requires educational interventions. • Oppositional defiant disorder or conduct disorder — Up to 35% of children with ADHD also have oppositional defiant disorder or conduct disorder. — Children with oppositional defiant disorder tend to lose their temper easily and annoy people on purpose, and they are defiant and hostile toward authority figures. — Children with conduct disorder break rules, destroy property, get suspended or expelled from school, violate the rights of other people, or can be cruel to other children or animals. — Children with coexisting conduct disorder are at much higher risk for getting into trouble with the law or having substance use problems than children who have only ADHD. Studies show that this type of coexisting condition is more common among children with the primarily hyperactive/impulsive and combination types of ADHD. Your child’s doctor may recommend behavioral therapy for your child if he has this condition. • Mood disorders/depression — About 18% of children with ADHD also have mood disorders, such as depression or bipolar disorder (formerly called manic depressive disorder). There is often a family history of these conditions. Coexisting mood disorders may put children at higher risk for suicide, especially during the teen years. These disorders are more common among children with inattentive and combined types of ADHD. Children with mood disorders or depression often require additional interventions or a different type of medication than those typically used to treat ADHD. • Anxiety disorders — About 25% of children with ADHD also have anxiety disorders. Children with anxiety disorders have extreme feelings of fear, worry, or panic that make it difficult to function. These disorders can produce physical symptoms, such as racing pulse, sweating, diarrhea, and nausea. Counseling and/or different medication may be needed to treat these coexisting conditions. • Language disorders — Children with ADHD may have difficulty with how they use language. This is referred to as a pragmatic language disorder. It may not show up with standard tests of

• Screening for thyroid problems

• Electroencephalography (EEG) or brain-wave testing While these evaluations are not helpful in diagnosing ADHD, your child’s doctor may see other signs or symptoms in your child that warrant blood tests, brain imaging studies, or EEG.

What causes ADHD? ADHD is one of the most studied conditions of childhood, and it may be caused by a number of things. Research to date has shown • ADHD is a neurobiological condition in which symptoms are also dependent on the child’s environment. • A lower level of activity in the parts of the brain that control attention and activity level may be associated with ADHD. • ADHD often runs in families. Sometimes ADHD is diagnosed in a parent at the same time it is diagnosed in the child. • In very rare cases, toxins in the environment may lead to ADHD. For instance, lead in the body can affect child development and behavior. Lead may be found in many places, including homes built before 1978, when lead was added to paint. • Significant head injuries may cause ADHD in some cases. • Preterm birth increases the risk of developing ADHD. • Prenatal substance exposures, such as alcohol or nicotine from smoking, increase the risk of developing ADHD. There is little evidence that ADHD is caused by • Eating too much sugar • Food additives or food colorings • Allergies • Immunizations

How is ADHD treated? Once the diagnosis is confirmed, the outlook for most children who receive treatment for ADHD is encouraging. There is no specific cure for ADHD, but there are many treatment options available, and some children learn to compensate for the difficulties as they mature. Each child’s treatment must be tailored to meet his individual needs. In most cases, treatment for ADHD should include • A long-term management plan with — Target outcomes for behavior — Follow-up activities — Monitoring

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• Education about ADHD • Teamwork among doctors, parents, teachers, caregivers, other health care professionals, and the child

Table 2. Behavioral Therapy Techniques Technique

Description

Example

Positive Complimenting the child reinforcement and providing rewards or privileges in response to a desired behavior.

The child completes an assignment and is permitted to play on the computer.

Treatment for ADHD is based on the same principles that are used to treat other chronic conditions, like asthma or diabetes. Long-term planning for many children is needed because these conditions are not curable. However, some children learn to compensate once they are adults. Families must manage chronic conditions on an ongoing basis. In the case of ADHD, schools and other caregivers must also be involved in managing the condition.

Time-out

Removing access to a desired activity because of unwanted behavior.

The child hits a sibling and, as a result, must sit for 5 minutes in the corner of the room.

Response cost

Withdrawing rewards or privileges because of unwanted behavior.

The child loses free-time privileges for not completing homework.

Educating the people involved with your child is a key part of treatment for ADHD. As a parent, you will need to learn about the condition. Read about it and talk with people who understand it. This will help you manage the ways ADHD affects your child and your family on a day-to-day basis. It will also help your child learn to help himself.

Token economy

Combining reward and consequence. The child earns rewards and privileges when exhibiting desired behaviors. He loses rewards and privileges for unwanted behaviors.

The child earns stars or points for completing assignments and loses stars for getting out of his seat. He cashes in the sum of his stars or points at the end of the week for a prize.

• Behavioral therapy, including parent training • Individual and family counseling • Medication

What are target outcomes? At the beginning of treatment, your child’s doctor should help you set around 3 target outcomes (goals) for your child’s behavior. These target outcomes will guide the treatment plan. Your child’s target outcomes should be chosen to help him function as well as possible at home, at school, and in your community. You need to identify what behaviors are most preventing your child from succeeding. Here are examples of target outcomes. • Improved relationships with parents, siblings, teachers, and friends — for example, fewer arguments with brothers or sisters or being invited more often to friends’ houses or parties. • Better schoolwork practices — for example, completing all classwork or homework assignments. • More independence in self-care or homework — for example, getting ready for school in the morning without supervision. • Improved self-esteem, such as feeling that he can get his work done. • Fewer disruptive behaviors — for example, decreasing the number of times he refuses to obey rules. • Safer behavior in the community — for example, being careful when crossing streets. The target outcomes should be • Realistic • Something your child will be able to do • Behaviors that you can observe and count (with rating scales) Your child’s treatment plan will be set up to help him achieve these goals.

What is behavioral therapy? Most experts recommend using both behavioral therapy and medication to treat ADHD. This is known as a multimodal treatment approach. There are many forms of behavioral therapy, but all have a common goal — to change the child’s physical and social environments to help the child improve his behavior.

Behavioral therapy has 3 basic principles. 1. Set specific, doable goals. Set clear and reasonable goals for your child, such as staying focused on homework for a certain amount of time or sharing toys with friends. 2. Provide rewards and consequences. Give your child a specified reward (positive reinforcement) every time he demonstrates the desired behavior. Give your child a consequence (unwanted result or punishment) consistently when he exhibits inappropriate behaviors. 3. Keep using the rewards and consequences. Using the rewards and consequences consistently for a long time will shape your child’s behavior in a positive way. Under this approach, parents, teachers, and other caregivers learn better ways to work with and relate to the child with ADHD. You will learn how to set and enforce rules, help your child understand what he needs to do, use discipline effectively, and encourage good behavior. Your child will learn better ways to control his behavior as a result. You will learn how to be more consistent. Table 2 shows specific behavioral therapy techniques that can be effective with children who have ADHD. Behavioral therapy is designed to recognize the limits that having ADHD puts on a child. It focuses on how the important people and places in the child’s life can adapt to encourage good behavior and discourage unwanted behavior. It is different from play therapy or other therapies that focus mainly on the child and his emotions.

How can I help my child control his behavior? As the child’s primary caregivers, parents play a major role in behavioral therapy. Parent training is available to help you learn more about ADHD and specific, positive ways to respond to ADHD-type behaviors. This will help your child improve. In many cases, attending parenting classes with other parents will be sufficient, but with more challenging children, individual work with a counselor or coach may be needed.

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Taking care of yourself will also help your child. Being the parent of a child with ADHD can be tiring and trying. It can test the limits of even the best parents. Parent training and support groups made up of other families who are dealing with ADHD can be a great source of help. Learn stress-management techniques to help you respond calmly to your child. Seek counseling if you feel overwhelmed or hopeless. Ask your child’s doctor to help you find parent training, counseling, and support groups in your community. See the Resources section. What you can do • Keep your child on a daily schedule. Try to keep the time that your child wakes up, eats, bathes, leaves for school, and goes to sleep the same each day. • Cut down on distractions. Loud music, computer games, and TV can be overstimulating to your child. Make it a rule to keep the TV or music turned off during mealtime and while your child is doing homework. Don’t place a TV in your child’s bedroom. Whenever possible, avoid taking your child to places that may be too stimulating, such as busy shopping malls. • Organize your house. If your child has specific and logical places to keep his schoolwork, toys, and clothes, he is less likely to lose them. Save a spot near the front door for his school backpack so he can grab it on the way out the door. • Reward positive behavior. Offer kind words, hugs, or small prizes for reaching goals in a timely manner or for good behavior. Praise and reward your child’s efforts to pay attention. • Set small, reachable goals. Aim for slow progress rather than instant results. Be sure that your child understands that he can take small steps toward learning to control himself. • Help your child stay “on task.” Use charts and checklists to track progress with homework or chores. Keep instructions brief. Offer frequent, friendly reminders.

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• Using small groups for activities • Encouraging students to pause a moment before answering questions • Keeping assignments short or breaking them into sections • Supervising the child closely and giving frequent, positive cues to stay on task • Changing where and how tests are given so students can succeed — for example, allowing students to take tests in a less distracting environment or allowing more time to complete tests Your child’s school should work with you and your child’s doctor to develop strategies to assist your child in the classroom. When a child has ADHD that is severe enough to interfere with his ability to learn, 2 federal laws offer help. These laws require public schools to provide or cover costs of evaluating the educational needs of the affected child and providing the needed services. 1. The Individuals With Disabilities Education Act (IDEA), Part B, requires public schools to provide or cover costs of evaluating the educational needs of the affected child and providing the needed special education services if your child qualifies because his learning is impaired by his ADHD. The diagnosis alone will not necessarily qualify your child for these services. 2. Section 504 of the Rehabilitation Act of 1973 does not have strict qualification criteria but is limited to changes in the classroom, modifications in homework assignments, and taking tests in a less distracting environment or allowing more time to complete tests. Usually, the diagnosis alone will qualify your child for these services. If your child has ADHD and a coexisting condition, he may need additional special services, such as a classroom aide, private tutoring, special classroom settings, or, in rare cases, a special school.

• Limit choices. Help your child learn to make good decisions by giving him only 2 or 3 options at a time.

It is important to remember that once ADHD is diagnosed and treated, children with the disorder are more likely to achieve their goals in school.

• Find activities at which your child can succeed. All children need to experience success to feel good about themselves.

What types of medication relieve ADHD symptoms?

• Use calm discipline. Use consequences such as time-out, removing the child from the situation, or distraction. Sometimes it is best to simply ignore the behavior. Physical punishment, such as spanking or slapping, is not helpful. Discuss your child’s behavior with him when both of you are calm.

For most children, stimulant medications are a safe and effective way to relieve ADHD symptoms. Just as glasses focus a person’s eyesight so they can see better, these medications help children with ADHD focus their thoughts better and ignore distractions. This makes them more able to pay attention and control their behavior.

• Reach out to teachers. Develop a good communication system with your child’s teachers so that you can coordinate your efforts and monitor your child’s progress.

Stimulants may be used alone or in combination with behavioral therapy. Studies show that about 80% of children with ADHD who are treated with stimulants improve a great deal once the right medication and dose are determined.

How can my child’s school help? Your child’s school is a key partner in providing effective behavioral therapy for your child. In fact, these principles work well in the classroom for most students. Classroom management techniques may include • Keeping a set routine and schedule for activities • Using a system of clear rewards and consequences, such as a point system or token economy (see Table 2) • Sending daily or weekly report cards or behavioral charts to parents to inform them about the child’s progress • Seating the child near the teacher

Two forms of stimulants are available: immediate release (short acting) and extended release (intermediate acting and long acting). (See Table 3.) Immediate-release medications are usually taken every 4 hours, when needed. They are the cheapest of the medications. Extended-release medications are usually taken once in the morning. Children who use extended-release forms of stimulants can avoid taking medication at school or after school. It is important not to chew or crush extended-release capsules or tablets. However, extendedrelease capsules that are made up of beads and lisdexamfetamine can be opened and sprinkled onto food for children who have difficulties swallowing tablets or capsules. Nonstimulants can be tried when stimulant medications don’t work or if they cause bothersome side effects.

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Table 3. Common ADHD Medications Type of Medication

Brand Name

Generic Name

Duration

Short-acting amphetamine stimulants

Adderall

Mixed amphetamine salts

4 to 6 hours

Dexedrine

Dextroamphetamine

4 to 6 hours

Focalin

Dexmethylphenidate

3 to 5 hours

Methylin

Methylphenidate (tablet, liquid, and chewable tablets)

3 to 5 hours

Ritalin

Methylphenidate

3 to 5 hours

Metadate ER

Methylphenidate

4 to 6 hours

Methylin ER

Methylphenidate

4 to 6 hours

Focalin XR

Dexmethylphenidate

6 to 8 hours

Metadate CD

Methylphenidate

6 to 8 hours

Ritalin LA

Methylphenidate

6 to 8 hours

Adderall XR

Mixed amphetamine salts

8 to 12 hours

Adzenys XR-ODT

Amphetamine

8 to 12 hours

Dyanavel XR

Amphetamine (liquid)

8 to 12 hours

Vyvanse

Lisdexamfetamine

8 to 12 hours

Concerta

Methylphenidate

10 to 12 hours

Daytrana

Methylphenidate (skin patch)

11 to 12 hours

Quillivant XR

Methylphenidate (liquid)

10 to 12 hours

Intuniv

Guanfacine

24 hours

Kapvay

Clonidine

12 hours

Strattera

Atomoxetine

24 hours

Short-acting methylphenidate stimulants

Mildly extended-release methylphenidate stimulants Intermediate-acting extended-release methylphenidate stimulants

Long-acting extended-release amphetamine stimulants

Long-acting extended-release methylphenidate stimulants

α-Adrenergic agents (nonstimulants) Selective norepinephrine reuptake inhibitors (nonstimulants)

Products are mentioned for informational purposes only and do not imply an endorsement by the American Academy of Pediatrics. Your doctor or pharmacist can provide you with important safety information for the products listed.

Which medication is best for my child?

• Sleep problems

It may take some time to find the best medication, dosage, and dosing schedule for your child.

• Social withdrawal

Your child may need to try different types of stimulants or other medication. Some children respond to one type of stimulant but not another.

• Rebound effect (increased activity or a bad mood as the medication wears off)

The amount of medication (dosage) that your child needs may also need to be adjusted. The dosage is not based solely on his weight. Your child’s doctor will vary the dosage over time to get the best results and control possible side effects. The medication schedule may also be adjusted, depending on the target outcome. For example, if the goal is to relieve symptoms that mostly occur at school, your child may take the medication only on school days. It is important for your child to have regular medical checkups to monitor how well the medication is working and check for possible side effects.

What side effects can stimulants cause? Side effects occur sometimes. These tend to happen early in treatment and are usually mild and short-lived, but in rare cases, they can be prolonged or more severe. The most common side effects include • Decreased appetite/weight loss

Some less common side effects include

• Transient muscle movements or sounds, called tics • Minor growth delay Very rare side effects include • Significant increase in blood pressure or heart rate • Bizarre behaviors • Hallucinations The same sleep problems do not exist for atomoxetine, but initially, this medication may make your child sleepy or upset his stomach. There have been very rare cases of atomoxetine needing to be stopped because it was causing liver damage. Rarely, atomoxetine increased thoughts of suicide. Extended-release guanfacine or clonidine can cause drowsiness, fatigue, or decreased blood pressure. More than half of children who have tic disorders, such as Tourette syndrome, also have ADHD. Tourette syndrome is a familial condition associated with frequent tics and unusual vocal sounds. The effect of stimulants on tics is not predictable, although most studies indicate that stimulants are safe for children with ADHD and tic disorders in most cases. It is also possible to use atomoxetine or guanfacine for children with ADHD and Tourette syndrome.

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Most side effects can be relieved by • Changing the medication dosage • Adjusting the schedule of medication • Using a different stimulant or trying a nonstimulant (see Table 3) Regular communication with your child’s doctor is required until you find the best medication and dose for your child. After that, periodic monitoring by your doctor is important to maintain the best effects. To monitor the effects of the medication, your child’s doctor will probably have you and your child’s teacher(s) fill out behavior rating scales, observe changes in your child’s target goals, notice any side effects, and monitor your child’s height, weight, pulse, and blood pressure. Stimulants, atomoxetine, and extended-release guanfacine or clonidine may not be an option for children who are taking certain other medications or who have some medical conditions, such as congenital heart disease.

How do I know if my child’s treatment plan is working? Ongoing monitoring of your child’s behavior and medications is required to find out if the treatment plan is working. Office visits, phone conversations, behavioral checklists, written reports from teachers, and behavioral report cards are common tools for following your child’s progress. Treatment plans for ADHD usually require long-term efforts on the part of families and schools. Medication schedules may be complex. Behavioral therapies require education and patience. Sometimes it can be hard for everyone to stick with it. Your efforts play an important part in building a healthy future for your child. Ask your child’s doctor to help you find ways to keep your child’s treatment plan on track.

What if my child does not reach his target outcomes? Most school-aged children with ADHD respond well when their treatment plan includes both medication and behavioral therapy. If your child is not achieving his goals, your child’s doctor will assess the following factors:

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adequately. According to the National Institute of Mental Health, about 80% of those who required medication for ADHD as children still need it during the teen years. Parents play an important role in helping their teens become independent. Encourage your teen to help himself with strategies such as • Using a daily planner for assignments and appointments • Being safety conscious, such as always wearing seat belts and using protective gear for sports • G etting enough sleep • Keeping a routine • Making lists • Organizing storage for items such as school supplies, clothes, CDs, and sports equipment • Setting aside a quiet time and place to do homework • Talking about problems with someone he trusts • Understanding his increased risk of abusing substances, such as tobacco and alcohol Activities such as sports, drama, and debate teams can be good places to channel excess energy and develop friendships. Find what your teen does well and support his efforts to “go for it.” Milestones such as learning to drive and dating offer new freedom and risks. Parents must stay involved and set limits for safety. Your teen’s ADHD increases his risk of incurring traffic violations and accidents. It remains important for parents of teens to keep in touch with teachers and make sure that their teen’s schoolwork is going well. Talk with your teen’s doctor if your teen shows signs of severe problems, such as depression, drug abuse, or gang-related activities.

What about other types of treatments? You may have heard media reports or seen advertisements for “miracle cures” for ADHD. Carefully research any such claims. Consider whether the source of the information is valid. At this time, there is no scientifically proven cure for this condition.

• Were the target outcomes realistic?

The following methods have no scientific evidence to prove that they work:

• Is more information needed about your child’s behavior?

• Megavitamins and mineral supplements

• Is the diagnosis correct?

• Anti–motion-sickness medication (to treat the inner ear)

• Is another condition hindering treatment?

• Treatment for Candida yeast infection

• Is the treatment plan being followed?

• EEG biofeedback (training to increase brain-wave activity)

• Has the treatment failed?

• Applied kinesiology (realigning bones in the skull)

While treatment for ADHD should improve your child’s behavior, it may not completely eliminate the symptoms of inattention, hyperactivity, and impulsivity. Children who are being treated successfully may still have trouble with their friends or schoolwork.

• Optometric vision training (which asserts that faulty eye movement and sensitivities cause the behavioral problems)

However, if your child is clearly not meeting his specific target outcomes, your child’s doctor will need to reassess the treatment plan.

How can I help my child during the teen years? The teen years can be a special challenge. Academic and social demands increase. In some cases, symptoms may be better controlled as your child grows older; however, frequently, the demands for performance also increase, so that in most cases, ADHD symptoms persist and continue to interfere with your child’s ability to function

Always tell your child’s doctor about any alternative therapies, supplements, or medications your child is using. These may interact with prescribed medications and harm your child.

Frequently Asked Questions Q: Will my child outgrow ADHD? What about a cure? A: ADHD continues into adulthood in most cases. However, by developing their strengths, structuring their environments, and using medication when needed, adults with ADHD can lead very productive lives. In some careers, having a high-energy behavioral pattern can be an asset.

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There is no cure for ADHD at this time. However, research is ongoing to learn more about the role of the brain in ADHD, long-term outcomes for people with ADHD, and the best ways to treat the disorder. Q: Why do so many children have ADHD? A: The number of children getting treatment for ADHD has risen. It is not clear whether more children have ADHD or more children are receiving a diagnosis of ADHD. Also, more children with ADHD are getting treatment for a longer period. ADHD is one of the most common and most studied conditions of childhood. Because of more awareness and better ways of diagnosing and treating this disorder, more children are being helped. It may also be the case that school performance has become more important because of the higher technical demand of many jobs, and ADHD often interferes with a child’s ability to function in school. Q: Are schools putting children on ADHD medication? A: Teachers are often the first to notice behavioral signs of possible ADHD. However, only physicians can prescribe medications to treat ADHD. The diagnosis of ADHD should follow a careful process. Q: Can children get high on stimulant medications? A: When taken as directed by a doctor, there is no evidence that children are getting high on stimulant drugs such as methylphenidate and amphetamine. At therapeutic doses, these drugs also do not sedate or tranquilize children and do not increase the risk of addiction.

Resources Here is a list of ADHD support groups and resources. Also, your child’s doctor may know about resources in your community. CHADD–The National Resource Center on ADHD 800/233-4050 www.chadd.org ADDA (Attention Deficit Disorder Association) www.add.org Center for Parent Information and Resources www.parentcenterhub.org National Institute of Mental Health 866/615-6464 www.nimh.nih.gov Tourette Association of America 888/4-TOURET (486-8738) www.tourette.org

From Your Doctor

However, stimulants are classified as Schedule II drugs by the US Drug Enforcement Administration because there is potential for abuse of this class of medication. If your child is taking medication, it is always best to supervise the use of the medication closely. Atomoxetine and guanfacine are not Schedule II drugs because they don’t have potential for abuse, even in adults. Q: Will use of stimulant medications lead to illegal drug or alcohol use? A: People with ADHD are naturally impulsive and tend to take risks. But patients with ADHD who are taking stimulants are not at a greater risk of using other drugs and may actually be at a lower risk. Children and teens who have ADHD combined with coexisting conditions may be at higher risk for drug and alcohol use, regardless of the medication used.

The American Academy of Pediatrics (AAP) is an organization of 66,000 primary care pediatricians, pediatric medical subspecialists, and pediatric surgical specialists dedicated to the health, safety, and well-being of infants, children, adolescents, and young adults. The persons whose photographs are depicted in this publication are professional models. They have no relation to the issues discussed. Any characters they are portraying are fictional. Listing of resources does not imply an endorsement by the American Academy of Pediatrics (AAP). The AAP is not responsible for the content of external resources. Information was current at the time of publication. Products are mentioned for informational purposes only and do not imply an endorsement by the American Academy of Pediatrics. The information contained in this publication should not be used as a substitute for the medical care and advice of your pediatrician. There may be variations in treatment that your pediatrician may recommend based on individual facts and circumstances.

© 2017 American Academy of Pediatrics. All rights reserved.

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medicines for ADHD questions from teens who have ADHD Q: What can I do besides taking medicines?

Q: Will medicines change my personality?

A: Medicines and behavior therapies are the only treatments that have been shown by scientific studies to work consistently for ADHD symptoms. Medicines are prescribed by a doctor, while behavior therapies usually are done with a trained counselor in behavior treatment. These 2 treatments are probably best used together, but you might be able to do well with one or the other. You can’t rely on other treatments such as biofeedback, allergy treatments, special diets, vision training, or chiropractic because there isn’t enough evidence that shows they work.

A: Medicines won’t change who you are and should not change your personality. If you notice changes in your mood or personality, tell your doctor. Occasionally when medicines wear off, some teens become more irritable for a short time. An adjustment of the medicines by your doctor may be helpful.

Counseling may help you learn how to cope with some issues you may face. And there are things you can do to help yourself. For example, things that may help you stay focused include using a daily planner for schoolwork and other activities, making to-do lists, and even getting enough sleep. Counseling can help you find an organization system or a checklist.

Q: How can medicines help me? A: There are several different ADHD medicines. They work by causing the brain to have more neurotransmitters in the right places. Neurotransmitters are chemicals in the brain that help us focus our attention, control our impulses, organize and plan, and stick to routines. Medicines for ADHD can help you focus your thoughts and ignore distractions so that you can reach your full potential. They also can help you control your emotions and behavior. Check with your doctor to learn more about this.

Q: Are medicines safe? A: For most teens with ADHD, stimulant medicines are safe and effective if taken as recommended. However, like most medicines, there could be side effects. Luckily, the side effects tend to happen early on, are usually mild, and don’t last too long. If you have any side effects, tell your doctor. Changes may need to be made in your medicines or their dosages. • M ost common side effects include decreased appetite or weight loss, problems falling asleep, headaches, jitteriness, and stomachaches. • Less common side effects include a bad mood as medicines wear off (called the rebound effect) and facial twitches or tics.

Q: Will medicines affect my growth? A: Medicines will not keep you from growing. Significant growth delay is a very rare side effect of some medicines prescribed for ADHD. Most scientific studies show that taking these medicines has little to no long-term effect on growth in most cases.

Q: Do I need to take medicines at school? A: There are 3 types of medicines used for teens with ADHD: short acting (immediate release), intermediate acting, and long acting. You can avoid taking medicines at school if you take the intermediate- or long-acting kind. Long-acting medicines usually are taken once in the morning or evening. Short-acting medicines usually are taken every 4 hours.

Q: Does taking medicines make me a drug user? A: No! Although you may need medicines to help you stay in control of your behavior, medicines used to treat ADHD do not lead to drug abuse. In fact, taking medicines as prescribed by your doctor and doing better in school may help you avoid drug use and abuse. (But never give or share your medicines with anyone else.)

Q: Will I have to take medicines forever? A: In most cases, ADHD continues later in life. Whether you need to keep taking medicines as an adult depends on your own needs. The need for medicines may change over time. Many adults with ADHD have learned how to succeed in life without medicines by using behavior therapies or finding jobs that suit their strengths and weaknesses. The persons whose photographs are depicted in this publication are professional models. They have no relation to the issues discussed. Any characters they are portraying are fictional. The information contained in this publication should not be used as a substitute for the medical care and advice of your pediatrician. There may be variations in treatment that your pediatrician may recommend based on individual facts and circumstances.

The American Academy of Pediatrics is an organization of 60,000 primary care pediatricians, pediatric medical subspecialists, and pediatric surgical specialists dedicated to the health, safety, and well-being of infants, children, adolescents, and young adults. American Academy of Pediatrics Web site—www.HealthyChildren.org

Copyright © 2011 American Academy of Pediatrics All rights reserved.

ADHD CLINICAL PRACTICE GUIDELINE QUICK REFERENCE TOOLS

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what is ADHD? questions from teens

Attention-deficit/hyperactivity disorder (ADHD) is a condition of the brain that makes it

difficult for people to concentrate or pay attention in certain areas where it is easy for others, like school or homework. The following are quick answers to some common questions:

Q: What causes ADHD? A: There isn’t just one cause. Research shows that • ADHD is a medical condition caused by small changes in how the brain works. It seems to be related to 2 chemicals in your brain called dopamine and norepinephrine. These chemicals help send messages between nerve cells in the brain—especially those areas of the brain that control attention and activity level. • ADHD most often runs in families. • In a few people with ADHD, being born prematurely or being exposed to alcohol during the pregnancy can contribute to ADHD. • Immunizations and eating too much sugar do NOT cause ADHD. And there isn’t enough evidence that shows allergies and food additives cause ADHD.

Q: How can you tell if someone has ADHD?

Q: Don’t little kids who have ADHD outgrow it by the time they are teens? A: Often kids with the hyperactive kind of ADHD get less hyperactive as they get into their teens, but usually they still have a lot of difficulty paying attention, remembering what they have read, and getting their work done. They may or may not have other behavior problems. Some kids with ADHD have never been hyperactive at all, but usually their attention problems also continue into their teens.

Q: If I have trouble with homework or tests, do I have ADHD? A: There could be many reasons why a student struggles with schoolwork and tests. ADHD could be one reason. It may or may not be, but your doctor is the best person to say for sure. Kids with ADHD often say it’s hard to concentrate, focus on a task (for example, schoolwork, chores, or a job), manage their time, and finish tasks. This could explain why they may have trouble with schoolwork and tests. Whatever the problem, there are many people willing to help you. You need to find the approach that works best for you.

A: You can’t tell if someone has ADHD just by looks. People with ADHD don’t look any different, but how they act may make them stand out from the crowd. Some people with ADHD are very hyperactive (they move around a lot and are not able to sit still) and have behavior problems that are obvious to everyone. Other people with ADHD are quiet and more laid back on the outside, but on the inside struggle with attention to schoolwork and other tasks. They are distracted by people and things around them when they try to study; they may have trouble organizing schoolwork or forget to turn in assignments.

Q: Does having ADHD mean a person is not very smart?

Q: Can ADHD cause someone to act up or get in trouble?

Q: Is ADHD more common in boys?

A: Having ADHD can cause you to struggle in school or have problems controlling your behavior. Some people may say or think that your struggles and problems are because you are bad, lazy, or not smart. But they’re wrong. It’s important that you get help so your impulses don’t get you into serious trouble.

A: Absolutely not! People who have trouble paying attention may have problems in school, but that doesn’t mean they’re not smart. In fact, some people with ADHD are very smart, but may not be able to reach their potential in school until they get treatment. ADHD is a common problem. Teens with ADHD have the potential to do well in school and live a normal life with the right treatment.

A: More boys than girls are diagnosed with ADHD—about 2 or 3 boys to every 1 girl. However, these numbers do not include the number of girls with the inattentive type of ADHD who are not diagnosed. Girls with the inattentive type of ADHD tend to be overlooked entirely or do not attract attention until they are older.

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Q: What do I do if I think I have ADHD?

From your doctor

A: Don’t be afraid to talk with your parents or other adults that you trust. Together you can meet with your doctor and find out if you really have ADHD. If you do, your doctor will help you learn how to live with ADHD and find ways to deal with your condition. The persons whose photographs are depicted in this publication are professional models. They have no relation to the issues discussed. Any characters they are portraying are fictional. The information contained in this publication should not be used as a substitute for the medical care and advice of your pediatrician. There may be variations in treatment that your pediatrician may recommend based on individual facts and circumstances.

The American Academy of Pediatrics is an organization of 60,000 primary care pediatricians, pediatric medical subspecialists, and pediatric surgical specialists dedicated to the health, safety, and well-being of infants, children, adolescents, and young adults. American Academy of Pediatrics Web site—www.HealthyChildren.org

Copyright © 2011 American Academy of Pediatrics All rights reserved.

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Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants •  Clinical Practice Guideline – PPI: AAP Partnership for Policy Implementation See Appendix 1 for more information. •  Executive Summary – PPI: AAP Partnership for Policy Implementation See Appendix 1 for more information.

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CLINICAL PRACTICE GUIDELINE

Guidance for the Clinician in Rendering Pediatric Care

Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants

Joel S. Tieder, MD, MPH, FAAP, Joshua L. Bonkowsky, MD, PhD, FAAP, Ruth A. Etzel, MD, PhD, FAAP, Wayne H. Franklin, MD, MPH, MMM, FAAP, David A. Gremse, MD, FAAP, Bruce Herman, MD, FAAP, Eliot S. Katz, MD, FAAP, Leonard R. Krilov, MD, FAAP, J. Lawrence Merritt II, MD, FAAP, Chuck Norlin, MD, FAAP, Jack Percelay, MD, MPH, FAAP, Robert E. Sapién, MD, MMM, FAAP, Richard N. Shiffman, MD, MCIS, FAAP, Michael B.H. Smith, MB, FRCPCH, FAAP, for the SUBCOMMITTEE ON APPARENT LIFE THREATENING EVENTS

This is the first clinical practice guideline from the American Academy of Pediatrics that specifically applies to patients who have experienced an apparent life-threatening event (ALTE). This clinical practice guideline has 3 objectives. First, it recommends the replacement of the term ALTE with a new term, brief resolved unexplained event (BRUE). Second, it provides an approach to patient evaluation that is based on the risk that the infant will have a repeat event or has a serious underlying disorder. Finally, it provides management recommendations, or key action statements, for lower-risk infants. The term BRUE is defined as an event occurring in an infant younger than 1 year when the observer reports a sudden, brief, and now resolved episode of ≥1 of the following: (1) cyanosis or pallor; (2) absent, decreased, or irregular breathing; (3) marked change in tone (hyper- or hypotonia); and (4) altered level of responsiveness. A BRUE is diagnosed only when there is no explanation for a qualifying event after conducting an appropriate history and physical examination. By using this definition and framework, infants younger than 1 year who present with a BRUE are categorized either as (1) a lower-risk patient on the basis of history and physical examination for whom evidence-based recommendations for evaluation and management are offered or (2) a higher-risk patient whose history and physical examination suggest the need for further investigation and treatment but for whom recommendations are not offered. This clinical practice guideline is intended to foster a patient- and family-centered approach to care, reduce unnecessary and costly medical interventions, improve patient outcomes, support implementation, and provide direction for future research. Each key action statement indicates a level of evidence, the benefit-harm relationship, and the strength of recommendation.

abstract

This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication. The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. All clinical practice guidelines from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time. DOI: 10.1542/peds.2016-0590 PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2016 by the American Academy of Pediatrics

To cite: Tieder JS, Bonkowsky JL, Etzel RA, et al. Brief Resolved Unexplained Events (Formerly Apparent LifeThreatening Events) and Evaluation of Lower-Risk Infants. Pediatrics. 2016;137(5):e20160590

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PEDIATRICS Volume 137, number 5, May 2016:e20160590

FROM THE AMERICAN ACADEMY OF PEDIATRICS

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INTRODUCTION This clinical practice guideline applies to infants younger than 1 year and is intended for pediatric clinicians. This guideline has 3 primary objectives. First, it recommends the replacement of the term apparent life-threatening event (ALTE) with a new term, brief resolved unexplained event (BRUE). Second, it provides an approach to patient evaluation that is based on the risk that the infant will have a recurring event or has a serious underlying disorder. Third, it provides evidence-based management recommendations, or key action statements, for lower-risk patients whose history and physical examination are normal. It does not offer recommendations for higherrisk patients whose history and physical examination suggest the need for further investigation and treatment (because of insufficient evidence or the availability of clinical practice guidelines specific to their presentation). This clinical practice guideline also provides implementation support and suggests directions for future research.

The term ALTE originated from a 1986 National Institutes of Health Consensus Conference on Infantile Apnea and was intended to replace the term “near-miss sudden infant death syndrome” (SIDS).1 An ALTE was defined as “an episode that is frightening to the observer and that is characterized by some combination of apnea (central or occasionally obstructive), color change (usually cyanotic or pallid but occasionally erythematous or plethoric), marked change in muscle tone (usually marked limpness), choking, or gagging. In some cases, the observer fears that the infant has died.”2 Although the definition of ALTE eventually enabled researchers to establish that these events are separate entities from SIDS, the clinical application of this classification, which describes a e2

constellation of observed, subjective, and nonspecific symptoms, has raised significant challenges for clinicians and parents in the evaluation and care of these infants.3 Although a broad range of disorders can present as an ALTE (eg, child abuse, congenital abnormalities, epilepsy, inborn errors of metabolism, and infections), for a majority of infants who appear well after the event, the risk of a serious underlying disorder or a recurrent event is extremely low.2

CHANGE IN TERMINOLOGY AND DIAGNOSIS The imprecise nature of the original ALTE definition is difficult to apply to clinical care and research.3 As a result, the clinician is often faced with several dilemmas. First, under the ALTE definition, the infant is often, but not necessarily, asymptomatic on presentation. The evaluation and management of symptomatic infants (eg, those with fever or respiratory distress) need to be distinguished from that of asymptomatic infants. Second, the reported symptoms under the ALTE definition, although often concerning to the caregiver, are not intrinsically life-threatening and frequently are a benign manifestation of normal infant physiology or a self-limited condition. A definition needs enough precision to allow the clinician to base clinical decisions on events that are characterized as abnormal after conducting a thorough history and physical examination. For example, a constellation of symptoms suggesting hemodynamic instability or central apnea needs to be distinguished from more common and less concerning events readily characterized as periodic breathing of the newborn, breath-holding spells, dysphagia, or gastroesophageal reflux (GER). Furthermore, events defined as ALTEs are rarely a manifestation of a more serious illness that, if left undiagnosed, could lead to morbidity

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or death. Yet, the perceived potential for recurring events or a serious underlying disorder often provokes concern in caregivers and clinicians.2,4,5 This concern can compel testing or admission to the hospital for observation, which can increase parental anxiety and subject the patient to further risk and does not necessarily lead to a treatable diagnosis or prevention of future events. A more precise definition could prevent the overuse of medical interventions by helping clinicians distinguish infants with lower risk. Finally, the use of ALTE as a diagnosis may reinforce the caregivers’ perceptions that the event was indeed “life-threatening,” even when it most often was not. For these reasons, a replacement of the term ALTE with a more specific term could improve clinical care and management.

In this clinical practice guideline, a more precise definition is introduced for this group of clinical events: brief resolved unexplained event (BRUE). The term BRUE is intended to better reflect the transient nature and lack of clear cause and removes the “lifethreatening” label. The authors of this guideline recommend that the term ALTE no longer be used by clinicians to describe an event or as a diagnosis. Rather, the term BRUE should be used to describe events occurring in infants younger than 1 year of age that are characterized by the observer as “brief” (lasting 95th percentile for age and gender.8

a more focused evaluation. (Evidence Quality: Grade B, Recommendation Strength: Recommendation.)

KEY ACTION STATEMENTS

Evidence Profile KAS 1

Key Action Statement 1: Screening for OSAS

 Aggregate evidence quality: B  Benefit: Early identification of OSAS

As part of routine health maintenance visits, clinicians should inquire whether the child or adolescent snores. If the answer is affirmative or if a child or adolescent presents with signs or symptoms of OSAS (Table 2), clinicians should perform

is desirable, because it is a highprevalence condition, and identification and treatment can result in alleviation of current symptoms, improved quality of life, prevention of sequelae, education of parents, and decreased health care utilization.

   

Role of patient preferences: None. Exclusions: None. Intentional vagueness: None. Strength: Recommendation.

Almost all children with OSAS snore,9–11 although caregivers frequently do not volunteer this information at medical visits.12 Thus, asking about snoring at each health maintenance visit (as well as at other appropriate times, such as when evaluating for tonsillitis) is a sensitive, albeit nonspecific, screening measure that is quick and easy to perform. Snoring is common in children and adolescents; however, OSAS is less common. Therefore, an affirmative answer should be followed by a detailed history and examination to determine whether further evaluation for OSAS is needed (Table 2); this clinical evaluation alone

TABLE 1 Definitions and Recommendation Implications Statement

Definition

Strong recommendation

A strong recommendation in favor of a particular action is made when the anticipated benefits of the recommended intervention clearly exceed the harms (as a strong recommendation against an action is made when the anticipated harms clearly exceed the benefits) and the quality of the supporting evidence is excellent. In some clearly identified circumstances, strong recommendations may be made when high-quality evidence is impossible to obtain and the anticipated benefits strongly outweigh the harms. A recommendation in favor of a particular action is made when the anticipated benefits exceed the harms but the quality of evidence is not as strong. Again, in some clearly identified circumstances, recommendations may be made when high-quality evidence is impossible to obtain but the anticipated benefits outweigh the harms. Options define courses that may be taken when either the quality of evidence is suspect or carefully performed studies have shown little clear advantage to one approach over another. No recommendation indicates that there is a lack of pertinent published evidence and that the anticipated balance of benefits and harms is presently unclear.

Recommendation

Option

No recommendation

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Implication Clinicians should follow a strong recommendation unless a clear and compelling rationale for an alternative approach is present.

It would be prudent for clinicians to follow a recommendation, but they should remain alert to new information and sensitive to patient preferences.

Clinicians should consider the option in their decision-making, and patient preference may have a substantial role. Clinicians should be alert to new published evidence that clarifies the balance of benefit versus harm.

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TABLE 2 Symptoms and Signs of OSAS History Frequent snoring (≥3 nights/wk) Labored breathing during sleep Gasps/snorting noises/observed episodes of apnea Sleep enuresis (especially secondary enuresis)a Sleeping in a seated position or with the neck hyperextended Cyanosis Headaches on awakening Daytime sleepiness Attention-deficit/hyperactivity disorder Learning problems Physical examination Underweight or overweight Tonsillar hypertrophy Adenoidal facies Micrognathia/retrognathia High-arched palate Failure to thrive Hypertension a

Enuresis after at least 6 mo of continence.

 Harm: Expense, time, anxiety/discomfort.

 Benefits-harms assessment: Preponderance of benefit over harm.

 Value judgments: Panelists weighed the value of establishing a diagnosis as more important than the minor potential harms listed.

 Role of patient preferences: Small be-

cause of preponderance of evidence that polysomnography is the most accurate way to make a diagnosis.

 Exclusions: See Key Action Statement 2B regarding lack of availability.

 Intentional vagueness: None.  Strength: Recommendation.

is overnight, attended, in-laboratory polysomnography (sleep study). This is a noninvasive test involving the measurement of a number of physiologic functions overnight, typically including EEG; pulse oximetry; oronasal airflow, abdominal and chest wall movements, partial pressure of carbon dioxide (PCO2); and video recording.13 Specific pediatric measuring and scoring criteria should be used.13 Polysomnography will demonstrate the presence or absence of OSAS. Polysomnography also demonstrates the severity of OSAS, which is helpful in planning treatment and in postoperative shortand long-term management.

Evidence Profile KAS 2A: Referral does not establish the diagnosis (see technical report). Occasional snoring, for example, with an upper respiratory tract infection, is less of a concern than snoring that occurs at least 3 times a week and is associated with any of the symptoms or signs listed in Table 2.

 Aggregate evidence quality: D  Benefits: Subspecialist may be better able to establish diagnosis and determine severity of OSAS.

 Harm: Expense, time, anxiety/discomfort.

 Benefits-harms assessment: Preponderance of benefit over harm.

Key Action Statement 2A: Polysomnography If a child or adolescent snores on a regular basis and has any of the complaints or findings shown in Table 2, clinicians should either (1) obtain a polysomnogram (Evidence Quality A, Key Action strength: Recommendation) OR (2) refer the patient to a sleep specialist or otolaryngologist for a more extensive evaluation (Evidence quality D, Key Action strength: Option). (Evidence Quality: Grade A for polysomnography; Grade D for specialist referral, Recommendation Strength: Recommendation.) Evidence Profile KAS 2A: Polysomnography

 Aggregate evidence quality: A  Benefits: Establish diagnosis and determine severity of OSAS.

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 Value judgments: Panelists weighed the value of establishing a diagnosis as more important than the minor potential harms listed.

   

Role of patient preferences: Large. Exclusions: None. Intentional vagueness: None. Strength: Option.

Although history and physical examination are useful to screen patients and determine which patients need further investigation for OSAS, the sensitivity and specificity of the history and physical examination are poor (see accompanying technical report). Physical examination when the child is awake may be normal, and the size of the tonsils cannot be used to predict the presence of OSAS in an individual child. Thus, objective testing is required. The gold standard test

Key Action Statement 2B: Alternative Testing If polysomnography is not available, then clinicians may order alternative diagnostic tests, such as nocturnal video recording, nocturnal oximetry, daytime nap polysomnography, or ambulatory polysomnography. (Evidence Quality: Grade C, Recommendation Strength: Option.) Evidence Profile KAS 2B

 Aggregate evidence quality: C  Benefit: Varying positive and nega-

tive predictive values for establishing diagnosis.

 Harm: False-negative and false-

positive results may underestimate or overestimate severity, expense, time, anxiety/discomfort.

 Benefits-harms assessment: Equilibrium of benefits and harms.

 Value judgments: Opinion of the

panel that some objective testing is better than none. Pragmatic decision based on current shortage of pediatric polysomnography facilities (this may change over time).

 Role of patient preferences: Small, if choices are limited by availability;

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families may choose to travel to centers where more extensive facilities are available.

 Exclusions: None.  Intentional vagueness: None.  Strength: Option. Although polysomnography is the gold standard for diagnosis of OSAS, there is a shortage of sleep laboratories with pediatric expertise. Hence, polysomnography may not be readily available in certain regions of the country. Alternative diagnostic tests have been shown to have weaker positive and negative predictive values than polysomnography, but nevertheless, objective testing is preferable to clinical evaluation alone. If an alternative test fails to demonstrate OSAS in a patient with a high pretest probability, full polysomnography should be sought. Key Action Statement 3: Adenotonsillectomy If a child is determined to have OSAS, has a clinical examination consistent with adenotonsillar hypertrophy, and does not have a contraindication to surgery (see Table 3), the clinician should recommend adenotonsillectomy as the first line of treatment. If the child has OSAS but does not have adenotonsillar hypertrophy, other treatment should be considered (see Key Action Statement 6). Clinical judgment is required to determine the benefits of adenotonsillectomy compared with other treatments in obese children with varying degrees of adenotonsillar hypertrophy. (Evidence Quality: Grade B, Recommendation Strength: Recommendation.) Evidence Profile KAS 3

 Aggregate evidence quality: B  Benefit: Improve OSAS and accompanying symptoms and sequelae.

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 Harm: Pain, anxiety, dehydration, an-

esthetic complications, hemorrhage, infection, postoperative respiratory difficulties, velopharyngeal incompetence, nasopharyngeal stenosis, death.

 Benefits-harms assessment: Preponderance of benefit over harm.

 Value judgments: The panel sees

the benefits of treating OSAS as more beneficial than the low risk of serious consequences.

 Role of patient preferences: Low;

continuous positive airway pressure (CPAP) is an option but involves prolonged, long-term treatment as compared with a single, relatively low-risk surgical procedure.

 Exclusions: See Table 3.  Intentional vagueness: None.  Strength: Recommendation. Adenotonsillectomy is very effective in treating OSAS. Adenoidectomy or tonsillectomy alone may not be sufficient, because residual lymphoid tissue may contribute to persistent obstruction. In otherwise healthy children with adenotonsillar hypertrophy, adenotonsillectomy is associated with improvements in symptoms and sequelae of OSAS. Postoperative polysomnography typically shows a major decrease in the number of obstructive events, although some obstructions may still be present. Although obese children may have less satisfactory results, many will be adequately treated with TABLE 3 Contraindications for Adenotonsillectomy Absolute contraindications No adenotonsillar tissue (tissue has been surgically removed) Relative contraindications Very small tonsils/adenoid Morbid obesity and small tonsils/adenoid Bleeding disorder refractory to treatment Submucus cleft palate Other medical conditions making patient medically unstable for surgery

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adenotonsillectomy; however, further research is needed to determine which obese children are most likely to benefit from surgery. In this population, the benefits of a 1-time surgical procedure, with a small but real risk of complications, need to be weighed against long-term treatment with CPAP, which is associated with discomfort, disruption of family lifestyle, and risks of poor adherence. Potential complications of adenotonsillectomy are shown in Table 4. Although serious complications (including death) may occur, the rate of these complications is low, and the risks of complications need to be weighed against the consequences of untreated OSAS. In general, a 1-time only procedure with a relatively low morbidity is preferable to lifelong treatment with CPAP; furthermore, the efficacy of CPAP is limited by generally suboptimal adherence. Other treatment options, such as anti-inflammatory medications, weight loss, or tracheostomy, are less effective, are difficult to achieve, or have higher morbidity, respectively. Key Action Statement 4: High-Risk Patients Undergoing Adenotonsillectomy Clinicians should monitor high-risk patients (Table 5) undergoing adenotonsillectomy as inpatients postoperatively. (Evidence Quality: Grade B, Recommendation Strength: Recommendation.) TABLE 4 Risks of Adenotonsillectomy Minor Pain Dehydration attributable to postoperative nausea/vomiting and poor oral intake Major Anesthetic complications Acute upper airway obstruction during induction or emergence from anesthesia Postoperative respiratory compromise Hemorrhage Velopharyngeal incompetence Nasopharyngeal stenosis Death

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TABLE 5 Risk Factors for Postoperative Respiratory Complications in Children With OSAS Undergoing Adenotonsillectomy Younger than 3 y of age Severe OSAS on polysomnographya Cardiac complications of OSAS Failure to thrive Obesity Craniofacial anomaliesb Neuromuscular disordersb Current respiratory infection a

It is difficult to provide exact polysomnographic criteria for severity, because these criteria will vary depending on the age of the child; additional comorbidities, such as obesity, asthma, or cardiac complications of OSAS; and other polysomnographic criteria that have not been evaluated in the literature, such as the level of hypercapnia and the frequency of desaturation (as compared with lowest oxygen saturation). Nevertheless, on the basis of published studies (primarily Level III, see Technical Report), it is recommended that all patients with a lowest oxygen saturation 19 Poorly controlled ≤15 C-ACT (7-item questionnaire) 4 filled out by child, 3 questions by parent/caregiver Composite numeric score (up to 27) MCID 2 points Controlled >19 ACQ (7 items: 6 questionnaire, and 1 FEV1) Composite numeric score (up to 6) MCID 0.5 points Controlled >19 ATAQ (4-item questionnaire in the control dimension; Composite numeric score (up to 4) overall 20 questions) MCID: none established Controlled (0); not well controlled (1–2), poorly controlled (3–4) TRACK (5-item questionnaire) Composite numeric score (up to 100) MCID: 10 Controlled (≥80) Adapted from Cloutier et al.6 MCID, minimally clinically important difference.

at a population level, they may not be accurate for an individual patient. Tracking the numerical and categorical responses over time for each individual patient may prove to be more helpful than looking at cutoff values alone. For instance, if a patient reports frequent nocturnal awakenings, following the response to that particular question may help individualize attainment of control. The minimal clinically important differences or temporal differences in scores that indicate clinical significance have been determined for a few of the instruments (ACQ, ACT, C-ACT, and TRACK6,13; Table 1). Three of the instruments (ACQ, ACT, and TRACK) have been validated in Spanish-speaking groups.14–16 The ACQ and ACT have been validated for use as self-administered instruments in person, at home, by telephone, and by Internet tracking.6,17 Poor asthma control, as measured by the commonly used composite

scores, is associated with reduced lung function and elevated exhaled nitric oxide fraction5,18 (discussed later in the article). Studies have shown that changes in these composite scores reflect changes in the overall clinical assessment of asthma control by physicians and the need to step-up therapy.19 However, a recent study showed that the degree of asthma control, as assessed by these tools, changes over time and shows variable concordance with the risk of exacerbations.12 Despite being fairly well validated, these scores share drawbacks that limit their usefulness in clinical practice.6 Although the short recall window facilitates reliable recollection of recent asthma events, it fails to represent the fluctuations in control. Children may be excellently controlled during one season and then have poor control during another. In addition, asthma exacerbations can occur

in children with good short-term asthma control.20 Exacerbations, an important component of the impairment domain of asthma control, are not covered in the ACT, C-ACT, and ACQ but are assessed in the TRACK and the Composite Asthma Severity Index.21,22

Quality of Life

A range of pediatric asthma qualityof-life instruments have been developed, encompassing the impact of asthma on children’s or their parents’ lives.23 The instruments have been validated but are timeintensive to fill out and are therefore not routinely used in clinical practice.

OBJECTIVE MEASURES Currently available objective measures of asthma control include (1) assessment of lung function, (2) evaluation of airway

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TABLE 2 Objective Measures of Asthma Control Spirometry

Bronchodilator reversibility (prebronchodilator and postbronchodilator spirometry)

PEF

Measured by ATS/ERS guidelines and using NHANES-3 normative values. Serial measures should be performed at the same time each day, if possible (Indicate whether bronchodilator was withheld before test.) Standardized methodology and equipment (ATS/ERS guidelines) Performed in a clinic/laboratory setting under the supervision of a qualified technician Can be performed by children >5 y (in general) under guidance of trained personnel Portable and handheld devices available for use in the field/home settings FEV1 report: Percent predicted values (at baseline and at any other time point, if applicable) Changes over the course of evaluation: Percent change from baseline in the absolute value Absolute change from baseline (in milliliters) Change from baseline in the percent predicted value FEV1/FVC report: Ratio of absolute values (at baseline and at any other time point, if applicable) Changes over the course of evaluation: Absolute change from baseline in the value of the ratio Change from baseline in the percent predicted value 1. Withhold bronchodilator before the measure (12–24 h for long-acting β-2-agonists or anticholinergics; 4–6 h for shortacting β-agonists) 2. Administer 4 separate puffs of albuterol (90 mg of albuterol base/puff) with spacer at 30-s intervals between puffs, followed by spirometry after 15 min Report: Prebronchodilator and postbronchodilator FEV1 (expressed as percent predicted) Percent change from prebronchodilator to postbronchodilator in the absolute value of FEV1 Absolute change in FEV1 from prebronchodilator to postbronchodilator (in milliliters) PEF is a measure of maximum instantaneous expiratory Can be self-administered on a daily basis and results recorded manually or electronically to obtain day-to-day or within-day variability Percent predicted values (NHANES-3 normative values) When measured with a peak flowmeter, PEF is usually expressed in units of L/min; in contrast, when PEF is measured with spirometry systems, it is usually expressed in units of liters/second Percent change from baseline in the absolute values over the course of evaluation Absolute change from baseline over the course of the evaluation (in liters/minute) Variability (diurnal amplitude as a percentage of the day’s mean)

Adapted from Tepper et al.24

hyperresponsiveness, and (3) biomarkers.

Assessment of Lung Function Peak Flow The PEF is defined as the highest instantaneous expiratory flow achieved during a maximal forced expiratory maneuver starting at total lung capacity.24 PEF variability is the degree to which the PEF varies among multiple measurements performed over time (Table 2). The management of acute exacerbations has traditionally been guided by PEF measurements. However, the correlation between PEF and FEV1 worsens in asthmatic patients with airflow limitation. Also, although reference to normal PEF values is important, the “personal best” value, and the trend of change in individual 4

patients, is of greater value in managing their asthma.24

The advantages of PEF are that it is easier to perform than a spirometric maneuver and it is measurable with a relatively small and inexpensive instrument. Thus, PEF may be suitable for individual testing at home, at school, and in patients who are poor perceivers of their degree of airway obstruction. It may help prevent delayed treatment in underperceivers and excessive use of services in overperceivers.

Many concerns regarding PEF have been described, with the primary ones being that the results are highly variable even when performed well, limiting its utility in the diagnosis and management of asthma. Parents and child should be appropriately trained

on use, but there is no gauge of effort, and it gives no information regarding the site of airflow obstruction. It cannot distinguish obstructive from restrictive ventilatory impairment. PEF meters from different manufacturers may show different results, and the “personal best” measurements may change with growth and degree of asthma control. Adherence to PEF monitoring is a challenge25 and is often the reason it is not widely used in clinical practice. Overall, PEF monitoring alone has not been shown to be more effective than symptom monitoring on influencing asthma outcomes26 and is no longer recommended.1

Spirometry

Measurement of spirometric indices of lung function, such as the FEV1,

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forced vital capacity (FVC), and FEV1/FVC ratio, are an integral part of the assessment of asthma severity, control, and response to treatment.1,2 They have been shown to be associated with the risk of asthma attacks in children.27 Children with chronic airway obstruction have been reported to be less likely to perceive dyspnea than those with acute obstruction.28 The EPR3, therefore, recommends performing officebased spirometry every 1 to 2 years and more frequently if clinically indicated in children 5 years or older with asthma.1 However, only 20% to 40% of primary care providers use lung function measurements in asymptomatic asthmatic patients, and up to 59% of pediatricians never perform lung function tests.29

Normal values for spirometry are well established and are based on height, age, sex, and race/ethnicity of the healthy US population. Spirometric measures are highly reproducible within testing sessions in approximately 75% of children older than 5 to 6 years of age. Guidance on performing spirometry in an office setting and coding for asthma visits have been described.30 The forced expiratory maneuver may be displayed as a flow-volume loop. Guidelines regarding interpretation of the primary measures (FEV1, FVC, and the FEV1/FVC ratio) are well outlined in the EPR3.1,31 Of note, most automatic interpretations of the spirometry report fail to comment on the FEV1/FVC ratio, an important parameter that, in children, is normally 85% predicted or greater.1 Forced expiratory flow between 25% and 75% of vital capacity (FEF25–75) may reflect obstructive changes that occur in the small airways of children with asthma. However, FEF25–75 is considered to be of secondary importance because it is not specific and is highly variable (effort dependent). Reduced spirometric measures are associated with symptom severity,

reduced quality of life, and poor asthma outcomes.24 However, individual patients, particularly children, may have misleadingly normal spirometry results, despite frequent or severe symptoms. An analysis of 2728 children between 4 and 18 years of age attending a tertiary care facility showed that the majority of asthmatic children had FEV1 values within normal ranges.32 Spirometry, by itself, is not useful in establishing the diagnosis of asthma because airflow limitation may be mild or absent, particularly in children. In other words, if the spirometry result is normal, it does not rule out asthma. Variability of airflow obstruction over time and the response to treatment, when clinically relevant, can aid in the diagnosis and assessment of asthma control.

Although there are organizations that are attempting to integrate spirometry results into the electronic health record with varying degrees of success, the most commonly used approach at this time is to scan the printed spirometry result into the electronic health record.

Prebronchodilator and Postbronchodilator Spirometry (Bronchodilator Reversibility)

Bronchodilator reversibility testing helps determine the presence and magnitude of reversible airflow limitation.24 Baseline spirometry is performed and repeated after administration of bronchodilator test agents (eg, 15 minutes after 4 inhalations of albuterol). Change in FEV1 is the most common parameter followed because the value of reversibility in other measurements is less established (eg, FEV1/FVC or FEF25–75).

The most widely used definition of “significant” bronchodilator response is that of the American Thoracic Society/European Respiratory Society (ATS/ERS) guidelines for

interpretation of spirometry and consists of an improvement in FEV1 greater than 12% and 200 mL.33 Other parameters that have been used in children include a 9% to 10% increase in percent predicted FEV1.24 Bronchodilator reversibility testing, although not specific, is useful for confirming the diagnosis of asthma. Increased bronchodilator reversibility correlates with increased asthma severity. Bronchodilator reversibility is diminished in patients with wellcontrolled asthma as well as those with narrowing or remodeling of the airways. Annual assessment of prebronchodilator and postbronchodilator FEV1 might help identify children at risk for developing progressive decline in airflow.34

Recent Advances in Monitoring PEF and Spirometry Advances in home-based airflow monitoring include the use of electronic, handheld devices with easily downloadable recordings of multiple PEF or FEV1 point measures with software that facilitates easy use and interpretation.35 The availability of these instruments for routine clinical use is limited at this time.

Impulse Oscillometry

Impulse oscillometry assesses airflow resistance and bronchodilator response in younger children. Measurement of airway resistance is a direct indicator of airway caliber with increased resistance indicating narrowing of airways. It is used largely as a research tool and is only available in a few centers.24

Airway Hyperresponsiveness

A major characteristic of asthma is the variability in bronchial tone in response to a variety of stimuli. Airway hyperresponsiveness (AHR) may be assessed by bronchial

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provocation tests. Bronchial provocation tests may be performed with agents such as methacholine or stimuli such as physical exercise.24,28,36 A positive test result for AHR is indicated by a 20% reduction in FEV1 after inhalation of a methacholine dose of 8 mg/mL or less. A negative test suggests a diagnosis other than asthma. A reduction in FEV1 of at least 10% during exercise testing is taken as a sign of exerciseinduced bronchoconstriction. These tests take approximately 2 hours and require trained personnel to perform them. In general, evidence does not support the routine assessment of AHR in the clinical management of asthma control.28

Biomarkers

Apart from exhaled nitric oxide measurements, the role and usefulness of noninvasive biomarkers in routine clinical practice for monitoring inflammation in children with asthma is undefined. Sputum eosinophilia, exhaled breath condensates, and urinary leukotrienes are used as tools primarily in research studies.28,37

Exhaled Nitric Oxide

The fractional concentration of nitric oxide in exhaled air (FENO) is a quantitative measure of airway nitric oxide, an endogenously produced gaseous mediator that is an indirect marker of airway inflammation. The joint ATS/ERS guideline for the measurement of FENO is the current standard.38,39 The testing is noninvasive, reproducible, easy to perform in patients (including children), feasible to measure in ambulatory clinical settings, and has no risk to patients.40,41

FENO is generally accepted as a marker of eosinophilic airway inflammation. Individuals with asthma have been reported to have elevated levels of FENO, but because FENO is also related to atopy, 6

elevated levels may be seen in atopic individuals without asthma. Although FENO levels overlap among healthy, atopic, and asthmatic cohorts, in general, the upper value of normal is 25 ppb. It has been suggested that a clinically important decrease of FENO is a change of 20% for values greater than 50 ppb or a change of 10 ppb for values less than 50 ppb.38 Studies in children suggest that FENO correlates with severity and with asthma control.42 FENO reduces in a dose-dependent manner with corticosteroid treatment43 and has been shown to increase with deterioration in asthma control.44 The value of additional FENO monitoring in children whose asthma is appropriately managed using guideline-based strategies is unproven,28,45–47 and insurance payment for this test varies by geographic location. Nevertheless, some asthma specialists have adopted the use of FENO as an adjunct ambulatory clinical tool for measuring airway inflammation and serial monitoring asthma control in individual patients with difficult-tocontrol asthma.

Assessing Asthma Control in Children Younger Than 5 Years

In children younger than 5 years, it is recommended that both symptom control and future risk be monitored.2 The risk domain is assessed by historical review of exacerbations with need for oral steroid. Validated measures to assess asthma control in this age group include the TRACK (0–5 years) and the C-ACT in children (4–11 years) of age.

Children younger than 5 years are typically unable to perform spirometry; hence, confirmation of the diagnosis of asthma is challenging in this age group. Recurrent wheezing occurs in a large proportion of these children, typically with viral infections. A therapeutic trial of

regular controller therapy (for 1–3 months) may often be necessary to evaluate response and maintenance of control.

Assessment of risk profiles using tools such as the asthma predictive index (API) may be helpful in predicting the likelihood of recurrent wheezing in school-age children. One study showed that children with a positive API had a fourfold to 10-fold greater chance of developing asthma at 6 through 13 years of age than those with a negative API, and 95% of children with a negative API remained free of asthma.48 The modified API suggests that the diagnosis of asthma in young children with a history of more than 3 episodes of wheezing is more likely if they meet 1 major or 2 minor criteria.49 Major criteria include a parent with asthma, physician diagnosis of atopic dermatitis, or sensitization to aeroallergens (positive skin or allergen-specific immunoglobulin E test results). Minor criteria include the presence of food allergies or sensitization to milk, egg, and peanut; blood eosinophil counts greater than 4%; or wheezing apart from colds.49

SUMMARY Recent advances in measuring lung function, biomarker profiles, adherence, utilization and outcomes data, and development of validated questionnaires have made ongoing assessment and monitoring of asthma control a reality. Following is a schema of suggested measures that may be used in routine ambulatory monitoring of asthma control in clinical practice.

Initial Consultation

• The encounter between patient

and health care provider may involve critical and empathetic listening to the patient and accurate elicitation of symptoms

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as indicators for asthma control, aided by validated asthma control tools such as the C-ACT/ACT. A complete environmental and social history should be obtained to evaluate for triggers.50

• Airway obstruction and AHR

can be assessed by measuring prebronchodilator and postbronchodilator FEV1. Some specialists may consider evaluation of airway inflammation by using FENO to be useful.

• Education and training regarding asthma and its management can be provided, taking into consideration the patient’s personal preference and goals while creating an individualized action plan.

• Action strategies can be based

on either symptoms or objective criteria, such as by monthly monitoring of the age-specific, validated asthma control instrument, or in individualized circumstances, by daily electronic FEV1 or conventional peak flow monitoring at home.

Subsequent Visits

• Symptom scores with validated

control instruments and FEV1 can be monitored at subsequent visits along with serial health care utilization data to tailor the medication dose to degree of asthma control. The risk domain is validated by a history of systemic steroid prescription, emergency department visits, or hospitalizations.

• In individuals whose FENO was

elevated at the initial visit and shows variation in response to therapy, repeat FENO monitoring may be considered.

• Education regarding asthma

triggers, review of inhaler techniques, assessment and reinforcement of adherence, treatment of comorbidities

(eg, gastroesophageal reflux, sinusitis, obesity), and encouragement and fortification of the collaborative provider-patient relationship can be provided at each follow-up visit.

• The need for continued assessment or reassessment by a pediatric allergist or pulmonologist can be considered when faced with challenges in attaining optimal asthma control.

• Information on appropriate

coding for the asthma management tools and services provided can be found in the Asthma Coding Fact Sheet at the following link: https:// www.aap.org/asthmacodingfacts heets.

LEAD AUTHORS

Chitra Dinakar, MD, FAAP Bradley Chipps, MD, PhD, FAAP

SECTION ON ALLERGY AND IMMUNOLOGY EXECUTIVE COMMITTEE, 2015–2016 Elizabeth C. Matsui, MD, MHS, FAAP, Chair Stuart L. Abramson, MD, PhD, AE-C, FAAP Chitra Dinakar, MD, FAAP Anne-Marie Irani, MD, FAAP Jennifer S. Kim, MD, FAAP Todd A. Mahr, MD, FAAP, Immediate Past Chair Michael Pistiner, MD, FAAP Julie Wang, MD, FAAP

FORMER EXECUTIVE COMMITTEE MEMBERS Thomas A. Fleisher, MD, FAAP Scott H. Sicherer, MD, FAAP Paul V. Williams, MD, FAAP

STAFF Debra L. Burrowes, MHA

SECTION ON PEDIATRIC PULMONOLOGY AND SLEEP MEDICINE EXECUTIVE COMMITTEE, 2015–2016 Julie P. Katkin, MD, FAAP, Chair Kristin N. Van Hook, MD, FAAP Lee J. Brooks, MD, FAAP Bonnie B. Hudak, MD, FAAP Richard M. Kravitz, MD, FAAP Shrutim Paranjape, MD, FAAP Michael S. Schechter, MD, FAAP, Immediate Past Chair Girish D. Sharma, MD, FAAP Dennis C. Stokes, MD, FAAP

STAFF Laura Laskosz, MPH

ABBREVIATIONS ACT: Asthma Control Test ACQ: Asthma Control Questionnaire AHR: airway hyperresponsiveness ATAQ: Asthma Therapy Assessment Questionnaire ATS/ERS: American Thoracic Society/European Respiratory Society C-ACT: Childhood Asthma Control EPR3: Expert Panel Report 3 FENO: fractional exhaled nitric oxide FEV1: forced expiratory volume in 1 second FEF25–75: forced expiratory flow between 25% and 75% of vital capacity FEV1/FVC ratio: ratio of forced expiratory volume in 1 second to forced expiratory volume FVC: forced expiratory volume PEF: peak flow TRACK: Test for Respiratory and Asthma Control in Kids REFERENCES 1. National Asthma Education and Prevention Program. Expert Panel Report 3 (EPR-3). Guidelines for the diagnosis and management of asthma—summary report 2007. J Allergy Clin Immunol. 2007;120(suppl 5):S94–S138 2. Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015 Update. 2015. Available at: www. ginasthma.org. Accessed June 14, 2016 3. Fuhlbrigge AL, Adams RJ, Guilbert TW, et al. The burden of asthma in the United States: level and distribution are dependent on interpretation of the national asthma education and prevention program guidelines.

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Am J Respir Crit Care Med. 2002;166(8):1044–1049 4. Carlton BG, Lucas DO, Ellis EF, ConboyEllis K, Shoheiber O, Stempel DA. The status of asthma control and asthma prescribing practices in the United States: results of a large prospective asthma control survey of primary care practices. J Asthma. 2005;42(7):529–535 5. Brand PL, Mäkelä MJ, Szefler SJ, Frischer T, Price D; ERS Task Force Monitoring Asthma in Children. Monitoring asthma in childhood: symptoms, exacerbations and quality of life. Eur Respir Rev. 2015;24(136):187–193 6. Cloutier MM, Schatz M, Castro M, et al. Asthma outcomes: composite scores of asthma control. J Allergy Clin Immunol. 2012;129(3 Suppl):S24–S33 7. Nathan RA, Sorkness CA, Kosinski M, et al. Development of the asthma control test: a survey for assessing asthma control. J Allergy Clin Immunol. 2004;113(1):59–65 8. Liu AH, Zeiger RS, Sorkness CA, et al The Childhood Asthma Control Test: retrospective determination and clinical validation of a cut point to identify children with very poorly controlled asthma. J Allergy Clin Immunol. 2010;126(2):267–273, 273.e1 9. Juniper EF, Gruffydd-Jones K, Ward S, Svensson K. Asthma Control Questionnaire in children: validation, measurement properties, interpretation. Eur Respir J. 2010;36(6):1410–1416 10. Chipps B, Zeiger RS, Murphy K, et al. Longitudinal validation of the Test for Respiratory and Asthma Control in Kids in pediatric practices. Pediatrics. 2011;127(3):e737–e747 11. Skinner EA, Diette GB, Algatt-Bergstrom PJ, et al. The Asthma Therapy Assessment Questionnaire (ATAQ) for children and adolescents. Dis Manag. 2004;7(4):305–313 12. Wu AC, Tantisira K, Li L, Schuemann B, Weiss ST, Fuhlbrigge AL; Childhood Asthma Management Program Research Group. Predictors of symptoms are different from predictors of severe exacerbations

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from asthma in children. Chest. 2011;140(1):100–107 13. Schatz M, Kosinski M, Yarlas AS, Hanlon J, Watson ME, Jhingran P. The minimally important difference of the Asthma Control Test. J Allergy Clin Immunol. 2009;124(4):719-23.e1 14. Okelo SO, Eakin MN, Patino CM, et al. The Pediatric Asthma Control and Communication Instrument asthma questionnaire: for use in diverse children of all ages. J Allergy Clin Immunol. 2013;132(1):55–62 15. Picado C, Badiola C, Perulero N, et al; Covalair Investigator Group. Validation of the Spanish version of the Asthma Control Questionnaire. Clin Ther. 2008;30(10):1918–1931 16. Rodrigo GJ, Arcos JP, Nannini LJ, et al. Reliability and factor analysis of the Spanish version of the asthma control test. Ann Allergy Asthma Immunol. 2008;100(1):17–22 17. Schatz M, Sorkness CA, Li JT, et al. Asthma Control Test: reliability, validity, and responsiveness in patients not previously followed by asthma specialists. J Allergy Clin Immunol. 2006;117(3):549–556 18. Piacentini GL, Peroni DG, Bodini A, et al. Childhood Asthma Control Test and airway inflammation evaluation in asthmatic children. Allergy. 2009;64(12):1753–1757 19. Chipps BE, Zeiger RS, Dorenbaum A, et al; TENOR Study Group. Assessment of asthma control and asthma exacerbations in the epidemiology and natural history of asthma: outcomes and treatment regimens (TENOR) observational cohort. Curr Respir Care Rep. 2012;1(4):259–269 20. Jackson DJ, Sykes A, Mallia P, Johnston SL. Asthma exacerbations: origin, effect, and prevention. J Allergy Clin Immunol. 2011;128(6):1165–1174 21. Chipps BE, Mellon MM, Murphy KR, Zeiger RS. Test for respiratory and asthma control in kids (TRACK): a validated control tool for preschoolaged children. J Allergy Clin Immunol. 2014;133(6):1776 22. Wildfire JJ, Gergen PJ, Sorkness CA, et al. Development and validation of the Composite Asthma Severity Index—an outcome measure for use in

children and adolescents. J Allergy Clin Immunol. 2012;129(3):694–701 23. Wilson SR, Rand CS, Cabana MD, et al. Asthma outcomes: quality of life. J Allergy Clin Immunol. 2012;129(suppl 3):S88–S123 24. Tepper RS, Wise RS, Covar R, et al. Asthma outcomes: pulmonary physiology. J Allergy Clin Immunol. 2012;129(suppl 3):S65–S87 25. Kamps AW, Roorda RJ, Brand PL. Peak flow diaries in childhood asthma are unreliable. Thorax. 2001;56(3):180–182 26. Gibson PG. Monitoring the patient with asthma: an evidence-based approach. J Allergy Clin Immunol. 2000;106(1 pt 1):17–26 27. Fuhlbrigge AL, Kitch BT, Paltiel AD, et al. FEV(1) is associated with risk of asthma attacks in a pediatric population. J Allergy Clin Immunol. 2001;107(1):61–67 28. Moeller A, Carlsen KH, Sly PD, et al; ERS Task Force Monitoring Asthma in Children. Monitoring asthma in childhood: lung function, bronchial responsiveness and inflammation. Eur Respir Rev. 2015;24(136):204–215 29. Dombkowski KJ, Hassan F, Wasilevich EA, Clark SJ. Spirometry use among pediatric primary care physicians. Pediatrics. 2010;126(4):682–687 30. American Academy of Pediatrics. Coding fact sheets and billing position papers. Available at: www.aap.org/ asthmacodingfactsheets. Accessed December 23, 2015 31. Spahn JD, Chipps BE. Office-based objective measures in childhood asthma. J Pediatr. 2006;148(1):11–15 32. Paull K, Covar R, Jain N, Gelfand EW, Spahn JD. Do NHLBI lung function criteria apply to children? A crosssectional evaluation of childhood asthma at National Jewish Medical and Research Center, 1999–2002. Pediatr Pulmonol. 2005;39(4):311–317 33. Miller MR, Hankinson J, Brusasco V, et al; ATS/ERS Task Force. Standardisation of spirometry. Eur Respir J. 2005;26(2):319–338 34. Horak E, Lanigan A, Roberts M, et al. Longitudinal study of childhood wheezy bronchitis and asthma: outcome at age 42. BMJ. 2003;326(7386):422–423

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35. Vilozni D, Barak A, Efrati O, et al. The role of computer games in measuring spirometry in healthy and “asthmatic” preschool children. Chest. 2005;128(3):1146–1155 36. Crapo RO, Casaburi R, Coates AL, et al. Guidelines for methacholine and exercise challenge testing-1999. This official statement of the American Thoracic Society was adopted by the ATS Board of Directors, July 1999. Am J Respir Crit Care Med. 2000;161(1):309–329 37. Szefler SJ, Wenzel S, Brown R, et al. Asthma outcomes: biomarkers. J Allergy Clin Immunol. 2012;129(suppl 3):S9–S23 38. Dweik RA, Boggs PB, Erzurum SC, et al; American Thoracic Society Committee on Interpretation of Exhaled Nitric Oxide Levels (FENO) for Clinical Applications. An official ATS clinical practice guideline: interpretation of exhaled nitric oxide levels (FENO) for clinical applications. Am J Respir Crit Care Med. 2011;184(5):602–615 39. AAAAI/ACAAI Joint Statement of Support of the ATS Clinical Practice Guideline. Interpretation of Exhaled Nitric Oxide for Clinical Applications. Available at: www.aaaai.org/Aaaai/media/ MediaLibrary/PDF%20Documents/ My%20Membership/FeNOJointStatemen t3-6-12.pdf. Accessed June 14, 2016

40. Dinakar C. Exhaled nitric oxide in asthma management. Ann Allergy Asthma Immunol. 2012;108(4):219–222 41. Hanson JR, De Lurgio SA, Williams DD, Dinakar C. Office-based exhaled nitric oxide measurement in children 4 years of age and older. Ann Allergy Asthma Immunol. 2013;111(5):358–363 42. Delgado-Corcoran C, Kissoon N, Murphy SP, Duckworth LJ. Exhaled nitric oxide reflects asthma severity and asthma control. Pediatr Crit Care Med. 2004;5(1):48–52 43. Kharitonov SA, Donnelly LE, Montuschi P, Corradi M, Collins JV, Barnes PJ. Dose-dependent onset and cessation of action of inhaled budesonide on exhaled nitric oxide and symptoms in mild asthma. Thorax. 2002;57(10):889–896 44. Jones SL, Kittelson J, Cowan JO, et al. The predictive value of exhaled nitric oxide measurements in assessing changes in asthma control. Am J Respir Crit Care Med. 2001;164(5):738–743 45. Szefler SJ, Mitchell H, Sorkness CA, et al. Management of asthma based on exhaled nitric oxide in addition to guideline-based treatment for innercity adolescents and young adults: a randomised controlled trial. Lancet. 2008;372(9643):1065–1072

46. Petsky HL, Cates CJ, Li A, Kynaston JA, Turner C, Chang AB. Tailored interventions based on exhaled nitric oxide versus clinical symptoms for asthma in children and adults. Cochrane Syst Database Rev. 2009(4):CD006340 47. Petsky HL, Cates CJ, Lasserson TJ, et al. A systematic review and meta-analysis: tailoring asthma treatment on eosinophilic markers (exhaled nitric oxide or sputum eosinophils). Thorax. 2012;67(3):199–208 48. Castro-Rodríguez JA, Holberg CJ, Wright AL, Martinez FD. A clinical index to define risk of asthma in young children with recurrent wheezing. Am J Respir Crit Care Med. 2000;162(4 pt 1):1403–1406 49. Chang TS, Lemanske RF Jr, Guilbert TW, et al. Evaluation of the modified asthma predictive index in high-risk preschool children. J Allergy Clin Immunol Pract. 2013;1(2):152–156 50. Matsui E, Abramson S, Sandel M; American Academy of Pediatrics, Section on Allergy and Immunology. Clinical report: indoor environmental control practices and asthma management. Pediatrics. Available at http://pediatrics.aappublications.org/ content/early/2016/10/27/peds.20162589. Accessed November 8, 2016

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Consent by Proxy for Nonurgent Pediatric Care • Clinical Report

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CLINICAL REPORT

Guidance for the Clinician in Rendering Pediatric Care

Consent by Proxy for Nonurgent Pediatric Care

Jonathan M. Fanaroff, MD, JD, COMMITTEE ON MEDICAL LIABILITY AND RISK MANAGEMENT

Minor-aged patients are often brought to the pediatrician for nonurgent acute medical care, physical examinations, or health supervision visits by someone other than their legally authorized representative, which, in most situations, is a parent. These surrogates or proxies can be members of the child’s extended family, such as a grandparent, adult sibling, or aunt/uncle; a noncustodial parent or stepparent in cases of divorce and remarriage; an adult who lives in the home but is not biologically or legally related to the child; or even a child care provider (eg, au pair, nanny, private-duty nurse/nurse’s aide, group home supervisor). This report identifies common situations in which pediatricians may encounter “consent by proxy” for nonurgent medical care for minors, including physical examinations, and explains the potential for liability exposure associated with these circumstances. The report suggests practical steps that balance the need to minimize the physician’s liability exposure with the patient’s access to health care. Key issues to be considered when creating or updating office policies for obtaining and documenting consent by proxy are offered.

abstract

This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication. Clinical reports from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, clinical reports from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent. The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

BACKGROUND Before providing nonurgent medical care to a minor patient not accompanied by a legally authorized representative (LAR), important questions regarding informed consent and the delegation of parental responsibilities need to be asked and answered. These questions include the following:

1. Who has a legal right to delegate consent to health care decisions for a child? 2. To whom can the power to consent to health care for a child be delegated?

3. In what circumstances can the power to consent to health care for a child be delegated?

4. What are the limitations on the right to delegate the power to consent to health care for a child?

All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time. DOI: 10.1542/peds.2016-3911 PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2017 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they do not have a financial relationship relevant to this article to disclose. FUNDING: No external funding. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

To cite: Fanaroff JM and AAP COMMITTEE ON MEDICAL LIABILITY AND RISK MANAGEMENT. Consent by Proxy for Nonurgent Pediatric Care. Pediatrics. 2017;139(2):e20163911

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5. How is authorization of proxy consent verified and documented? 6. When or how often does information on proxy consent need to be updated?

Many aspects of informed consent in pediatrics have been set forth in previous policy statements from the American Academy of Pediatrics (AAP). Some of these statements addressed informed consent in broad terms, and others addressed narrowly focused situations. The AAP statement on informed consent1 noted that, unlike in other specialties, “the doctrine of ‘informed consent’ has limited direct application in pediatrics,” because parents or other surrogates provide informed permission, rather than informed consent, for diagnosis and treatment of children. Other AAP policy statements have provided guidance to pediatricians on consent for treatment of minor patients in specific circumstances such as emergency care,2 genetic testing and newborn screening,3 procedures that involve sedation,4 and parental denial of medical care for religious reasons.5

This report does not replace the aforementioned policy statements; they stand on their own merit. In addition, it is important to recognize the relevance of the AAP policy “Achieving Quality Health Services for Adolescents”6 (noting the importance of confidentiality for quality adolescent care). This clinical report does not replace or supersede this policy, nor does it apply when a parent has given consent during an early- or mid-adolescent visit for a pediatrician to provide ongoing care to the teenager alone. Instead, this report addresses the potential liability risks that physicians may incur when providing nonurgent medical care to pediatric patients without obtaining permission or consent directly from the patient’s LAR. This report is a revision of the e2

2010 clinical report on consent by proxy.7 The authors acknowledge that not permitting consent by proxy may pose a challenge to the efficient operation of a busy pediatric practice. However, suggestions are offered to help pediatricians minimize their exposure to legal risk in situations in which an LAR has delegated the authority to consent to nonurgent medical care to another adult. Pediatricians should use their good judgment in balancing the patient’s health care needs with their own need for legal protection. Because pediatricians are primarily concerned with their patients’ welfare, discretion should be used to differentiate situations in which care can be delayed pending appropriate LAR consent from situations in which the pediatrician should provide care and accept the risk of legal repercussions. Careful planning and good office policies can minimize those instances.

LEGAL BACKGROUND All states, as supported by AAP policy, allow the provision of specified services (eg, the treatment of sexually transmitted diseases) to minors without parental consent. In general, however, people who have not yet reached the age of majority are not considered adults and do not usually have the right to consent to their own medical care. In most states, the age of majority is 18 years. Thus, a physician is required to obtain consent from an LAR before performing a medical or surgical test, procedure, or treatment on a minor.8 Under some scenarios, the consent can be obtained from the LAR via telephone, even if a proxy accompanies the minor. It is advisable to have a witness confirm and document phone consent. In addition, judicial decisions and legislative action have resulted in several exceptions to the LARconsent requirement, which depends

on the specific state rule (eg, emergency treatment; treatment of an emancipated or “mature” minor; treatment of an adolescent for a specific clinical situation such as sexual assault, sexually transmitted infections, contraception, pregnancy-related care, mental health disorders, drug abuse, or alcohol dependency).

A physician who provides nonurgent care, including the physical examination, to a minor without the consent of someone who is legally authorized to speak for the minor may be vulnerable to legal action. Lawsuits that allege a lack of informed consent usually are based on the concept of negligence but may involve battery as well.9–11 In general, battery is the unsolicited physical touching of a person. Medical battery may be alleged if treatment is provided without appropriate informed consent, when a procedure is performed that is substantially different from the one for which consent was given, when the treatment exceeds the scope of the consent, or when a physician different than the one to whom consent was granted performs the procedure.12 A physician may face a battery claim even if the treatment or procedure may have been performed without any negligence.13 When a plaintiff (person who files the lawsuit, usually parents on behalf of their child) is not satisfied with the results of the medical treatment or procedure but is unable to prove negligence in litigation against the physician, the plaintiff may resort to the theory of battery to seek a recovery. If the plaintiff who alleges an unauthorized procedure cannot prove actual harm, typically only nominal damages will be recovered. However, in a successful battery case, punitive damages may be assessed, which may not be covered by malpractice insurance or dischargeable by bankruptcy. Some states have replaced the

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theory of battery with the theory of medical negligence. In addition to civil liability, physicians may face penalties from licensing boards for performing services without appropriate consent.14

The impact of state privacy laws and the federal Health Insurance Portability and Accountability Act (HIPAA)15 on physician liability for disclosure of health information of minors to unauthorized individuals has not yet been tested. Although HIPAA, as a federal law, takes priority when it conflicts with state laws, in most situations HIPAA expressly incorporates state laws regarding disclosure. To date, physician liability for treating without consent by an LAR seems to be uncommon. However, past frequency may not reflect future likelihood, because the concepts of informed consent and consent by proxy have evolved both ethically and legally. In fact, inadequate informed consent, which had not previously been a major source of liability for physicians, has become increasingly problematic, especially in the context of issues such as limited English proficiency (LEP) and limited health literacy (discussed later). Consent by proxy could become a source of future concern, and physicians should not ignore the risks associated with it. Many of the published cases are of older judicial decisions.16 The ramifications of these cases are unclear to a contemporary jury and judge. In addition, these older cases did not address issues such as LEP and limited health literacy, which may affect informed-consent situations, including consent by proxy. In many of these cases, treatment without consent by an LAR was deemed appropriate by the court either on the basis of the emergency treatment doctrine or because the court deemed the minor patient to be a “mature” or emancipated minor.16

However, there is also judicial precedent in which liability was imposed on the physician.10,17–19

Although not specifically addressing consent by proxy, more recent court cases have assessed the validity of informed consent when a parent was not present.20,21 These cases have involved consent by adolescents for treatments and diagnoses other than those already permitted in most jurisdictions, such as treatment of sexually transmitted infections and mental health disorders. In viewing the informed consent as valid, these courts have determined that the adolescents were “mature minors,” although the minors had not previously sought mature-minor status through adjudication. The courts relied on the adolescents’ age, ability, education, training, degree of maturity and judgment, conduct and demeanor, and the nature and risks of the treatments in assessing whether the minor adolescents were capable of consenting on their own. Nevertheless, despite this legal precedent, pediatricians should be wary of treating adolescents without parental consent unless the adolescent is seeking treatment of a legally permitted condition.

A claim of “inadequate” informed consent is usually predicated on the notion that a “reasonable” person would have refused the treatment or procedure offered to the plaintiff had proper informed consent been conducted.12 A claim of inadequate informed consent may be added to a claim of medical malpractice because proof of inadequate informed consent might imply to a jury that the physician was careless about the care delivered.22 The importance of appropriate informed consent is underscored by appellate court decisions that held that neither proof of medical malpractice nor battery is required for a claim of inadequate informed consent to be valid.23,24

DEFINITION OF TERMS Nonurgent Pediatric Care For the purposes of this clinical report, nonurgent pediatric care is defined as preventive medicine (ie, services encompassed in pediatric health supervision visits, including immunizations and screening tests) and outpatient medical encounters for minor illnesses or injuries. Differences in operations and procedures may depend on whether the nonurgent medical encounter is the initial visit or a follow-up visit.

Informed Consent

Informed consent is a general principle of law that imposes on physicians a duty to disclose to their patients the benefits and risks associated with each of the following: (1) the proposed course of treatment, (2) alternate treatments, and (3) no treatment at all (informed refusal). In general, informed consent is meant to allow patients to exercise their right to autonomy and to voluntarily consent to medical interventions by reasonably balancing the probable risks against the probable benefits.25 State standards in assessing the adequacy of disclosure under informed consent can be physician/ professional based (ie, benefits and risks that a reasonable physician would disclose), patient based (ie, benefits and risks that a reasonable patient would want to know), or a hybrid of both. Some states have appointed interdisciplinary panels to develop specific informed-consent disclosure requirements for selected procedures.26

Consent by Proxy

The process by which people delegate to another person the legal right to consent to medical treatment of themselves, for a minor, or for a ward is called consent by proxy. There are 3 fundamental constraints on this right to delegate consent for children: (1) the guardian of a minor must have the right to consent to

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medical treatment of that minor, (2) the guardian must be legally and medically competent to delegate the right to consent to medical treatment of that child, and (3) the right to consent to medical treatment of the child must be delegated to a legally and medically competent adult.8,16,27 Physicians should realize that people who have been delegated consent-by-proxy status may have different opinions than the LAR about both recommended and alternate treatment.

Physicians need to be aware that state laws may mandate a hierarchy of people who may give consent by proxy to nonurgent treatment if an LAR cannot be contacted.28–30 An example of such a hierarchy is as follows: (1) stepparent, (2) grandparent of minor, (3) adult brother/sister, and (4) adult aunt/ uncle of minor.31 When a hierarchy is the rule, a person lower on the list generally cannot give consent if a person higher on the list is available. A written power of attorney or affidavit may be needed. Such a document may need to be notarized or witnessed,27,32,33 may have a time limit to it,27,32–34 and may be needed to supersede this hierarchy.31 State law or custodial agreement may not permit a noncustodial parent to consent to treatment of a child. State law may permit foster care licensees and court-appointed guardians to consent, depending on the scope of authority granted by the court and the treatment proposed. Typically, consent to “routine” care is permitted, although the definition of routine may vary among states. Some states have permitted proxies to consent to routine or “ordinary” medical and dental care, which can include radiography, surgery, and anesthesia.35 Other states have excluded surgery, anesthesia, and even psychotropic drugs from the definition of ordinary care.27,28,36,37 Immunizations may be excluded from consent by proxy.27 Some state laws e4

on consent by proxy lack specific guidelines for implementation. In addition, some states provide immunity for physicians from civil and criminal liability if the physician obtains the consent in good faith.27

Even in states without laws defining “ordinary” care, it is important for the physician to recognize and distinguish between appropriate non-LAR consent and inappropriate non-LAR consent. It would be perfectly appropriate, for example, to perform a rapid test for group A streptococcal infection in a patient with a sore throat with consent by proxy. It would be inappropriate, on the other hand, to perform most genetic testing (ie, for Huntington disease) with non-LAR consent.

Minor

A person who is younger than the age of legal competence is a minor by definition. In most states, a person is no longer a minor after reaching 18 years of age.

Current Pediatric Practice

Because there is no legal requirement to provide nonurgent pediatric care to a minor without the consent of an LAR, pediatricians who choose to treat such patients should be aware of potential liability risks. Many pediatricians have not adopted policies to minimize liability risks.38 For example, one-third of pediatricians in an AAP survey responded that they had no set policy regarding treating patients brought in for nonurgent acute care or preventive visits by child care providers. A different national study showed that 64% of pediatricians and family physicians often or always saw adolescent patients for routine health maintenance examinations without a parent present.39 Practices that maintained a specific clinic policy were less likely to see an adolescent for routine care without a parent present than those without such a policy.39

FAMILY LIVING ARRANGEMENTS Changes in family living arrangements and the use of child care are leading reasons why someone other than an LAR may bring a minor patient in for nonurgent ambulatory pediatric care. The US Census Bureau has described many aspects of family living arrangements. Although the majority of children spend their childhood living in 2-parent families, millions of children in the United States live in homes with other family configurations. More than one-quarter (23.4 million) of all children younger than 21 years lived with only 1 of their parents.40 In addition, an increasing number of children (5.4 million [7%]) live with a grandparent. Overall, approximately one-third of all children in the United States do not have 2 parents in the home with legal authority to consent to medical treatment. At the initial visit, pediatricians should ask about the child’s living arrangements. At future visits, changes in living arrangements can be ascertained either through a questionnaire or direct inquiry.

CHILD CARE Census reports confirm that an increasing proportion of children spend substantial amounts of time in the care of a person other than their parents. According to recent census data, 12.5 million (61%) of children younger than 5 years had some type of regularly scheduled child care arrangement.41 The time spent in child care was significant, averaging 33 hours per week. A number of arrangements were reported, including care by relatives such as siblings and grandparents, nonrelatives such as babysitters and neighbors, and organized child care facilities such as day care or child care centers, nursery schools, preschools, and Head Start programs.41 Other children are cared

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for by private-duty nurses or nurse’s aides, who should be considered as proxies when they bring a child in for medical care.

DOCUMENTING CONSENT BY PROXY Whenever someone other than the LAR accompanies the child for medical care, it affords an opportunity to assess the relationship between the child and the caregiver, but it precludes face-to-face contact between the pediatrician and the LAR. If it has been anticipated that a caregiver other than an LAR may bring the child to pediatric visits, arrangements should be made for the LAR to provide a written consent by proxy. In general, these documents specify the name of the LAR, the name of the person to whom the LAR’s legal authority to consent to the child’s medical care has been delegated, and the relationship of that person to the child. Such documentation may need to delineate the extent of the surrogate’s authorization (ie, the circumstances, the kinds of medical services, or the specified time period for which the surrogate may provide consent for medical care). State law related to consent by proxy should be reviewed. Signatures may be required, and state law may require that the signatures be notarized.27,42 State law may also dictate the specific time period for which a written consent by proxy is valid.27,34

The proxy relationship should be verified and documented periodically. The proxy accompanying the patient should be the same person to whom proxy has been delegated on the aforementioned form. Requesting a dated signature and government-issued photograph identification from the proxy is 1 way to document that verification. Dissimilar signatures may indicate a problem. It should also be verified that the person is authorized to consent for the specific care that

will be provided. The patient’s medical record should be flagged to alert all pediatric care team members of situations in which the caregiver cannot provide consent. If the pediatrician has any doubts about the caregiver’s capability to provide permission for medical care (eg, lack of maturity, presence of intoxication,43 unclear legal standing, or the inability to understand risk communication, perhaps because of language barriers or limited health literacy), then the pediatrician may need to consider deferring elective care until permission from the LAR can be obtained.

If the pediatrician is uncomfortable with consent-by-proxy arrangements, it needs to be communicated with the LAR as soon as possible. The topic could be broached during early discussions of child care arrangements at prenatal or newborn visits or addressed during medical encounters before the parent returns to employment outside the home. If parents are the caregivers, the pediatrician can explain the importance of the “therapeutic alliance”44 between the pediatrician, parents, and patient and emphasize why it is preferable for at least 1 parent to be present during nonurgent visits. Offering extended office hours (evenings or weekends) is another way pediatricians have made it possible for working parents to attend their children’s medical appointments.

INITIAL VISIT Pediatricians should be cautious about proxy situations if they are providing initial care for the child. Medical decisions may be made on the basis of information obtained from the proxy that may not be entirely accurate. Similarly, medical decisions may be made on the basis of follow-up visits that are contingent on the accuracy of the information from the documentation during

the initial visit. Pediatricians who decide to treat children under these circumstances may want to consider “flagging” such charts so that baseline information obtained from the initial visit can be later verified by the LAR. This flagging procedure would be especially important for details such as medication allergy and family history.

UNACCOMPANIED TRAVEL Consent-by-proxy forms can be useful in other situations as well. Children who travel without their LAR sometimes require medical treatment of a minor injury or illness, which often occurs when children are visiting friends or relatives without their LAR. Although most LARs will sign a proxy consent form when their children go to school or summer camp, few LARs think about sending a signed proxy consent form along when their children leave home for an extended period (eg, a week visiting grandparents). Depending on state law, a child may not be able to obtain routine medical care (which may or may not be defined under state law) without consent to such care by an authorized adult. Pediatricians may encourage LARs to anticipate these problems and to take appropriate action so that their children traveling without an LAR can receive needed nonurgent medical care. When in doubt, pediatricians should consider the best interests of the child in making their decision about rendering care.

CUSTODY AND CONSENT It is prudent for the physician to inquire about marital status and custody issues when relevant. In most states, parents who are married to each other have an equal right to consent to medical care for the children of that marriage, and the consent of only 1 parent is required for nonurgent pediatric care in

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such cases. The physician should not assume which parent has the right to consent for the child when the parents are divorced or legally separated. The right to consent in these situations may be contingent on state law or court order. Some states limit the rights of noncustodial parents and fathers of children born out of wedlock, in which case proof of paternity may not be available, to provide consent to medical care for children.

One of the most difficult situations for securing parental consent for a child’s health care occurs when children are used as pawns in marital conflict. “Physical custody” refers to where the child lives. A “residential custodial parent” has sole physical custody, and this parent’s home is the child’s primary residence. A “noncustodial parent” is usually granted visitation or access rights to the child. “Legal custody,” which can be sole (if only 1 parent has legal custody) or joint (if both parents equally share legal custody), refers to parental rights and responsibilities, which include medical decisions and other issues that pertain to the child’s general welfare. “Joint custody,” when used generically, can either be joint legal custody (parents share nearly equal responsibilities for parenting decisions, such as medical care) or joint physical custody (providing the child with a home). It should be noted that each divorce or legal separation agreement is unique, and specific rights may be granted or denied to a parent, even when the court document describes them as having legal custody of the child. It is important, therefore, to inquire about who has “medical decision-making rights,” because it is more directly pertinent to the issue of providing consent for the child’s medical care. Disputing parents can use situations for deciding whether the child should receive nonurgent medical care as an opportunity to spar over parental rights. Generally, if both parents e6

have equal right to consent to care for their child, the physician need only obtain consent from 1 parent to provide that care. However, there may be situations in which it is not clear whether the pediatrician may seek consent from 1 parent if consent has been refused by the other.8 The pediatrician should clarify who has the right to medical information and may specifically ask for a copy of any joint physical or legal custody agreement.45 Joint legal custody may be relevant to coordinating medical care, because some joint custody agreements require that both parents need to give consent and be informed about their child’s medical needs.

Less commonly recognized is the problem of children visiting a noncustodial parent in another state, especially if that state’s law does not permit a noncustodial parent to give permission for the child to receive medical care. These situations are usually unexpected but not unmanageable. For instance, a pediatrician may be puzzled when a family associated with the practice seeks medical care for a child never mentioned or seen previously. It may be a child or stepchild from a previous marriage or relationship who lives in another state and who, while visiting the family, develops a minor illness and requires medical attention. In such situations, pediatricians need to make sure that the adult accompanying the child has the authority to consent to the medical care before treating. Unless a stepparent has legally adopted the child or has been designated as a legally authorized caregiver, he or she may have no legal authority to give consent for treatment.8 It is suggested that office staff document the name and relationship of the person providing permission and how his or her authority to do so was ascertained.

OTHER CIRCUMSTANCES A significant number of children in the United States do not live with either of their biological parents.40 Children may be in foster care, under the care of a relative, with a potential adoptive parent, wards of the juvenile justice system, or in other situations in which their caregiver is not a biological parent. The pediatrician should ascertain the exact nature of the relationship, verify the authority of the proxy, and document the legal basis of the proxy-child relationship and the exercise of the informed consent process within that context.

For some children, a request has not yet been made to the court for a guardian to be appointed. For this reason, authority to consent to these children’s nonurgent care may be unclear, but a physician should probably not deny them necessary care because of their legal status. The pediatrician should use his or her best judgment in deciding whether to postpone care until a guardian can be appointed or to render the care. If care is provided, careful documentation of the circumstances is recommended. Pediatricians should notify child protective services when a child needs a legal guardian. As noted previously, for children in state custody under a foster care arrangement, there may be restrictions on consent by proxy. Consent for surgery may require a court order.28,30

IMMUNIZATIONS Although some would debate the logic of requiring informed consent for state-mandated services such as immunizations, it is clear that open dialogue about risk is at the crux of the national Vaccine Injury Compensation Program (VICP).46 Vaccine information statements (VISs) were created to meet the informational requirements of the VICP; the VIS alone is not considered

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informed consent. The VICP requires that providers distribute a VIS to the patient’s legal representative every time a covered immunization is administered. Federal law does not require parental consent for immunizations but instead uses the term “legal representative” as one who may consent. Federal law defines legal representative as a parent or other individual who is qualified under state law to consent to the immunization of a minor. Thus, regarding immunizations, state law controls consent. Non-LAR consent to immunizations may be restricted under some state laws.47,48 These state laws may cover procedural requirements (eg, whether consent may be verbal or must be written) or substantive requirements (eg, types of information required). Most states require separate consent for each injection when more than 1 injection is required to complete immunization. Most states require consent for immunization services provided to adolescents.49 Some states allow adolescents to provide informed consent for immunization. Unless the law provides otherwise, immunizations should not be given without appropriate consent. The Centers for Disease Control and Prevention Web site contains information on state laws at http:// www.cdc.gov/vaccines/imzmanagers/laws. Each state also has a Department of Health or Bureau of Immunization that can provide beneficial information. VISs explain the benefits and risks associated with each childhood immunization. They are intended to facilitate, not replace, effective risk communication and proper informed consent between the health care professional and the patient’s legal representative. Instructions for using VISs and documentation requirements are available from the Centers for Disease Control and Prevention50 and are summarized in the AAP Red Book.51 In addition, the

AAP produces vaccine administration record forms to help pediatricians comply with the VICP documentation requirements. For non–Englishspeaking patients, VISs have been translated into more than 40 languages. These VISs can be accessed and downloaded from the Immunization Action Coalition Web site (www.immunize.org/vis).52

LANGUAGE BARRIERS TO INFORMED CONSENT BY PROXY An increasing number of patients and their proxies in the United States have LEP. A similar approach may be needed for patients or LARs with hearing impairment.53 LEP can impede communication, affect the quality of care, and become a major future medical malpractice issue relating to informed consent.54 These issues will only be compounded in scenarios that involve consent by proxy. Various federal and state laws and regulations apply to individuals with LEP, including the Americans with Disabilities Act,55 the Rehabilitation Act of 1973,56 title VI of the Civil Rights Act,57 and HIPAA.15 More than 60 million people in the United States speak a language other than English in the home.58 If the proxy does not speak the same language as the pediatrician, it may be difficult to obtain informed consent.59 Although patient education materials and consent forms can be developed in various languages for common procedures that require informed consent, it would be unwise to rely exclusively on written informedconsent methods. Translations that are accurate according to the textbook language may not be appropriate to the comprehension level of the reader. Most pediatricians report the use of untrained interpreters to communicate with patients and families with LEP, not only in smaller and rural practices but also in states with higher

proportions of people with LEP.60 If the pediatrician suspects that language barriers may compromise the communication between him or her and the proxy necessary for informed consent, other steps may need to be taken. Health care professionals who participate in federal health programs (eg, Medicaid, state Children’s Health Insurance Program, TriCare, Medicare) are expected to meet requirements for accommodating patients with LEP, which may involve qualified translators other than family members.61 Some patients with LEP may be eligible for language assistance if their health care provider participates in a federal government program.62 Health care providers may be placing themselves at risk of liability if proxies have problems understanding them because of a language barrier. Malpractice lawsuits related to the issue of LEP have been based on both negligence and inadequate informed consent.63,64 It is preferable to have someone who is medically knowledgeable explain the illness, treatment options, and known risks and benefits in the proxy’s own language. The practice should record and retain on file the name, address, and background of the translator. Translators should be instructed that they are to communicate the caregiver’s answer directly, which is vital for conveying to the pediatrician whether the respondent’s answer indicates an understanding of the elements needed for informed consent and whether an agreement has been reached as to the medical treatment. It is not advisable to use children (eg, the patient or an older sibling or relative) as translators for informed consent. The use of adult family members as translators may result in incorrect history because of concerns about their desire to not disclose personal information. Certain scenarios could violate section 601 of title VI of the Civil Rights Act, which states that no

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person shall “on the ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance.”61

PROBLEMS WITH PROXIES WITH LIMITED HEALTH LITERACY Modern health care is very complex, and many patients and parents have poor health literacy, defined as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”59 Indeed, nearly 9 of 10 adults have a hard time understanding routinely available health information,65 and the Institute of Medicine has estimated that 90 million American adults lack the literacy skills to effectively use the health care system in this country.59 Informed consent works best when efforts are made to help proxies understand the health information that is being conveyed to them.

SUMMARY When the care provided is done so in the best interest of the child, the liability risk is generally low, even without appropriate consent. This risk is likely to be higher in certain situations, such as in those that involve immunizations, language barriers, limited health literacy, and the initial visit. Medical practice is primarily regulated by the states, and it is essential that pediatricians are aware of the medical consent laws where they practice. Pediatric practices need to anticipate that situations that involve consent by proxy can occur for a variety of reasons. Policies should be developed that promote good, informed decision-making and risk management. Care should be taken to make sure that such policies meet e8

applicable laws without blocking access to necessary but nonurgent health care. Pediatricians have sought ways to accommodate the diverse living and working arrangements of their patients’ families. Many pediatricians are working parents themselves and know well the challenges of family life. Developing a legally sound office policy on consent by proxy is essential for maintaining efficient office operations and strong physician-patient relationships.

IMPLEMENTATION SUGGESTIONS 1. Determine whether the practice will see minor patients without an LAR present. It is usually best if all physicians within the practice adopt the same policy; otherwise, problems can occur during coverage situations.

2. If the practice’s decision is to not provide nonurgent care to patients without an LAR present, then the policy for the office and an information sheet explaining it should be provided to patients and their LAR. The policy should also be made clear during contacts with new or prospective patients. 3. If the practice decides to provide nonurgent care to patients accompanied by someone other than their LAR, then it should establish a policy and procedural guide for the office as well as a patient information sheet that explains the policy. This statement may spell out the LAR’s responsibilities in providing and documenting his or her consentby-proxy arrangement. The pediatrician should educate office staff members, particularly those involved in telephone triage and scheduling appointments, so that they understand the policy and their responsibilities, including verifying the identity of the proxy. In addition, the pediatrician and practice should determine the consent-by-proxy policy of

ancillary services that may be used during an office visit, such as radiology or laboratory services.

4. It is advisable to create a template form to be used in cases in which individuals other than LARs may be expected to accompany a child to the office. Suggested items to address include the following: a. Who has the legal right to delegate consent to health care decisions for the child?

b. To whom can the power to consent to health care for a child be delegated?

c. In what circumstances can the power to consent to health care for a child be delegated (eg, while child is vacationing out of state with grandparents or while parents are traveling overseas and the child remains home with the nanny)? d. For which services (eg, radiology, preventive care, immunizations, laboratory tests) can the power to consent to health care for a child be delegated?

e. With what limitations can the power to consent to health care for a child be delegated? (For example, the proxy may consent to treatment of a child’s sprained ankle but may not be authorized to take the child to the visit with the orthopedic surgeon.) f. How is authorization of proxy consent verified and documented?

g. When or how often should information on proxy consent be updated?

5. The proxy relationship should be verified and documented periodically. In addition, when the office or pediatrician does not know the proxy personally, photo identification, such as a driver’s license, may be required.

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6. Establish an office procedure for providing and documenting informed consent for proxies with LEP, hearing impairment, and limited health literacy. Similarly, information sheets related to office policies should be accessible for proxies with LEP and limited health literacy.

7. A number of state and federal laws affect the ability to give consent by proxy.27,30 Pediatricians need to be aware of these laws (available at www.plol.org). In addition, it is advisable to have legal counsel review office policy and supporting documents to promote compliance with applicable laws.

8. It is recommended that informed consent, including consent by proxy, be included in residency training and continuing medical education. Such educational efforts have been effective in improving knowledge and attitudes about informed consent.66

9. When in doubt about informed consent in a proxy situation, pediatricians should use discretion in deciding whether to treat and should base the decision on the best interests of the child. LEAD AUTHOR

Jonathan M. Fanaroff, MD, JD, FAAP, FCLM

COMMITTEE ON MEDICAL LIABILITY AND RISK MANAGEMENT, 2015–2016 William M. McDonnell, MD, JD, FAAP Robin L. Altman, MD, FAAP Steven A. Bondi, JD, MD, FAAP Jonathan M. Fanaroff, MD, JD, FCLM, FAAP Sandeep K. Narang, MD JD, FAAP Richard L. Oken, MD, FAAP John W. Rusher, MD, JD, FAAP Karen A. Santucci, MD, FAAP James P. Scibilia, MD, FAAP Susan M. Scott, MD, JD, FAAP

STAFF Julie Kersten Ake

ABBREVIATIONS AAP: American Academy of Pediatrics HIPAA: Health Insurance Portability and Accountability Act LAR: legally authorized representative LEP: limited English proficiency VICP: Vaccine Injury Compensation Program VIS: vaccine information statement REFERENCES 1. American Academy of Pediatrics Committee on Bioethics. Informed consent, parental permission, and assent in pediatric practice. Pediatrics. 1995;595(2):314–317. Reaffirmed May 2011

7. McAbee GN; American Academy of Pediatrics Committee on Medical Liability and Risk Management. Consent by proxy for nonurgent pediatric care. Pediatrics. 2010;126(5):1022–1031 8. Vukadinovich DM. Minors’ rights to consent to treatment: navigating the complexity of State laws. J Health Law. 2004;37(4):667–691 9. Gouveia v Phillips, 823 So2d 215 (Fla 4th DCA 2002) 10. Bonner v Moran, 126 F2d 121 (DC Cir 1941) 11. Mohr v Williams, 104 NW 12 (Minn 1905) 12. Merz JF. An empirical analysis of the medical informed consent doctrine: search for a standard of disclosure. Risk Issues Health Saf. 1991;2:27–76 13. Buie v Reynolds, 571 P2d 1230 (Okla Civ App 1977) 14. Fla Stat §458.331(1)(p) (2014)

2. American Academy of Pediatrics Committee on Pediatric Emergency Medicine; Committee on Bioethics. Consent for emergency medical services for children and adolescents. Pediatrics. 2011;128(2):427–433. Reaffirmed September 2015

15. Health Insurance Portability and Accountability Act of 1996 (Pub L No. 104-191)

3. Committee on Bioethics; Committee on Genetics; American College of Medical Genetics and Genomics Social, Ethical, and Legal Issues Committee. Ethical and policy issues in genetic testing and screening of children. Pediatrics. 2013;131(3):620–622

17. Moss v Rishworth, 222 SW 225 (Tex Com App 1920)

4. Cote CJ, Wilson S; American Academy of Pediatrics; American Academy of Pediatric Dentistry, Work Group on Sedation. Clinical report: guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures. Pediatrics. 2006;118(6):2587–2602. Reaffirmed March 2011 5. American Academy of Pediatrics Committee on Bioethics. Religious objections to medical care. Pediatrics. 1997;99(2):279–281. Reaffirmed May 2009 6. Committee on Adolescence. Achieving quality health services for adolescents. Pediatrics. 2016;138(2):e20161347

16. Coleman DL, Rosoff PM. The legal authority of mature minors to consent to general medical treatment. Pediatrics. 2013;131(4):786–793

18. Tabor v Scobee, 254 SW2d 474 (Ky Ct App 1951) 19. Zaman v Schultz, 19 Pa D&C 309 (1933) 20. Belcher v Charleston Area Medical Center, 422 SE2d 827 (W Va Ct App 1992) 21. Caldwell v Bechtol, 724 SW2d 739 (Tenn 1987) 22. Housel v James, 172 P3d 712 (Wash App 2007) 23. McQuitty v Spangler, 976 A2d 1020 (Md 2009) 24. Bubb v Brusky, 768 NW2d 903 (WI 2009) 25. Garner BA. Black’s Law Dictionary. 8th ed. St Paul, MN: West Publishing Co; 2004 26. 25 Tex Admin Code §601.1 27. American Bar Association. Medical consent law. Available at: www. americanbar.org/content/dam/aba/

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migrated/child/PublicDocuments/ medical.authcheckdam.pdf. Accessed March 7, 2016 28. Fla Stat Ann §743.0645 (2006) 29. Tex Fam Code Ann §32.001(a) (2006) 30. American Bar Association. Kinship caregiving and medical consent laws: an in-depth analysis. Available at: www. americanbar.org/content/dam/aba/ migrated/child/PublicDocuments/ summary_memo2.authcheckdam.pdf. Accessed March 7, 2016 31. Fla Stat §743.0645(2)(a–e) (2006) 32. Fla Stat §709.02, §709.08 (2005) 33. Del Code Ann Tit 13 §707(b)(6), §708(a) (2006) 34. Idaho Code Ann §15-5-104 (2007) 35. Cal Fam Code 6902 (2006) 36. Department of Children and Family Services v GM and JJ, 816 So2d 830 (Fla 5th DCA 2002) 37. Ariz Rev Stat Ann §8-514.05(c) (2006) 38. American Academy of Pediatrics, Division of Health Policy and Research. Periodic Survey of Fellows No. 58: Pediatricians’ Experiences With Child Care Health and Safety. Elk Grove Village, IL: American Academy of Pediatrics; 2004 39. Bravender T, Price CN, English A. Primary care providers’ willingness to see unaccompanied adolescents. J Adolesc Health. 2004;34(1): 30–36 40. Grall T. Custodial mothers and fathers and their child support: 2011. Available at: www.census.gov/prod/2011pubs/ p60-240.pdf. Accessed March 7, 2016 41. Laughlin L. Who’s Minding the Kids? Child Care Arrangements. 2013 Current Population Reports. Washington, DC: US Census Bureau; 2013:70–135 42. Fla Stat §709.02, §709.08 (2006) 43. Fraser JJ Jr, McAbee GN; American Academy of Pediatrics Committee on Medical Liability. Dealing with the parent whose judgment is impaired by alcohol or drugs: legal and

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ethical considerations. Pediatrics. 2004;114(3):869–873. Reaffirmed September 2010 44. Cohen GJ; Committee on Psychosocial Aspects of Child and Family Health. The prenatal visit. Pediatrics. 2009;124(4):1227–1232 45. Cohen GJ; American Academy of Pediatrics Committee on Psychosocial Aspects of Child and Family Health. Clinical report: helping children and families deal with divorce and separation. Pediatrics. 2002;110(5):1019–1023. Reaffirmed January 2006 46. The National Childhood Vaccine Injury Act of 1986, 42 USC §300aa-1–300aa-34 47. NY Public Health Law, Article 25, Title I, §2504 (2012) 48. Tex Fam Code Ann 32.001 49. English A, Shaw FE, McCauley MM, Fishbein DB; Working Group on Legislation, Vaccination, and Adolescent Health. Legal basis of consent for health care and vaccination for adolescents. Pediatrics. 2008;121(suppl 1):S85–S87 50. Centers for Disease Control and Prevention. Vaccine information statements: at a glance. Available at: www.cdc.gov/vaccines/hcp/vis/index. html. Accessed March 7, 2016 51. Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2015 Report of the Committee on Infectious Diseases. 30th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2015 52. Immunization Action Coalition Web site. Vaccine information statements (VIS). Available at: www.immunize.org/vis. Accessed March 7, 2016 53. Borngesser v Jersey Shore Medical Center, 340 NJ Super 369 (App Div 2001) 54. Ku L, Flores G. Pay now or pay later: providing interpreter services in health care. Health Aff (Millwood). 2005;24(2):435–444 55. American with Disabilities Act 1990 (42 USC §12101–12213, amended 2008)

56. Rehabilitation Act of 1973 (Pub L No. 93-112, 87 Stat 355 [codified at 29 USC and 31-41c USC]) 57. Title VI of the Civil Rights Act of 1964 (42 USC §2000d et seq) 58. Ryan C. Language use in the United States: 2011. American Community Survey Reports. August 2013. Available at: www.census.gov/prod/2013pubs/ acs-22.pdf. Accessed March 7, 2016 59. Institute of Medicine, Committee on Health Literacy. In: Nielsen-Bohlaman L, Panzer AM, Kindig DA, eds. Health Literacy: Prescription to End Confusion. Washington, DC: National Academies Press; 2004 60. Kuo DZ, O’Connor KG, Flores G, Minkovitz CS. Pediatricians’ use of language services for families with limited English proficiency. Pediatrics. 2007;119(4). Available at: www. pediatrics.org/cgi/content/full/119/4/ e920 61. US Department of Health and Human Services, Office for Civil Rights. Title VI: Prohibition Against National Origin Discrimination as It Affects Persons With Limited English Proficiency. Available at: www.hhs.gov/ocr/ civilrights/resources/specialtopics/ lep/. Accessed March 7, 2016 62. Revised guidance to federal financial assistance recipient regarding Title VI prohibition against national origin discrimination affecting limited English proficient persons. Fed Regist. 2003;68:47311 63. Harsham P. A misinterpreted word worth $71 million. Med Econ. 1984;61(12):289–292 64. Quintero v Encarnacion, no. 99-3258, Lexis 30228 (10th Cir 2000) 65. US Department of Health and Human Services, Office of Disease Prevention and Health Promotion. National Action Plan to Improve Health Literacy. Washington, DC: US Department of Health and Human Services; 2010 66. Sherman HB, McGaghie WC, Unti SM, Thomas JX. Teaching pediatrics residents how to obtain informed consent. Acad Med. 2005;80(10 suppl): S10–S13

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Cord Blood Banking for Potential Future Transplantation • Policy Statement

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Organizational Principles to Guide and Define the Child Health Care System and/or Improve the Health of all Children

Cord Blood Banking for Potential Future Transplantation

William T. Shearer, MD, PhD, FAAP,a Bertram H. Lubin, MD, FAAP,b Mitchell S. Cairo, MD, FAAP,c Luigi D. Notarangelo, MD,d SECTION ON HEMATOLOGY/ONCOLOGY, SECTION ON ALLERGY AND IMMUNOLOGY

This policy statement is intended to provide information to guide pediatricians, obstetricians, and other medical specialists and health care providers in responding to parents’ questions about cord blood donation and banking as well as the types (public versus private) and quality of cord blood banks. Cord blood is an excellent source of stem cells for hematopoietic stem cell transplantation in children with some fatal diseases. Cord blood transplantation offers another method of definitive therapy for infants, children, and adults with certain hematologic malignancies, hemoglobinopathies, severe forms of T-lymphocyte and other immunodeficiencies, and metabolic diseases. The development of universal screening for severe immunodeficiency assay in a growing number of states is likely to increase the number of cord blood transplants. Both public and private cord blood banks worldwide hold hundreds of thousands of cord blood units designated for the treatment of fatal or debilitating illnesses. The procurement, characterization, and cryopreservation of cord blood is free for families who choose public banking. However, the family cost for private banking is significant and not covered by insurance, and the unit may never be used. Quality-assessment reviews by several national and international accrediting bodies show private cord blood banks to be underused for treatment, less regulated for quality control, and more expensive for the family than public cord blood banks. There is an unquestionable need to study the use of cord blood banking to make new and important alternative means of reconstituting the hematopoietic blood system in patients with malignancies and blood disorders and possibly regenerating tissue systems in the future. Recommendations regarding appropriate ethical and operational standards (including informed consent policies, financial disclosures, and conflict-of-interest policies) are provided for physicians, institutions, and organizations that operate or have a relationship with cord blood banking programs. The information on all aspects of cord blood banking gathered in this policy statement will facilitate parental choice for public or private cord blood banking.

abstract

aDepartment

of Pediatrics and Pathology and Immunology, College of Medicine, Baylor University and Section of Immunology, Allergy, and Rheumatology, Texas Children’s Hospital, Houston, Texas; bChildren’s Health, University of California, San Francisco and Benioff Children’s Hospital, San Francisco, California; cDepartment of Pediatrics, Medicine, Pathology, Microbiology and Immunology, and Cell Biology and Anatomy, Maria Fareri Children’s Hospital and New York Medical College, Valhalla, New York; and dLaboratory of Host Defenses, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland All of the authors shared responsibility for writing and editing the document and reviewing and responding to questions and comments from reviewers and the Board of Directors. This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication. Policy statements from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, policy statements from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent. The guidance in this statement does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time. DOI: https://doi.org/10.1542/peds.2017-2695

To cite: Shearer WT, Lubin BH, Cairo MS, et alAAP SECTION ON HEMATOLOGY/ONCOLOGY, AAP SECTION ON ALLERGY AND IMMUNOLOGY. Cord Blood Banking for Potential Future Transplantation. Pediatrics. 2017;140(5):e20172695

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InTrODucTIOn Hematopoietic stem cells have the potential to reconstitute any blood cell type and rescue children with malignancies and other types of lifethreatening diseases. The need for cord blood transplantation to treat malignancies, hemoglobinopathies, primary immunodeficiencies, and metabolic diseases within the last decade1 has prompted the American Academy of Pediatrics (AAP) to revise its 2007 policy statement “Cord Blood Banking for Potential Future Transplantation.”2 This revised policy statement reviews the new applications for transplantation of the hematopoietic cells contained in cord blood taken from the placenta of normal newborn infants, blood that was previously discarded because of a lack of need for it.3 By 2013, more than 30 000 hematopoietic stem cell transplants (HSCTs) have been performed by using cord blood as the source of stem cells worldwide.4,5 The disease distributions were 57% for malignancies, 32.5% for hemoglobinopathies, 6% for severe combined immunodeficiency disease (SCID) or related T-lymphocyte disorders, and 1.5% for other disorders6,7 (Table 1). Approximately 800 000 cord blood units are being stored in public cord blood banks, and more than 5 000 000 cord blood units are stored in private cord blood banks.8 The trajectory of increase in the number of cord blood units being transplanted in patients older than 16 years has progressively increased over the past decade (Fig 1). Clinical outcomes of both malignant and nonmalignant disorders are beginning to emerge in the literature, and it is certain that HLA barriers can be breached more easily with cord blood transplants compared with nonmatched marrow or peripheral blood HSCT transplants.9–15 Stem cell quantity limitations in cord blood may be addressed by laboratory expansion 2

of hematopoietic stem cells to meet the increased use of cord blood in older children and adults, as was seen in 1 limited study (which requires confirmation in a larger study).3,15–17 The implementation of universal newborn screening by using dried blood on filter paper and the T-lymphocyte receptor excision circle assay in more than 3 000 000 newborn infants permitted the recognition of the true incidence of SCID requiring HSCT; it was found to be nearly double (ie, 1 in 58 000 live births) previous estimates.18 This new development has prompted the search for a more convenient method of HSCT, a method that applies to the use of cord blood. However, other sources of hematopoietic stem cells (eg, haploidentical parent donors) may prove useful for patients with infections.19,20 Perhaps the most immediate challenge is that of educating medical personnel, parents, and the public about the increasing need and uses of cord blood banking. In the following sections, several important features of public versus private cord blood banking are compared: (1) purpose; (2) quality control and accreditation; (3) cost and use of banked cord blood; (4) education of medical personnel, expectant parents, and the public; (5) summary; and (6) recommendations. A review of these components will enable parents and medical personnel to make informed decisions on public or private cord blood banking for patients.

PublIc Versus PrIVaTe cOrD blOOD bankIng: PurPOse anD OPInIOns Purpose The primary goal of this policy statement is to help physicians address the question of the value of cord blood banking in public or private cord blood banks.2 Parents who save their children’s cord blood in private cord blood banks

Table 1 Diseases Treated by Umbilical Cord Blood Transplant by Using Either Sibling or Unrelated Donors Malignant Diseases

Nonmalignant Diseases

Acute lymphocytic leukemia Acute myelocytic leukemia Juvenile chronic myelogenous leukemia Chronic myelogeneous leukemia Neuroblastoma

Fanconi anemia

Myelodysplastic syndrome

Idiopathic aplastic anemia Thalassemia

Sickle cell anemia

Amegakaryocytic thrombocytopenia Kostman syndrome Blackfan-Diamond syndrome Severe combined immunodeficiency X-linked lymphoproliferative syndrome Wiskott-Aldrich syndrome Hurler syndrome Hunter syndrome Gunther disease Osteopetrosis Globoid cell leukodystrophy Adrenoleukodystrophy Lesch-Nyhan syndrome

Adapted from Cairo MS, Rocha V, Gluckman E, Hale G, Wagner J. Alternative allogenic donor sources for transplantation for childhood diseases: unrelated cord blood and haploidentical family donors [published correction appears in Biol Blood Marrow Transplant. 2008;14(11):1317–1318]. Biol Blood Marrow Transplant. 2008;14(1, suppl 1):44–53. Copyright ©2008 American Society for Blood and Marrow Transplantation.

need to be aware that should their child develop leukemia, the child’s stored cord blood already contains premalignant cells and cannot, therefore, be used to treat the child (autologous transplant).21,22 In that case, the cord blood from an unrelated child (an allogeneic transplant) is needed. When there is a known genetic defect in a family, there can be a need for directed cord blood that could be stored in a cord blood bank location (usually at a major medical institute) at which HLA typing could be performed before transplant. New developments in early clinical trial research for regenerative purposes

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World Marrow Donor Association,26 the AAP,2 the American Congress of Obstetricians and Gynecologists,27 and the American Society for Blood and Marrow Transplantation.8

FIgure 1

Umbilical cord blood transplant by age (based on unpublished data from the Center for International Blood and Marrow Transplant Research [CIBMTR] and reproduced with permission). Shown are the latest data available. a Numbers for 2012–2013 are lower because of a reporting lag.

may affect cord blood banking in the future. Some examples of these trials of cord blood transplants are those for Alzheimer disease, autism spectrum disorder, diabetes, cerebral palsy, hypoxic ischemic encephalopathy, systemic lupus erythematosus, and systemic sclerosis.4,5,23 However, no breakthrough in therapy has yet been realized.

Worldwide Opinion on Public Versus Private cord blood banking

Since the publication of the previous AAP policy statement on cord blood banking,2 several other professional societies have issued similar statements. The American Society for Blood and Marrow Transplantation’s view is that donation of cord blood to the public is preferable because the use of cord blood stored in private cord blood banks for therapy rarely occurs (ie, 1 in several 1000).3 The American Society for Blood and Marrow Transplantation acknowledges that private donation may be used for family members with nonmalignant conditions if there is good HLA matching between a donor and recipient.

Other professional groups that favor public cord blood bank donations over private cord blood banking include the International Federation of Gynecology and Obstetrics and the United Kingdom’s Royal College of Obstetricians and Gynecologists.8 Petrini24 has addressed the critical issue of the ethics of private cord blood banking versus public cord blood banking. Most professional organizations support donation to public institutions. An exception to the preference of public cord blood banking would be in instances when a family member is identified as having a disease that can be cured by cord blood transplantation. In those instances, the use of family-directed cord blood banks (normally located within universities or, in some cases, nested in private cord blood banks) may be preferred. The review by Petrini24 lists all of the European and US professional organizations that strongly advocate for donation to and use of cord blood in public institutions: the Society of Obstetricians and Gynecologists of Canada,25 the

European countries have advocated for the adoption of strict guidelines regarding public collection and use of cord blood for transplant in the case of lifethreatening illnesses.28–39 The most expressive opinion of these position statements is from the Italian Committee for the Proper Use of Umbilical Cord Blood to the Chairman of the Health Commission of the European Parliament, which noted (1) the total absence of scientifically valid data proving that the therapeutic use of autologous cord blood stored for preventive purposes is appropriate, effective, and risk free; (2) the for-profit nature of the private collection and storage of umbilical cord blood; and (3) the contrast between this type of storage of cord blood and both the general interest and the principle of altruistic donations and solidarity repeatedly affirmed by the European Parliament.40 Canada and Australia, although favoring the promotion of public cord blood banking, nevertheless advocate for a cooperative relationship between public and private cord blood banks.41,42 Some attempts have been made to merge the concepts of public and private cord blood banking by holding private cord blood banks to the same level of excellence and regulation of laboratory experiments and storage facilities as public cord blood banks in preparation for allogeneic transplantation.43 One such hybrid cord blood bank has been evaluated and was found to be of less benefit to patients than either public or private cord blood banks separately.44 The authors concluded that continued emphasis should be placed on public cord blood banking.44

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QualITy cOnTrOl anD accreDITaTIOn OF cOrD blOOD banks As noted in the 2007 AAP policy statement,2 the emphasis on quality control and accreditation of cord blood banks is extremely important.45 Several programs have such guidelines for accreditation, including NetCord and the Foundation for the Accreditation of Cellular Therapy (FACT),46 FACT and the Joint Accreditation Committee,47 and the American Association of Blood Banks.48 For example, their recommendations address the collection and storage of cord blood and prescribe the following: (1) cord blood receptacles, (2) time processing, (3) standard freezing and storage conditions, (4) segments of cord blood for testing and confirmation of identity, (5) extra cells for potential extra testing, (6) rapid testing for infectious agents, and (7) long-term storage of cord blood units in liquid nitrogen.36,40–48 These standards are critical for the safety of the prospective recipient and essential to physicians selecting products for use in HSCT. Only approximately 25% to 40% of collected umbilical cord blood units satisfy these criteria for storage in a public bank; in contrast, most private banks store the product regardless of cell count.49,50 Sun et al51 and others51–53 have compared the differences in quality between privately and publicly banked cord blood. The authors of these studies concluded that publicly stored cord blood was of a higher quality because private cord blood banks are not subject to the same regulatory oversight and have lesserquality stored cord blood units with decreased viability.51–53

access, cOsT, anD use OF bankeD cOrD blOOD access: number of cord blood banks in north america As of 2017, there are 28 public cord blood banks in North America (the United States, Canada, and Mexico; 4

https://parentsguidecordblood. org/en/public-banking). These banks have sufficient capacity for those requesting a donation of cord blood. However, an area of concern is the relatively limited number of banked cord blood units that are HLA matched to patients belonging to ethnic and/or minority patients who need a cord blood transplant. More individuals from these groups need to store their infants’ cord blood in cord blood banks. Education for ethnic and/or minority members of society is important to allow public cord blood banks to build their inventory to increase specific, HLAcompatible cord blood sets to serve the needs of all people.

cost

There are no placement or maintenance fees for public cord blood banks. For private cord blood banks, a placement fee of $1350 to $2300 and an annual maintenance fee of $100 to $175 is required of families.54

use

Ballen et al54 reported the results of 59 private cord blood banks surveyed for case reports of family cord blood units released for clinical use and compared these results to the World Marrow Donor Association data on public cord blood storage and release for clinical use. These authors reported that 30-fold more cord blood units stored in public cord blood banks have been released for clinical purposes as compared with those released from private cord blood banks.54

eDucaTIOn: MeDIcal PersOnnel, exPecTanT ParenTs, anD The PublIc need for education about cord blood banking In an AAP periodic survey of fellows, only 18% of pediatricians

surveyed were somewhat familiar with the 2007 AAP policy regarding cord blood banking 1 year after its publication.55 This lack of awareness represents an opportunity to provide more education to physicians regarding the policy statement and information regarding cord blood banking. Using a survey tool with women in the third trimester of pregnancy or postpartum, Bhandari et al56 was able to show that the main reason women refuse donating the cord blood of their infants was a lack of information about the procedure and its outcome. Therefore, it is important that physicians become familiar with the advantages and disadvantages of public versus private cord blood banking to serve as a trusted resource to their patients. Educational opportunities on cord blood banking should be enhanced by educational seminars at national meetings and through electronic means of communication. The public has access to information through a variety of sources. Physicians can play a critical role in directing families to reliable sources of information on this topic. For example, additional information about cord blood banking is available through the Parent’s Guide to Cord Blood Foundation (https:// parentsguidecordblood.org/en/ public-banking) and Be The Match (https://bethematch.org/About-us/). In addition, physicians have the opportunity to discuss key issues, including:

key educational Points to share With Parents When expectant parents are present during a medical office visit for their child or are establishing a relationship with the obstetrician or pediatrician before the child’s birth, that physician and other health care providers may use that time as an opportunity to address the following:

• The rationale for public and private cord blood banking. Public cord

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blood banking serves the entire world, whereas private cord blood banking serves the needs of 1 family;

• The value of public cord blood

banking to society. The parents of children who suffer fatal congenital disease or fatal acquired disease will be able to search the public cord blood banks throughout the United States and other countries as well for matching of cord blood stem cells with a patient’s HLA antigens;

• Accreditation and regulatory

oversight of public and private cord blood banking. Public cord blood banking is highly regulated by oversight accrediting institutions, whereas private cord blood banking may not meet the strict requirements of some accreditation bodies. Parents who are intent on donating their child’s cord blood to a private cord blood bank are encouraged to ask industry representatives for evidence of validation and accreditation, financial cost, failure of cord blood to achieve successful engraftment, and backup electrical systems in case of storage equipment failure;

• Costs associated with public

and private cord blood banking. There is no cost to families donating their infants’ cord blood to public banks, whereas families who place their infants’ cord blood with a private cord blood bank must pay a placement fee ($1350–$2300) as well as a smaller annual maintenance fee ($100–$175)54;

• The probability of use of public

and private cord blood banking. The use rate of previously banked cord blood stem cells is at least 30-fold greater in public cord blood banks compared with that of private cord blood banks54; and

• Informed consent and the

decision time frame, financial disclosure, and conflict of interest. The optimal time to obtain informed consent and to make a decision on which form of cord blood banking (public or private) is at the first prenatal visit when the obstetrician and/ or pediatrician or other medical personnel can discuss the option in an unhurried environment. Parents should not be asked to make a decision after labor has begun. Disclosure of any medical personnel with conflicts of interest in cord blood collection should be made to the expectant family at this time. In addition, a declaration of potential conflict of interest needs to be made to the institution in which the collection of cord blood cells is to be made.

cOnclusIOns selection criteria The AAP policy statement on cord blood banking for future transplantation has been revised because of the rapidly expanding need for cord blood for HSCT for patients with childhood malignancies, hemoglobinopathies, primary immunodeficiencies, metabolic disease, and other disorders. Because of the evolving use of cord blood transplants for new applications in medicine, there is an important need to inform medical personnel, parents, and the public alike about advances in therapeutic approaches for cellular immune reconstitution. The number of cord blood transplants for primary immunodeficiency is expected to increase because SCID is increasingly being added to newborn screening programs in more and more states. Although this number of cord blood transplants is small compared with total HSCTs,

such as bone marrow and peripheral blood stem cell transplants (ie, >600 000), appreciation for alternative features and advantages of cord blood transplants, such as the use of partially HLA-matched donor stem cells over haploidentical stem cells, has not been fully evaluated. External oversight of cord blood banking systems is critical in monitoring the quality of the blood product from collection to longterm storage. External agencies (such as FACT, which has developed accreditation guidelines and monitors public cord blood banks) serve as an important mechanism to ensure across-the-board conformity with the strict purity of product due to or expected by patients in need of cord blood transplants. It is important that similar mechanisms be implemented to monitor private cord blood banks.

As of today, public and private cord blood banking systems serve different purposes. Private cord blood banks serve parents who elect to store their children’s cord blood for potential self-use later in life, although to date, there is little evidence supporting use for this purpose. Private cord blood banks also store cord blood for use in families with an identified sibling in need of a transplant or a genetic risk of producing a sibling with a transplantable disease. Public cord blood banks store donated blood for non–self-use (allogeneic) by individuals in the general public. On average, cord blood stored in private cord blood banks is (1) underused, (2) not subject to strict regulatory oversight, (3) expensive for the family, and (4) and may be of lesser quality (in number and quality of stem cells) than that stored in public cord blood banks. In contrast, cord blood donated to public banks is more commonly used and heavily regulated. Thus, the cost and value

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of the maintenance of private cord blood banks is not supported by the evidence for use at the present time.5

Future research

New developments in cord blood stem cell research may demonstrate a need for the use of autologous or close-relative use of long-term cord blood in a private banking system. A smaller but no less important need for family-directed cord blood banks continues to be demonstrated for families with known malignancies or congenital diseases (eg, children with severe primary immunodeficiencies and hemoglobinopathies). These special cord blood banks are frequently located at university teaching hospitals. Private or autologous cord blood banking may be considered for experimental stem cell regenerative research, in which stem cell transplants are used to attempt to restore nonfunctioning or diseased nonhematologic tissue (eg, central nervous system or heart muscle). However, local institutional review board–approved protocols are necessary in addition to Food and Drug Administration approval, if applicable. Moreover, parents would need to sign the institutional review board–approved informed consent document if private banking is used for this purpose.

recOMMenDaTIOns 1. Public cord blood banking is the preferred method of collecting, processing, and using cord blood cells for use in transplantation in infants and children with fatal diseases, such as malignancies, blood disorders, immune deficiencies, and metabolic disorders. There is a more limited role of private cord blood banking with families with a known fatal illness that can be rescued by a healthy cord blood transplant within the family; 6

2. It is important that the concepts of autologous and allogeneic use of cord blood units be explained to parents by physicians and medical staff to enable expectant parents to make informed choices regarding where they should deposit their infant’s cord blood and whether to restrict the blood for the infant’s or family’s use or release it to the public for any child in need of stem cell transplantation;

3. Physicians need to convey accurate information about the potential benefits and limitations of allogeneic and autologous cord blood banking and transplantation to parents, including that autologous cord blood would not be used as a stem cell source if the donor developed leukemia later in life. It is important for parents to be aware that at this time, there are no scientific data to support the claim that autologous cord blood is a tissue source proven to be of value for regenerative medical purposes, although researchers are examining this possibility; 4. It is expected that physicians and designated medical staff obtain specific permission for maintaining demographic medical information and that the potential risks of breaches of confidentiality be disclosed to parents. Specific efforts need to be made to recruit underserved ethnic minorities for cord blood donations to enlarge the public cord blood repositories and better serve these patient populations. Before the onset of active labor, written permission needs to be obtained from parents to collect the cord blood for banking purposes. If the cord blood bank is conducting therapeutic human research involving cord blood, review and approval of the recruitment strategies and parental consent

forms by the institutional review board are necessary;

5. The AAP advocates for regulatory agencies (eg, the Food and Drug Administration, the Federal Trade Commission, and state equivalents of these federal agencies) to have an active role in providing oversight of the cord blood program. It is important that all cord blood banking programs comply with FACT or equivalent accreditation standards; and

6. Physicians or other professionals who recruit pregnant women and their families for for-profit placental cord blood stem cell banking need to disclose any financial interest or other potential conflict of interest they have relative to the procedure to their patients. Similarly, professionals affiliated with institutions or organizations that promote for-profit placental blood stem cell banking need to make annual financial-disclosure and potential-conflicts-of-interest statements to an appropriate institutional review committee that possesses oversight authority.

acknOWleDgMenTs We thank Ms Janice Hopkins and Ms Carolyn Jackson for their assistance in preparing this policy statement. leaD auThOrs

William T. Shearer, MD, PhD, FAAP Bertram H. Lubin, MD, FAAP Mitchell S. Cairo, MD, FAAP Luigi D. Notarangelo, MD

secTIOn On heMaTOlOgy/OncOlOgy execuTIVe cOMMITTee, 2015–2016 Jeffrey Hord, MD, FAAP, Chairperson Gary Crouch, MD, FAAP Gregory Hale, MD, FAAP James Harper, MD, FAAP Jeffrey Lipton, MD, FAAP Zora Rogers, MD, FAAP

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Eric Werner, MD, FAAP, Immediate Past Chairperson

sTaFF Suzanne Kirkwood, MS

secTIOn On allergy anD IMMunOlOgy execuTIVe cOMMITTee, 2015–2016 Elizabeth C. Matsui, MD, FAAP, Chairperson Stuart L. Abramson, MD, PhD, FAAP Chitra Dinakar, MD, FAAP Anne-Marie Irani, MD, FAAP Todd A. Mahr, MD, Immediate Past Chairperson

Jennifer S. Kim, MD, FAAP Michael Pistiner, MD, FAAP Julie Wang, MD, FAAP

aDDITIOnal cOnTrIbuTOrs Thomas A. Fleisher, MD, FAAP, past member Scott H. Sicherer, MD, FAAP, past member Paul V. Williams, MD, FAAP, liaison to the American Academy of Allergy, Asthma, and Immunology

sTaFF Debra Burrowes, MHA

abbreVIaTIOns AAP: American Academy of Pediatrics FACT: Foundation for the Accreditation of Cellular Therapy HSCT: hematopoietic stem cell transplant SCID: severe combined immunodeficiency disease

Address correspondence to William T. Shearer, MD, PhD, FAAP. E-mail: [email protected] PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2017 by the American Academy of Pediatrics FInancIal DIsclOsure: Dr Notarangelo is supported by the Intramural Research Program of the National Institute of Allergy and Infectious Diseases, National Institutes of Health; and Drs Shearer, Lubin, and Cairo have indicated they have no financial relationships relevant to this article to disclose. FunDIng: No external funding. POTenTIal cOnFlIcT OF InTeresT: Dr Notarangelo has had a consulting relationship with Sigma-Tau; this relationship is not currently active; and Drs Shearer, Lubin, and Cairo have indicated they have no potential conflicts of interest to disclose.

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7. Cairo MS, Rocha V, Gluckman E, Hale G, Wagner J. Alternative allogenic donor sources for transplantation for childhood diseases: unrelated cord blood and haploidentical family donors [published correction appears in Biol Blood Marrow Transplant. 2008;14(11):1317–1318]. Biol Blood Marrow Transplant. 2008;14(1, suppl 1):44–53 8. Kurtzberg J. A history of cord blood banking and transplantation. Stem Cells Transl Med. 2017;6(5):1309–1311 9. Cutler C, Ballen KK. Improving outcomes in umbilical cord blood transplantation: state of the art. Blood Rev. 2012;26(6):241–246 10. Barker JN, Scaradavou A, Stevens CE. Combined effect of total nucleated cell dose and HLA match on transplantation outcome in 1061 cord blood recipients with hematologic malignancies. Blood. 2010;115(9):1843–1849 11. Fernandes JF, Rocha V, Labopin M, et al; Eurocord and Inborn Errors Working Party of European Group for Blood and Marrow Transplantation. Transplantation in patients with SCID: mismatched related stem cells or unrelated cord blood? Blood. 2012;119(12):2949–2955

12. Cavazzana-Calvo M, André-Schmutz I, Fischer A. Haematopoietic stem cell transplantation for SCID patients: Where do we stand? Br J Haematol. 2013;160(2):146–152 13. Parikh S, Szabolcs P. Reduced-intensity conditioning (RIC) in children with nonmalignant disorders (NMD) undergoing unrelated donor umbilical cord blood transplantation (UCBT). Biol Blood Marrow Transplant. 2012;18(suppl 1):S53–S55 14. Geyer MB, Jacobson JS, Freedman J, et al. A comparison of immune reconstitution and graft-versus-host disease following myeloablative conditioning versus reduced toxicity conditioning and umbilical cord blood transplantation in paediatric recipients. Br J Haematol. 2011;155(2):218–234 15. Horwitz ME, Chao NJ, Rizzieri DA, et al. Umbilical cord blood expansion with nicotinamide provides long-term multilineage engraftment. J Clin Invest. 2014;124(7):3121–3128 16. Herr AL, Kabbara N, Bonfim CM, et al. Long-term follow-up and factors influencing outcomes after related HLA-identical cord blood transplantation for patients

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with malignancies: an analysis on behalf of Eurocord-EBMT. Blood. 2010;116(11):1849–1856 17. Broxmeyer HE. Enhancing engraftment of cord blood cells via insight into the biology of stem/progenitor cell function. Ann N Y Acad Sci. 2012;1266(1):151–160 18. Kwan A, Abraham RS, Currier R, et al. Newborn screening for severe combined immunodeficiency in 11 screening programs in the United States. JAMA. 2014;312(7):729–738 19. Pai S-Y, Logan B, Griffith LM, et al. Transplant outcomes for severe combined immunodeficiency from 2000-2009. N Engl J Med. 2014;371(5):434–446 20. Moratto D, Giliani S, Bonfim C, et al. Long-term outcome and lineagespecific chimerism in 194 patients with Wiskott-Aldrich syndrome treated by hematopoietic cell transplantation in the period 1980-2009: an international collaborative study. Blood. 2011;118(6):1675–1684 21. Shlush LI, Zandi S, Mitchell A, et al. Identification of preleukaemic haematopoietic stem cells in acute leukaemia. Nature. 2014;506(7488):328–333 22. Yasuda T, Ueno T, Fukumura K, et al. Leukemic evolution of donor-derived cells harboring IDH2 and DNMT3A mutations after allogeneic stem cell transplantation. Leukemia. 2014;28(2):426–428 23. Cotten CM, Murtha A, Goldberg R, et al. Feasibility of autologous cord blood cells for infants with hypoxicischemic encephalopathy. J Pediatr. 2014;164(5):973–979 24. Petrini C. Ethical issues in umbilical cord blood banking: a comparative analysis of documents from national and international institutions. Transfusion. 2013;53(4):902–910 25. Armson A; Maternal/Fetal Medicine Committee, Society of Obstetricians and Gynaecologists of Canada. Umbilical cord blood banking: implications for perinatal care providers. J Obstet Gynaecol Can. 2005;27(3):263–290 26. World Marrow Donor Association. WMDA policy statement for the utility

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of autologous or family cord blood unit storage. Approved and adopted by the WMDA board on the 25th of May 2006. Updated 2011. Available at: http://bloodcell.transplant.hrsa.gov/ cord/files/wmdapolicystatement.pdf. Accessed December 6, 2016 27. American College of Obstetricians and Gynecologists, Committee on Obstetric Practice, Committee on Genetics. Umbilical cord blood banking. ACOG Opinion No. 399. February 2008 (Replaces No. 183, April 1997). Obstet Gynecol. 2008;111(2, pt 1):475–477 28. Assemblée Nationale de la République Française; Sénat de la République Française. Loi no 2011-814 du 7 juillet 2011 relative à la bioéthique. Journal Officiel de la République Française. 2011:157 29. États Généraux de la Bioéthique. Rapport final. 2009. Available at: http:// benoit.urgelli.free.fr/Recherches/ Formation/Consultation-OGM-2009/ RapportFinalEtatsGeneraux2009Extra itCSE.pdf. Accessed September 20, 2017

www.cngof.asso.fr/D_TELE/com_ press10-12-09.pdf. Accessed July 11, 2012 34. Centro Nazionale Sangue (CNS), Centro Nazionale Trapianti (CNT). Posizione del Centro Nazionale Sangue e del Centro Nazionale Trapianti sull’uso autologo del sangue cordonale. 2010. Available at: www.trapianti.salute.gov. it/cnt/comunicato/notacongiunta.pdf. Accessed December 6, 2016 35. Agence de la Biomédecine (République Française). Le don de sang placentaire. Une source irremplaçable de cellules souches pour la greffe allogénique. 2010. Available at: www.agencebiomedecine.fr/IMG/pdf/doc_don_ placentaire-2.pdf. Accessed July 11, 2012 36. Agence de la Biomédecine (République Française). Le don, le prélèvement et la greffe de sang de cordon. 2012. Available at: https://www. agence-biomedecine.fr/Donation-andtransplantation-of?lang=fr. Accessed July 11, 2012

30. Assemblée Nationale de la République Française. Leonetti J, ed. Rapport d’information fait au nom de la mission d’information sur la révision des lois de bioéthique, n°2235. Tome 1: Rapport. 2010. Available at: www. assembleenationale.fr/13/rap-info/ i2235-t1.asp. Accessed July 11, 2012

37. Société Française de Greffe de Moelle et de Thérapie Cellulaire (SFGM-TC). Appel à la vigilance sur les sociétés privées incitant à la conservation de sang à visée autologue. Communiqué de presse. Available at: https://www. agence-biomedecine.fr/IMG/pdf/ sfgmtcsangplacentaire81209vdef.pdf. Accessed September 20, 2017

31. Assemblée Nationale de la République Française. Leonetti J, ed. Rapport d’information fait au nom de la mission d’information sur la révision des lois de bioéthique, n°2235. Tome 2: Auditions. 2010. Available at: www. assembleenationale.fr/13/rap-info/ i2235-t2.asp. Accessed July 11, 2012

38. Agence de la Biomédecine (République Française). Utilisation thérapeutique du sang de cordon: une clarification s’impose. Communiqué de presse. 2010. Available at: https://www. agence-biomedecine.fr/Communiquesde-presse-2010?lang=fr. Accessed September 20, 2017

32. Académie Nationale de Médecine. , eds. Les cellules souches du cordon et du placenta: de la recherche aux applications thérapeutiques. Rapport adopté le. 2010. Available at: www.academie-medecine.fr/ detailpublication.cfm?idrub=26& idligne=1772. Accessed September 20, 2017

39. .Agence de la Biomédecine (République Française). Organisation du don de sang de cordon en France en 2010. 2010. Available at: https://www.agencebiomedecine.fr/IMG/pdf/panoramasang-cordon-janv-2010.pdf. Accessed September 20, 2017

33. Collège National des Gynécologues et Obstétriciens Français. Non aux sociétés à but lucratif incitant à la conservation de sang de cordon à visée autologue. 2009. Available at:

40. Comité Italo-Français pour le bon usage du sang du cordon ombilical. Audition au Parlement Européen sur le don de la solidarité, collection privée et la préservation du sang de cordon ombilical. 2011. Available at: http:// www.adoces.it/wordpress/wp-content/

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uploads/2011/03/Eurodeputatifrancese.pdf. Accessed July 11, 2012 41. Isasi R, Dalpe G, Knoppers BM. Fostering public cord blood banking and research in Canada. Stem Cells Dev. 2013;22(suppl 1):29–34 42. Stewart CL, Aparicio LC, Kerridge IH. Ethical and legal issues raised by cord blood banking - the challenges of the new bioeconomy. Med J Aust. 2013;199(4):290–292 43. NetCord. Position Statement on Cord Blood for Autologous Use. Arlington Heights, IL: NetCord Newsletter; 2008 44. Guilcher G, Fernandez CV, Joffe S. Are hybrid umbilical cord blood banks really the best of both worlds? J Med Ethics. 2015;41(3):272–275 45. Petrini C. Umbilical cord blood collection, storage and use: ethical issues. Blood Transfus. 2010;8(3):139–148 46. NetCord, Foundation for the Accreditation of Cell Therapy. NetCordFACT international standards for cord blood collection, processing, and release for administration. 4th ed. 2010. Available at: http://stemcellbank. org.ua/wp-content/uploads/2013/ 08/INTERNATIONAL-STANDARDS-FORCORD-BLOOD-COLLECTION-BANKING-ANDRELEASE-FOR-ADMINISTRATION-4th_ Edition.pdf. Accessed December 6, 2016

47. Foundation for the Accreditation of Cell Therapy, Joint Accreditation Committee ISCT-EBMT. FACTJACIE international standards for cellular therapy product collection, processing and administration. 5th ed. 2012. Available at: www.jacie.org/documentcentre/Standards%205th%20ed. pdf?attredirects=0&d=1. Accessed December 6, 2016 48. Boo M, Welte K, Confer D. Accreditation and regulation of cord blood banking. In: Brokmeyer HE, ed. Cord Blood: Biology, Transplantation, Banking, and Regulation. Bethesda, MD: American Association of Blood Banks; 2011:663–672 49. Butler MG, Menitove JE. Umbilical cord blood banking: an update. J Assist Reprod Genet. 2011;28(8):669–676 50. National Cord Blood Program. Available at: http://nationalcordbloodprogram. com. Accessed December 6, 2016 51. Sun J, Allison J, McLaughlin C, et al. Differences in quality between privately and publicly banked umbilical cord blood units: a pilot study of autologous cord blood infusion in children with acquired neurologic disorders. Transfusion. 2010;50(9):1980–1987 52. American College of Obstetricians and Gynecologists. Umbilical cord blood

banking. ACOG Committee Opinion No. 399. Obstet Gynecol. 2008;111(2, pt 1):475–477 53. Cord Blood Working Group. Combined private and public banking of cord blood and other related products. Leiden, NL: World Marrow Donor Association; 2012. Available at: www.worldmarrow.org/fileadmin/ committees/cord_blood_working_ group/20120328-CBWG-PPR-Hybrid.pdf. Accessed December 6, 2016 54. Ballen KK, Verter F, Kurtzburg J. Umbilical cord blood donation: public or private? Bone Marrow Transplant. 2015;50(10):1271–1278 55. Lubin BH, Yeaton-Massey A, Lewak N, O’Connor KG. To bank or not to bank cord blood: a national survey of pediatrician counseling practices. In: Annual Meeting of the Pediatric Academic Societies; May 2–5, 2009; Baltimore, MD. Available at: www.aap. org/en-us/professional-resources/ Research/Pages/To-Bank-or-Not-toBank-Cord-Blood-A-National-Survey-ofPediatrician-Counseling-Practices.aspx. Accessed December 6, 2016 56. Bhandari R, Lindley A, Bhatla D, et al. Awareness of cord blood collection and the impact on banking. Pediatr Blood Cancer. 2017;64(7):e26412

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Counseling Parents and Teens About Marijuana Use in the Era of Legalization of Marijuana • Clinical Report

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CLINICAL REPORT

Guidance for the Clinician in Rendering Pediatric Care

Counseling Parents and Teens About Marijuana Use in the Era of Legalization of Marijuana

Sheryl A. Ryan, MD, FAAP,a Seth D. Ammerman, MD, FAAP,b COMMITTEE ON SUBSTANCE USE AND PREVENTION

Many states have recently made significant changes to their legislation making recreational and/or medical marijuana use by adults legal. Although these laws, for the most part, have not targeted the adolescent population, they have created an environment in which marijuana increasingly is seen as acceptable, safe, and therapeutic. This clinical report offers guidance to the practicing pediatrician based on existing evidence and expert opinion/ consensus of the American Academy of Pediatrics regarding anticipatory guidance and counseling to teenagers and their parents about marijuana and its use. The recently published technical report provides the detailed evidence and references regarding the research on which the information in this clinical report is based.

BACKGROUND The legalization of medical marijuana in many states and the District of Columbia and the outright legalization of recreational marijuana for adults aged 21 years and older in a few states and the District of Columbia have resulted in changes in the access to and availability of this drug. Most of these states now allow the use of marijuana for a variety of medical conditions in adults as well as in children (with parental permission). In addition, many states have reduced penalties for the recreational use of marijuana; criminal penalties have been reduced from felonies in some cases to misdemeanors or infractions.1 For up-todate information on the numbers of states allowing these laws related to marijuana use, the reader is referred to www.aap.org/marijuana. Although there are currently no initiatives to legalize the recreational use of marijuana for minors and marijuana is still a federally controlled substance, changes in the legal status of marijuana, even if limited to adults, may affect use among adolescents by decreasing the perceived risk of harm or through the marketing of legal marijuana, despite restrictions that prohibit marketing and advertising to this age group. The National Survey on Drug

abstract

aDepartment

of Pediatrics/Adolescent Medicine, Yale University School of Medicine, New Haven, Connecticut; and bDepartment of Pediatrics/ Adolescent Medicine, Stanford University School of Medicine, Stanford, California Drs Ryan and Ammerman were each responsible for all aspects of writing and editing the document and reviewing and responding to questions and comments from reviewers and the Board of Directors. This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication. Clinical reports from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, clinical reports from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent. The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time. DOI: 10.1542/peds.2016-4069 Address correspondence to Sheryl Ryan, MD, FAAP. E-mail: [email protected] yale.edu PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

To cite: Ryan SA, Ammerman SD, AAP COMMITTEE ON SUBSTANCE USE AND PREVENTION. Counseling Parents and Teens About Marijuana Use in the Era of Legalization of Marijuana. Pediatrics. 2017;139(3):e20164069

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Use and Health recently documented a decline in the percentage of 12- to 17-year-olds who perceived that there is “great risk” in smoking marijuana once a month or 1 to 2 times per week, which is concerning, because the same survey has documented that decreases in perceived risk typically precede or occur at the same time as increases in use.2 The concentration of tetrahydrocannabinol, or THC, the psychoactive substance in the marijuana plant, has increased considerably, from approximately 4% in the early 1980s to upward of 12% in 2012,3 increasing the risk of adverse effects and the potential for addiction.

Studies have been conducted in adults to research the potential therapeutic effects of the class of chemicals known as cannabinoids (the active compounds in marijuana) administered either as a pharmaceutical preparation or as marijuana leaves, distilled oils, or edibles and drinkables. Cannabinoids have been shown to be helpful for adults in addressing some symptoms, such as increasing appetite and decreasing nausea and vomiting in patients receiving chemotherapy and reducing pain in chronic neuropathic pain syndromes. Cannabinoids may have adverse effects, however, such as dizziness, dysphoria, and clouded sensorium.4,5 The only studies that have been published on the use or efficacy of medicinal marijuana in children and adolescents have been limited to its use in the treatment of refractory seizures.6,7 The adverse effects of marijuana have been well documented. Numerous published studies have shown the potential negative consequences of short- and longterm use of recreational marijuana in adolescents.8 These consequences include impaired short-term memory and decreased concentration, attention span, and problem-solving skills, all of which interfere with learning. Alterations in motor control, coordination, judgment, reaction time, and tracking ability have also e2

been documented. These effects may contribute to unintentional deaths and injuries among adolescents, especially those who drive after using marijuana. Negative health effects on lung function associated with smoking marijuana also have been documented9; in addition, longitudinal studies linking marijuana use with higher rates of mental health disorders, such as depression and psychosis, recently have been published, raising concerns about longer-term psychiatric effects.8,10 Secondhand marijuana smoke can also be detected in adults who are passively exposed, and new data also suggest that secondhand marijuana smoke may be harmful to children.11 A recent study found that in an inpatient sample of infants admitted for respiratory compromise, 1 in 6 had detectable traces of marijuana in their systems.12

The adolescent brain, particularly the prefrontal cortex areas that control judgment and decision-making, is not fully developed until the early 20s, raising questions about how any substance use may affect the developing brain.8,13–15 Studies examining brain functioning in youth who use cannabis regularly or heavily (defined as using 10–19 times/month or 20 or more times/ month, respectively) show potential abnormalities that occur across a number of brain regions including those affecting memory (hippocampus) and executive functioning and planning (prefrontal cortex).13–15 Studies assessing the role of marijuana on brain morphology are inconsistent, with 1 study citing increased and decreased volumes of subcortical structures16 and another citing no effect on structures such as the amygdala and hippocampus.17 A major study also has shown that long-term marijuana use initiated in adolescence has negative effects on intellectual function and that the deficits in cognitive areas, such as executive function and processing speed, did

not recover by adulthood, even when cannabis use was discontinued.18

As with other psychoactive substances, the younger an adolescent begins using drugs, including marijuana, the more likely it is that drug dependence or addiction will develop in adulthood.15,19 Evidence clearly shows that marijuana is an addictive substance; overall, 9% of those experimenting with marijuana will become addicted; this percentage increases to 17% among those who initiate marijuana use in adolescence and to a range of between 25% and 50% among teenagers who smoke marijuana daily.20 It should be noted that most teenage patients addicted to marijuana do not have lifelong addiction; however, significant effects on cognitive and psychosocial function may occur during the addiction period.21 Marijuana use during pregnancy has adverse effects on the fetus, including growth retardation. Longer-term consequences of prenatal marijuana use that have been reported in infants and children include subtle deficits in learning and memory as well as deficits in executive functions, such as problem-solving skills that require sustained attention, analysis, and integration.22

ROLE OF THE PEDIATRICIAN Pediatricians are in an influential position to counteract the perception of teenage marijuana use as benign. Research findings regarding the health effects of marijuana on children and adolescents provide guidance for parents and their children. The office setting provides an excellent opportunity for education and counseling to prevent marijuana use as well as to implement brief interventions and referrals if needed. Parents who use marijuana may not fully realize the problems that their own use may present for their children’s health; the effect that their modeling of

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recreational use may have on their child, adolescent, or young adult23,24; or the risks of ingestion25,26 and/or secondhand smoke.9

The American Academy of Pediatrics (AAP) recognizes that parents may choose to administer marijuana to children with severely debilitating or severe chronic conditions when other standard therapies have proven inadequate or in compassionate care/end-of-life care situations and that they may seek support for this practice from their child’s pediatrician. However, because marijuana use is still considered a federal offense, there may be legal ramifications for a pediatrician formally recommending the use of medical marijuana in these extenuating circumstances. Awareness of one’s state laws and protections for medical providers is essential, and direct discussion of this issue with one’s state medical board may be appropriate. The following sections include key facts and suggested talking points for the pediatrician to use in speaking with youth and their parents about marijuana and the effects of its use. For detailed references to the data listed in this statement, the reader is referred to the full technical report published by the AAP.1

Office Approach to the Adolescent Patient

1. Adolescents and preteens may be screened for substance use and brief intervention, as recommended in the Screening, Brief Intervention, and Referral for Treatment (SBIRT) policy statement.27 The effectiveness of the SBIRT technique has been documented in adults with alcohol use problems; because of the lack of information in the adolescent population, the US Preventive Services Task Force recently gave SBIRT an “I” rating, stating that there was insufficient evidence to recommend either for or against this technique. However, on the basis of the limited evidence

TABLE 1 DSM-5 Criteria for Marijuana Use Disorder29 Taking the substance in larger amounts or for longer than you meant to Wanting to cut down or stop using the substance but not managing to Spending a lot of time getting, using, or recovering from use of the substance Cravings and urges to use the substance Not managing to do what you should at work, home, or school because of substance use Continuing to use, even when it causes problems in relationships Giving up important social, occupational, or recreational activities because of substance use Using substances again and again, even when it puts you in danger Continuing to use, even when you know you have a physical or psychological problem that could have been caused or made worse by the substance Needing more of the substance to get the effect you want (tolerance) Development of withdrawal symptoms, which can be relieved by taking more of the substance Each specific substance other than caffeine (which is not a diagnosable substance use disorder) is addressed as a separate use disorder (eg, alcohol use disorder, stimulant use disorder); nearly all substances use these same overarching criteria. Severity is divided into mild, moderate, or severe: mild = meeting 2–3 criteria; moderate = meeting 4–5 criteria; severe = meeting ≥6 criteria. DSM-5, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.

available and the low cost of this brief intervention, the AAP and the National Institute on Alcohol Abuse and Alcoholism both recommend that this technique be used in pediatric practices as part of routine care.

2. For adolescents who do not use marijuana, motivational techniques may be helpful in eliciting reasons for abstaining from use and resisting peer pressure in a manner that supports their decision to abstain.

3. Adolescents who use marijuana regularly or heavily are more likely to meet criteria for a substance use disorder. For these teenagers, a brief motivational intervention may be used to target: (1) reducing use and (2) continuing the conversation either with the pediatrician or a mental health or behavioral counselor. Additional advice for gathering information that is helpful to determine the extent and severity of use follows:

⚬ Ask the adolescent how much and how often he or she uses marijuana. Also ask about the circumstances (ie, where the marijuana is obtained, if use is with others versus alone, if use is before or during school versus on the weekends) and motivations (when stressed, bored, alone, angry, etc) associated with the decision

to use the substance. Although teenagers may use marijuana for the positive euphoric effects or for social acceptance, they also may use marijuana for selfmedication, such as to relieve negative moods (ie, stress, anxiety, or depression)28 or for sleep problems. Teenagers who use marijuana for these purposes who meet criteria for a co-occurring mental health disorder may benefit from treatment, including counseling and/or a psychiatric evaluation.

⚬ Take a detailed history that

includes identifying concerns associated with marijuana use. Criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (see Table 1), can be useful as a guideline in ruling out problematic marijuana use.29

⚬ If the adolescent does not report

regular use of marijuana and denies any associated problems, offer a “challenge.” Ask the adolescent to quit using the drug for a brief period of time, and see what happens. If the adolescent is able to stop completely, ask whether life was “better, worse, or the same” during the quit period to prompt a discussion of pros and cons of use. If the adolescent was unable to stop completely, explore possible

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triggers and high-risk situations that were barriers to success. Work with the adolescent to problem-solve and try again. If the adolescent was unwilling to quit, even for a limited period of time, explore the motivations for drug use (see talking point 1) and consider whether any additional interventions or supports may be helpful. Talking points can be introduced as areas of concern but also can be used to trigger engagement and discussion during brief interventions (eg, information about the modeling effect of parental smoking and the current understanding of marijuana effects in teenagers). If there are major concerns for the teenager’s safety or the teenager is considered at high risk of adverse consequences, breaking confidentiality and notifying the parents may be advisable to ensure the patient’s safety.

TALKING POINTS FOR PARENTS AND TEENS: HANDOUT

1. Marijuana is not a benign drug for teens. The teen brain is still developing, and marijuana may cause abnormal brain development.

2. Teens who use marijuana regularly may develop serious mental health disorders, including addiction, depression, and psychosis.

3. There are no research studies on the use of medical marijuana in teens, so actual indications, appropriate dosing, effects, and side effects are unknown. The only data available on medical marijuana in the pediatric population are limited to its use in children with severe refractory seizures.

4. Recreational use of marijuana by minors and young adults under the age of 21 years is illegal and, if prosecuted, may result e4

in a permanent criminal record, affecting schooling, jobs, etc.

5. Never drive under the influence of marijuana or ride in a car with a driver who is under the influence of marijuana. Adults and teens regularly get into serious and even fatal car accidents while under the influence of marijuana.

6. Marijuana smoke is toxic, similar to secondhand tobacco smoke. The use of vaporizers or hookahs does not eliminate the toxic chemicals in marijuana smoke. 7. For parents: You are role models for your children, and actions speak louder than words. So if you use marijuana in front of your teens, they are more likely to use it themselves, regardless of whether you tell them not to. (See the AAP Healthy Children Web site: www.healthychildren. org/English/ages-stages/teen/ substance-abuse/Pages/DrugAbuse-Prevention-Starts-withParents.aspx.)

8. For parents: It is important to keep all marijuana products away from children. As with other medications and toxic products, containers that are child-proof and kept out of reach should be used. For small children, marijuana edibles and drinks can be particularly dangerous.

9. For parents: Remember that intoxication and euphoria are predictable effects of using marijuana products. Being “high” from your own recreational or medical marijuana use may alter your capacity to function safely as a parent or to provide a safe environment for infants and children.30

10. For parents: If your child asks you directly whether you have used marijuana, a brief, honest answer may help the child feel comfortable talking with you about drug use issues. However,

it is best to not share your own histories of drug use with your children. Rather, discussion of drug use scenarios, in general, may be a more helpful approach.

SUMMARY AND CONCLUSIONS Pediatricians are in a unique position to provide parents and teenagers with accurate information and counseling regarding the consequences of marijuana or cannabis use by children, teenagers, and adults. A number of strategies can be used to counsel families about preventing use and to intervene if marijuana is being used either recreationally or medically by the families for whom they provide medical care. AUTHORS

Sheryl A. Ryan, MD, FAAP Seth D. Ammerman, MD, FAAP

COMMITTEE ON SUBSTANCE USE AND PREVENTION, 2016–2017 Sheryl A. Ryan, MD, FAAP, Chairperson Pamela K. Gonzalez, MD, MS, FAAP Stephen W. Patrick, MD, MPH, MS, FAAP Joanna Quigley, MD, FAAP Leslie R. Walker, MD, FAAP

FORMER COMMITTEE MEMBERS Seth D. Ammerman, MD, FAAP Sharon Levy, MD, MPH, FAAP Lorena Siqueira, MD, MSPH, FAAP Vincent C. Smith, MD, MPH, FAAP

LIAISONS Vivian B. Faden, PhD – National Institute of Alcohol Abuse and Alcoholism Gregory Tau, MD, PhD – American Academy of Child and Adolescent Psychiatry

STAFF Renee Jarrett, MPH

ABBREVIATIONS AAP: American Academy of Pediatrics SBIRT: Screening, Brief Intervention, and Referral for Treatment

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Copyright © 2017 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they do not have a financial relationship relevant to this article to disclose. FUNDING: No external funding. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

REFERENCES 1. Ammerman S, Ryan S, Adelman WP; Committee on Substance Abuse; Committee on Adolescence. The impact of marijuana policies on youth: clinical, research, and legal update. Pediatrics. 2015;135(3). Available at: www. pediatrics.org/cgi/content/full/135/3/ e769 2. Results from the 2013 National Survey on Drug Use and Health: summary of national findings. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2014. Available at: www.samhsa.gov/data/ sites/default/files/NSDUHresultsPDFWH TML2013/Web/NSDUHresults2013.pdf. Accessed October 6, 2016 3. El Sohly MA. Potency Monitoring Project. Quarterly report 123— reporting period: 09/16/2013– 12/15/2013. Oxford, MS: University of Mississippi, National Center for Natural Products Research; 2014 4. Aggarwal SK, Carter GT, Sullivan MD, ZumBrunnen C, Morrill R, Mayer JD. Medicinal use of cannabis in the United States: historical perspectives, current trends, and future directions. J Opioid Manag. 2009;5(3): 153–168 5. Cotter J. Efficacy of crude marijuana and synthetic delta-9tetrahydrocannabinol as treatment for chemotherapy-induced nausea and vomiting: a systematic literature review. Oncol Nurs Forum. 2009;36(3):345–352 6. Press CA, Knupp KG, Chapman KE. Parental reporting of response to oral cannabis extracts for treatment of refractory epilepsy. Epilepsy Behav. 2015;45:49–52 7. Devinsky O, Marsh E, Friedman D, et al. Cannabidiol in patients with treatmentresistant epilepsy: an open-label interventional trial. Lancet Neurol. 2016;15(3):270–278

8. Volkow ND, Baler RD, Compton WM, Weiss SR. Adverse health effects of marijuana use. N Engl J Med. 2014;370(23):2219–2227 9. Joshi M, Joshi A, Bartter T. Marijuana and lung diseases. Curr Opin Pulm Med. 2014;20(2):173–179 10. Evins AE, Green AI, Kane JM, Murray RM. The effect of marijuana use on the risk for schizophrenia. J Clin Psychiatry. 2012;73(11):1463–1468 11. Cone EJ, Roache JD, Johnson RE. Effects of passive exposure to marijuana smoke. NIDA Res Monogr. 1987;76:150–156 12. Wilson K, Torok M, Wei B, et al. Marijuana smoke exposure in children hospitalized for bronchiolitis. Presented at: Pediatric Academic Societies Annual Meeting; April 30–May 3, 2016; Baltimore, MD 13. Schepis TS, Adinoff B, Rao U. Neurobiological processes in adolescent addictive disorders. Am J Addict. 2008;17(1):6–23 14. Schweinsburg AD, Brown SA, Tapert SF. The influence of marijuana use on neurocognitive functioning in adolescents. Curr Drug Abuse Rev. 2008;1(1):99–111 15. Hammond CJ, Mayes LC, Potenza MN. Neurobiology of adolescent substance use and addictive behaviors: treatment implications. Adolesc Med State Art Rev. 2014;25(1): 15–32 16. Battistella G, Fornari E, Annoni JM, et al. Long-term effects of cannabis on brain structure. Neuropsychopharmacology. 2014;39(9):2041–2048 17. Weiland BJ, Thayer RE, Depue BE, Sabbineni A, Bryan AD, Hutchison KE. Daily marijuana use is not associated with brain morphometric measures in adolescents or adults. J Neurosci. 2015;35(4):1505–1512

18. Meier MH, Caspi A, Ambler A, et al. Persistent cannabis users show neuropsychological decline from childhood to midlife. Proc Natl Acad Sci USA. 2012;109(40):E2657–E2664 19. Winters KC, Lee CY. Likelihood of developing an alcohol and cannabis use disorder during youth: association with recent use and age. Drug Alcohol Depend. 2008;92(1–3):239–247 20. Hall W, Degenhardt L. Adverse health effects of non-medical cannabis use. Lancet. 2009;374(9698):1383–1391 21. Farmer RF, Kosty DB, Seeley JR, et al. Natural course of cannabis use disorders. Psychol Med. 2015;45(1):63–72 22. Behnke M, Smith VC; Committee on Substance Abuse; Committee on Fetus and Newborn. Prenatal substance abuse: short- and long-term effects on the exposed fetus. Pediatrics. 2013;131(3). Available at: www. pediatrics.org/cgi/content/full/131/3/ e1009 23. National Center on Addiction and Substance Abuse. Adolescent substance use: America’s #1 public health problem. New York, NY: National Center on Addiction and Substance Abuse (CASA); June 2011:64, 264. Available at: www.casacolumbia. org/addiction-research/reports/ adolescent-substance-use. Accessed October 6, 2016 24. Napper LE, Hummer JF, Chithambo TP, LaBrie JW. Perceived parent and peer marijuana norms: the moderating effect of parental monitoring during college. Prev Sci. 2015;16(3): 364–373 25. Moon MA. Striking rise in accidental marijuana poisonings. Pediatric News Digital Network. May 28, 2013. Available at: www.pediatricnews.com/?id=7791& tx_ttnews[tt_news]=143729&cHash= 5453c65f0404a55f3451852940acace6. Accessed October 6, 2016

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26. Wang GS, Roosevelt G, Heard K. Pediatric marijuana exposures in a medical marijuana state. JAMA Pediatr. 2013;167(7):630–633 27. Committee on Substance Use and Prevention. Substance use screening, brief intervention, and referral to treatment. Pediatrics. 2016;138(1):e20161210

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28. Shrier LA, Ross CS, Blood EA. Momentary positive and negative affect preceding marijuana use events in youth. J Stud Alcohol Drugs. 2014;75(5):781–789 29. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013

30. Substance Abuse and Mental Health Services Administration. Handout: the effects of substance abuse on behavior and parenting. Available at: https://www.ncsacw. samhsa.gov/files/TrainingPackage/ MOD2/EffectsofSubstanceAbuse.pdf. Accessed October 6, 2016

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Detention of Immigrant Children • Policy Statement

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POLICY STATEMENT

Organizational Principles to Guide and Define the Child Health Care System and/or Improve the Health of all Children

Detention of Immigrant Children

Julie M. Linton, MD, FAAP,a Marsha Griffin, MD, FAAP,b Alan J. Shapiro, MD, FAAP,c COUNCIL ON COMMUNITY PEDIATRICS

Immigrant children seeking safe haven in the United States, whether arriving unaccompanied or in family units, face a complicated evaluation and legal process from the point of arrival through permanent resettlement in communities. The conditions in which children are detained and the support services that are available to them are of great concern to pediatricians and other advocates for children. In accordance with internationally accepted rights of the child, immigrant and refugee children should be treated with dignity and respect and should not be exposed to conditions that may harm or traumatize them. The Department of Homeland Security facilities do not meet the basic standards for the care of children in residential settings. The recommendations in this statement call for limited exposure of any child to current Department of Homeland Security facilities (ie, Customs and Border Protection and Immigration and Customs Enforcement facilities) and for longitudinal evaluation of the health consequences of detention of immigrant children in the United States. From the moment children are in the custody of the United States, they deserve health care that meets guideline-based standards, treatment that mitigates harm or traumatization, and services that support their health and well-being. This policy statement also provides specific recommendations regarding postrelease services once a child is released into communities across the country, including a coordinated system that facilitates access to a medical home and consistent access to education, child care, interpretation services, and legal services.

abstract

aDepartment

of Pediatrics, Wake Forest School of Medicine, WinstonSalem, North Carolina; bDepartment of Pediatrics, University of Texas Rio Grande Valley School of Medicine, Harlingen, Texas; and cDepartment of Pediatrics, Albert Einstein College of Medicine, Children’s Hospital at Montefiore, Bronx, New York Drs Linton, Griffin, and Shapiro collectively drafted, critically revised, and reviewed this policy. This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication. Policy statements from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, policy statements from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent. The guidance in this statement does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time. DOI: 10.1542/peds.2017-0483

INTRODUCTION

Address correspondence to Julie M. Linton, MD, FAAP. E-mail: [email protected] wakehealth.edu PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Communities nationwide have become homes to immigrant and refugee children who have fled countries across the globe.1 However, in the dramatic increase in arrivals that began in 2014 and continues at the time of writing this policy statement, more than 95% of undocumented children have emigrated from Guatemala, Honduras, and El Salvador (the Northern Triangle countries of Central America), with much smaller numbers from Mexico and other countries. Most of these undocumented children cross into the United States through the southern border.2 Unprecedented violence, abject poverty, and lack of state protection

Copyright © 2017 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. FUNDING: No external funding.

To cite: Linton JM, Griffin M, Shapiro AJ, AAP COUNCIL ON COMMUNITY PEDIATRICS. Detention of Immigrant Children. Pediatrics. 2017;139(5):e20170483

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of children and families in Central America are driving an escalation of migration to the United States from Guatemala, Honduras, and El Salvador.3,4 Children, unaccompanied and in family units, seeking safe haven* in the United States often experience traumatic events in their countries of origin, during the journeys to the United States, and throughout the difficult process of resettlement.5,6 In fiscal year (FY) 2014, Customs and Border Protection (CBP) detained 68 631 unaccompanied children and another 68 684 children in family units7 (a child with parent[s] or legal guardian[s]). In response to these numbers, the US government implemented a media campaign in Central America and increased immigration enforcement at the southern border of Mexico in an effort to deter immigration.8 Yet despite decreasing numbers of unaccompanied children and children in family units attempting to emigrate to the United States in FY 2015, another significant increase of both groups began in FY 2016, with 59 692 unaccompanied children and 77 674 family units detained in FY 2016.2 Interviews with children in detention from Mexico and the Northern Triangle Countries revealed that 58% had fear sufficient to merit protection under international law,4 and in another survey, 77% reported violence as the main reason for fleeing their country.9 Children first detained at the time of entry to the United States, whether they are unaccompanied or in family units, are held by the Department of Homeland Security (DHS) in CBP processing centers.10,11 If an accompanying adult cannot verify that he or she is the biological parent or legal guardian, this adult is separated from the child, and the *The term safe haven encompasses the diverse immigration statuses that may be pursued and acknowledges the humanitarian needs of those seeking relief.

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child is considered unaccompanied.10 After processing, unaccompanied immigrant children are placed in shelters or other facilities operated by the US Department of Health and Human Services (HHS) Office of Refugee Resettlement (ORR), and the majority are subsequently released to the care of community sponsors (parents, other adult family members, or nonfamily individuals) throughout the country for the duration of their immigration cases.11 Children detained with a parent or legal guardian are either repatriated back to their home countries under expedited removal procedures, placed in Immigration and Customs Enforcement (ICE) family residential centers, or released into the community to await their immigration hearings.12 Pediatricians who care for previously detained immigrant children in communities throughout the United States should be aware of the traumatic events these children have invariably experienced to better understand and address their complex medical, mental health, and legal needs. Pediatricians also have an opportunity to advocate for the health and well-being of vulnerable immigrant children. This policy statement applies principles established by numerous previous statements, including care of immigrant children,13 toxic stress,14 and social determinants of health,15 to the specific topic of detention of immigrant children.

HISTORY In the 1980s, the United States experienced a dramatic increase in numbers of migrant children fleeing Central America as a result of civil wars in those countries.16 At that time, the Immigration and Naturalization Service (INS), under the Department of Justice, was responsible for enforcing the immigration law and seeking the

deportation of unaccompanied children and for their care and custody while they were in the United States. In 1997, after more than a decade of litigation responding to unjust treatment of unaccompanied children in the care of the INS, the government entered into a settlement agreement, still in force today, for the care of children.17 The Flores Settlement Agreement set strict national standards for the detention, treatment, and release of all minors detained in the legal custody of the INS. It requires that children be held in the least restrictive setting appropriate for a child’s needs and that they be released without unnecessary delay to a parent, designate of the parent, or responsible adult as deemed appropriate.17,18 After September 11, 2001, the Homeland Security Act of 2002 attempted to resolve the conflict of interest between the dual role of the INS as both a prosecutor and caretaker of unaccompanied children.19 That law divided the functions of the former INS between the DHS and HHS (Fig 1). Under the DHS, CBP and ICE are charged with border control and homeland security.20,21 The care and custody of unaccompanied immigrant children were transferred to the HHS Administration for Children and Families, specifically the ORR. The responsibility of the ORR is to promote the well-being of children and families, including refugees and migrants.22

CURRENT PRACTICE AND TERMINOLOGY Noncitizen children younger than 18 years are processed through the immigration system in several ways depending on where they are first detained, whether they are accompanied or unaccompanied by a parent, and whether they come from a contiguous or noncontiguous

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FIGURE 1

Restructuring of INS after September 11, 2001.19 (The Anti-Trafficking in Persons Organization is now called the Office on Trafficking in Persons, and the Division of Unaccompanied Children’s Services is now called the Division of Children’s Services.) Reproduced with permission: Byrne O, Miller E. The Flow of Unaccompanied Children Through the Immigration System. New York, NY: Vera Institute of Justice; 2012:7

country. An unaccompanied alien child, referred to as an unaccompanied immigrant child in this policy statement, is defined by the Homeland Security Act as a child who “has no lawful immigration status in the United States; has not attained 18 years of age; and with respect to whom—(i) there is no parent or legal guardian in the United States; or (ii) no parent or legal guardian in the United States is available to provide care and physical custody.”11,23,24 A parent or legal guardian is considered “not available” if not present at the time of the child’s apprehension. Accompanied children are those who are detained with their parent or legal guardian, most often the mother. DHS refers to accompanied

children as part of a family unit.11 Most children who come into immigration custody are first detained at the border; a smaller number are apprehended within the country (ie, more than 100 miles away from a border), known as internal apprehensions.11

Lastly, the immigration process is different for children who come from contiguous countries (most from Mexico and smaller numbers from Canada). When the Trafficking Victims Protection Reauthorization Act (TVPRA) was passed in 2008, Congress mandated that CBP screen children from Mexico and Canada for trafficking (child labor or sex) and other harms before allowing them to return to their countries and before they are placed in US immigration proceedings.

Specifically, CBP must screen a child from Mexico or Canada to ensure that the child is not a potential victim of trafficking, has no possible claim to asylum, and can and does voluntarily accept return. If a child from Canada or Mexico does not have authorization to enter the United States and can be returned safely, the child can be repatriated without ever being placed in immigration proceedings. If any of the answers to the aforementioned inquiries into protection concerns are positive, or if no determination of all 3 criteria can be made within 48 hours, the TVPRA mandates that the child shall “immediately” be transferred to custody of ORR. Once transferred to ORR, Mexican and Canadian children are treated like all other unaccompanied children in detention.11,19

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Immigration Pathway CBP Processing Centers When first detained at or near the border, both unaccompanied children and those in family units are sent to CBP processing centers. Each year, hundreds of thousands of detained people are held in these processing centers along the US southern border.10 By law, under the Homeland Security Act of 2002 and TVPRA of 2008, unaccompanied immigrant children must be moved to ORR custody within 72 hours.24,25 Processing centers are secure facilities of various sizes with locked enclosures to detain children and families; the largest, in McAllen, Texas, currently has a capacity of 1000.† Reports by advocacy organizations, including interviews with detainees and the DHS Office of Inspector General,26 have cataloged egregious conditions in many of the centers, including lack of bedding (eg, sleeping on cement floors), open toilets, no bathing facilities, constant light exposure, confiscation of belongings, insufficient food and water, and lack of access to legal counsel,10,24,‡ and a history of extremely cold temperatures. At times children and families are kept longer than 72 hours, denied access to medical care and medications, separated from one another, or physically and emotionally maltreated.10,24,25 In processing centers, children and families lack a comprehensive orientation process that outlines procedures and possible time of detainment in each facility. To respond to increasing numbers of children and families who are first detained in the Rio Grande Valley, a central processing center in McAllen, Texas has made changes to increase capacity, expedite processing, and address some of these concerns.§ †Personal observations and notes from authors of this policy from an AAP delegation site visit. ‡Personal observations and notes from authors of this policy from an AAP delegation site visit. §Personal observations and notes from authors of this policy from an AAP delegation site visit.

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At the time of apprehension by CBP, children pass through 1 or more CBP processing facilities, some of which provide limited medical screening (eg, scabies, lice, varicella); complete medical histories and physical examinations (including vital signs) are not conducted. Screening is performed by a variety of nonmedical and medical personnel, such as border patrol officers, emergency medical technicians, nurse practitioners, or physician assistants.¶ Children with medical problems beyond the scope of aforementioned personnel are taken to a local hospital emergency department.**

At the time of release from CBP processing centers, the immigration pathway diverges for unaccompanied immigrant children and children accompanied by a parent or legal guardian.

ORR Children Shelters: Unaccompanied Immigrant Children

ORR contracts with a network of child welfare agencies, both nonprofit and government organizations, to care for unaccompanied immigrant children in a variety of facility types that range in size and level of security. A small number of these contracts are with local foster care agencies.23 With more than 9200 beds located across the country, these shelters have procedures ensuring compliance with federal law regarding the care and custody of immigrant children.27 Children are provided with dormitory-style rooms, shared bathrooms, showers, clothes, hot meals, year-round educational services, recreational activities, and limited legal services. In FY 2015, the average length of stay in the program was 34 days,28 although some children remain in ORR custody for significantly longer ¶Personal observations and notes from authors of this policy from an AAP delegation site visit. **Personal observations and notes from authors of this policy from an AAP delegation site visit.

periods of time, for a number of different reasons.

At the time of entry into an ORR facility, children receive an initial medical and mental health evaluation.29 The ORR is responsible for providing the children with ongoing medical and mental health care, which may be provided on or off site, while in custody. Pediatricians caring for previously detained children released into communities can access the American Academy of Pediatrics (AAP) Immigrant Health Toolkit (https://www.aap.org/ en-us/about-the-aap/CommitteesCouncils-Sections/Council-onCommunity-Pediatrics/Pages/ Immigrant-Child-Health-Toolkit. aspx) for more comprehensive guidelines (eg, universal hearing and sexual health screenings)30 and can ask the child or sponsor for the medical records, provided to each child at the time of release from the shelter, or request records (including vaccinations and tuberculosis testing) from the ORR Web site (https:// www.acf.hhs.gov/orr/resource/ unaccompanied-childrens-services).31

Family Residential Centers: Accompanied Children

Some family units are released from CBP processing centers directly into the community to await immigration proceedings, some undergo expedited return to their country of origin, and others are sent to ICE-contracted family residential centers. Three family detention centers exist nationally, including 2 in Texas, operated by for-profit prison corporations (ie, GEO Group and CCA) and 1 in Pennsylvania operated by local government (ie, Berks County); 2 other centers were closed because of “dangerously inadequate” conditions.32,33 The present total operating capacity of the detention facilities is 3326 beds.34 Each residential center has staff comprising representatives from their contracting organizations and

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ICE employees.34 In general, multiple families stay in dormitory-style rooms. Nearly all the family detention beds are for mothers with children younger than 18 years, and 1 facility (Berks County) accepts fathers.35 An August 2015 ruling by a California US District Court in a case brought against DHS, Flores v Johnson, found that family detention centers are in violation of the Flores Settlement Agreement.36 The court did not exclude children in family units from the requirement that children be held in the least restrictive environments. Despite this order, children continue to be detained, and even with shorter lengths of stay, some were still found to suffer traumatic effects.32,37 Care of children held in detention centers is subject to the standards outlined on the ICE Web site.38,39 Limited medical, dental, and mental health services are provided by the prison corporations in the Texas facilities and through public health services in Pennsylvania.38,39 Detention centers also rely on nearby emergency departments and tertiary care centers for the treatment of medical and mental health conditions beyond their scope. Visits to family detention centers in 2015 and 2016 by pediatric and mental health advocates revealed discrepancies between the standards outlined by ICE and the actual services provided, including inadequate or inappropriate immunizations, delayed medical care, inadequate education services, and limited mental health services.40–45 Alternatives to detention offer opportunities to respond to families’ needs in the community as their immigration cases proceed. For most families, release into the community allows families to live their lives as normally as possible.34 In the setting of community-based alternatives to detention, many families are able to comply with immigration proceedings when they are provided information about

rights and responsibilities, referrals to legal services, and psychosocial supports.34 Some families may benefit from case management,34 which is cost-effective11 and can increase the likelihood of compliance with government requirements.33 Alternatives to detention may better allow families to identify legal services and seek proper medical and mental health care that can importantly contribute to winning asylum cases.46

Release of Children Into the Community: Unaccompanied Immigrant Children

Before release, the ORR seeks to reunite an unaccompanied immigrant child with a sponsor, preferably a parent or other family member. Sponsors must be considered suitable for caring for a child and go through background checks, occasionally including home visits.11,23,24 Most children are released to parents or other family members; in some cases, the sponsor may be someone the child does not know well or at all. The ORR must approve the child’s release, but in almost all cases, the sponsor is financially responsible for transportation and other expenses incurred.47 Some children receive limited postrelease services from nongovernment organizations funded by ORR. These services are typically provided only to children whose release followed a home study, required for certain children under TVPRA, including those who have histories of abuse or trafficking or those with disabilities.48,49 Most children released from the ORR do not qualify for Medicaid, the Children’s Health Insurance Program, or other state and federal public benefit programs. Other important stressors may also arise once the child has been placed with a sponsor, including relationship conflicts between child and sponsor or other household members, school enrollment and other educational challenges, food insecurity, housing insecurity, other financial strain

(eg, clothes, school supplies), and acculturation difficulties.

Release of Children Into the Community: Family Units

Family units arriving together at the US border are currently placed into “expedited removal proceedings,” which means that the adult must pass a “credible fear interview” or, in some cases, a “reasonable fear interview” (for families with previous orders of removal from the United States) before a US Customs and Immigration Service officer to establish a basis for the presence of persecution or torture. If the interview is passed, families may be released from the detention center on bond or released under other conditions, such as being required to wear an electronic monitor, but only for the duration of their immigration case. If they do not pass the credible fear or reasonable fear interview or a judge concurs with a negative “fear” decision, they will be removed from the United States.39 Currently, more than 75% of families held in family residential centers pass their “credible fear” or “reasonable fear” interviews or are successful in appealing adverse decisions after retaining an attorney, meaning that most have a right to seek protection in the United States.34,50 Families who are granted release into communities pending immigration proceedings may be taken to nearby bus terminals or local churches but must independently navigate reunification with family members across the country. Families must also find attorneys to represent them in their immigration cases, which will continue until they appear for an asylum hearing before an immigration judge or pursue some other immigration benefit (such as a visa for trafficking victims). These families must rely on family members living in the United States for assistance or incur their own travel and legal expenses. Many adult members of family units have been

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released into the community with electronic monitors to ensure that their whereabouts can be tracked.33

Impact of Detention on Child and Family Health Detention of children is a global issue condemned by respected human rights and professional organizations both within and beyond US borders.11,32,33,51 Moreover, the United Nations Convention on the Rights of the Child, an internationally recognized legal framework for the protection of children’s basic rights (ratified by every country in the world except for the United States), emphasizes freedom from arbitrary arrest and detention (Article 37), the provision of special protection to children seeking asylum (Article 22), humane and appropriate treatment of children in detention (Article 37), and guidelines regarding maintaining family unity (Article 9).52 The AAP has endorsed this human rights treaty as an important legal instrument.53 US state court proceedings and the United Nations Convention on the Rights of the Child underscore the “best interests of the child,” including safety and wellbeing, the child’s expressed interests, health, family integrity, liberty, development (including education), and identity.54

Studies of detained immigrants, primarily from abroad, have found negative physical and emotional symptoms among detained children,55–57 and posttraumatic symptoms do not always disappear at the time of release.56 Young detainees may experience developmental delay58 and poor psychological adjustment, potentially affecting functioning in school.59 Qualitative reports about detained unaccompanied immigrant children in the United States found high rates of posttraumatic stress disorder, anxiety, depression, suicidal ideation, and other behavioral problems.60 Additionally, expert consensus has 6

concluded that even brief detention can cause psychological trauma and induce long-term mental health risks for children.51

Studies of adults in detention have demonstrated negative physical and mental health effects that can reasonably be applied to adult members of detained family units. For instance, detained adult asylum seekers suffered from musculoskeletal, gastrointestinal, respiratory, and neurologic symptoms.61 They also commonly experienced anxiety, depression, posttraumatic stress disorder, difficulty with relationships, and selfharming behavior.62–66 Detention itself undermines parental authority and capacity to respond to their children’s needs; this difficulty is complicated by parental mental health problems.56,67 Although data are limited regarding the effects of a short detention time on the health of children, there is no evidence indicating that any time in detention is safe for children.

In the United States, reports from human rights groups and other child advocates, including pediatricians, corroborate the deleterious effects of detention found in the aforementioned studies.33,35,41–44 These reports describe prisonlike conditions; inconsistent access to quality medical, dental, or mental health care; and lack of appropriate developmental or educational opportunities.11,33,35,62 Parents interviewed for these reports described regressive behavioral changes in their children, including decreased eating, sleep disturbances, clinginess, withdrawal, self-injurious behavior, and aggression.33,44 Parents exhibited depression, anxiety, loss of locus of control, and a sense of powerlessness and hopelessness.44,68 Parents often faced difficulty parenting their children and subsequently experienced strained parent–child relationships.44 Detained families’ sense of isolation

and desperation were intensified by detention center practices that created communication barriers with the outside world (eg, expensive telephone service and lack of Internet services). Additionally, detainees reported being anxious about the lack of access to legal advocates.33,68 After almost a year of investigation, the DHS Advisory Committee on Family Residential Centers ultimately made this recommendation34: DHS’s immigration enforcement practices should operationalize the presumption that detention is generally neither appropriate nor necessary for families— and that detention or the separation of families for purposes of immigration enforcement or management are never in the best interest of children.

THE ROLE OF PEDIATRICIANS IN THE COMMUNITY Awareness of the immigration pathway, conditions in detention facilities, and medical care during detention can help community pediatricians provide sensitive and targeted care based on AAP recommendations (https://www. aap.org/en-us/about-the-aap/ Committees-Councils-Sections/ Council-on-Community-Pediatrics/ Pages/Immigrant-Child-HealthToolkit.aspx) for newly arrived immigrant children30 and Centers for Disease Control and Prevention refugee health guidelines.69 Many of these children have never had access to a medical home or regular primary care surveillance. A traumainformed approach acknowledges the impact of trauma and potential paths for recovery, recognizes signs and symptoms of trauma, responds by integrating knowledge into the system of care, and resists retraumatization.70–72 Traumainformed care is essential for medical, mental health, and community-based services. Unfortunately, access to postrelease services is limited, because lack of legal status leaves immigrant children ineligible for

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most public benefits. Most states do not provide health care benefits to children of undocumented immigration status.73,†† However, by law children have the right to a free, public education without regard to immigration status.74 Pediatricians can make families aware that newly arrived children are entitled to a free education and direct them to local public school districts for enrollment. By facilitating access to legal representation through screening and referral, pediatricians may ultimately increase access to health care once the immigrant child has lawful status. Furthermore, pediatricians may provide key evidence used by attorneys to assist in children’s immigration cases. By some estimates, nearly 45% of unaccompanied children in deportation proceedings do not have attorneys in immigration court.75 Not surprisingly, children without counsel are far more likely to be deported, regardless of the merits of their case or the dangers to which they would return.76 The complexity of immigration law makes it all the more imperative for practitioners who care for immigrant children and youth to have a referral network of legal experts (preferably nonprofit or pro bono) with whom they work closely.

A basic understanding of the different forms of legal relief can help pediatricians collect key medical and psychosocial histories and clinical evidence that may be used to support legal claims by children seeking safe haven. The most common legal statuses pursued by previously detained children include special immigrant juvenile status, asylum, and what are often referred to as visas for victims of trafficking (T visa) or serious crimes (U visa).11 Histories ††At the time of writing this policy statement, only 5 states (New York, Massachusetts, Washington, Illinois, and California) and the District of Columbia provided health care benefits to all children regardless of immigration status.

of abuse, neglect, abandonment, persecution, trafficking, or violence may be disclosed to clinicians but not lawyers because of fear or shame. Furthermore, victims of labor or child sex trafficking and commercial sexual exploitation of children rarely self-identify. When assessing the trauma history of previously detained children, pediatricians may identify concerns for trafficking77 and subsequently facilitate needed medical and mental health care and initiate referrals to law enforcement, child protective services, and legal services.78 Children who are identified as victims of trafficking may be eligible for a T visa, and children who are victims of crimes in this country, including exposure to domestic violence, may be eligible for a U visa if they are willing to cooperate with law enforcement. Trauma-focused treatment can facilitate disclosure of painful histories to children’s lawyers and judges, thereby improving chances for winning legal relief. By referring children for legal services and providing affidavits or court testimonies, pediatricians can directly advocate on behalf of children facing immigration proceedings.

RECOMMENDATIONS Pediatricians have the opportunity to advocate for systems that mitigate trauma and protect the health and well-being of vulnerable immigrant children. Children, especially those who have been exposed to trauma and violence, should not be placed in settings that do not meet basic standards for children’s physical and mental health and that expose children to additional risk, fear, and trauma. Until the unprecedented 2014 increase in Central American migration, children detained with a parent or legal guardian were released into the community. The government’s decision in 2014 to

place them in family detention was intended, in part, to send a message of deterrence abroad.8 It is the position of the AAP that children in the custody of their parents should never be detained, nor should they be separated from a parent, unless a competent family court makes that determination. In every decision about children, government decisionmakers should prioritize the best interests of the child.54 The following recommendations pertain to handling of immigrant children, including their health care, while they are in custody:

• Treat all immigrant children and

families seeking safe haven who are taken into US immigration custody with dignity and respect to protect their health and well-being.

• Eliminate exposure to conditions

or settings that may retraumatize children, such as those that currently exist in detention, or detention itself.

• Separation of a parent or primary

caregiver from his or her children should never occur, unless there are concerns for safety of the child at the hand of parent. Efforts should always be made to ensure that children separated from other relatives are able to maintain contact with them during detention.

• While in custody, unaccompanied children and family units should be provided with child-friendly orientation and regular updates regarding their current status, expectations, and rights.

• Because conditions at CBP

processing centers are inconsistent with AAP recommendations for appropriate care and treatment of children, children should not be subjected to these facilities.

• Processing of children and family units should occur in a childfriendly manner, taking place outside current CBP processing

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centers or conducted by child welfare professionals, to provide conditions that emphasize the health and well-being of children and families at this critical stage of immigration proceedings.

• DHS should discontinue the general use of family detention and instead use community-based alternatives to detention for children held in family units.

• Community-based case

management should be implemented for children and families, thus ending both detention and the placement of electronic tracking devices on parents. Government funding should be provided to support case management programs.

• Children, whether unaccompanied or accompanied, should receive timely, comprehensive medical care that is culturally and linguistically sensitive by medical providers trained to care for children. This care should be consistent throughout all stages of the immigration processing pathway.

• Trauma-informed mental health

screening and care are critical for immigrant children seeking safe haven. Screening should be conducted once a child is in the custody of US officials via a validated mental health screening tool, with periodic rescreening, additional evaluation, and traumainformed care available for children and their parents.

• When children are in the custody

of the federal government, extra precautions must be in place to identify and protect children who have been victims of trafficking and to prevent recruitment of new children into the trafficking trade.

• Children should be provided with

language-appropriate, year-round educational services, including special education if needed,

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throughout the immigration pathway.

• Recreational and social enrichment activities, such as opportunities for physical activity and creative expression, may alleviate stress and foster resiliency and should be part of any program for detained children. At a minimum, outdoor and major muscle activity should meet the minimum standards set by the Flores Settlement Agreement.

• Children and families should have

access to legal counsel throughout the immigration pathway. Unaccompanied minors should have free or pro bono legal counsel with them for all appearances before an immigration judge.

• The AAP encourages longitudinal evaluation of the health consequences of detention of immigrant children in the United States.

Given the complex medical, mental health, and legal needs of these children, the following recommendations pertain to postrelease care of previously detained immigrant children in the community. Children and families need a coordinated system that facilitates access to a medical home that can address the children’s physical and mental health needs and facilitates access to education, child care, and legal and interpretation services.

• The AAP advocates for expanded funding for postrelease services to promote the safety and wellbeing of all previously detained immigrant children and to facilitate connection and access to comprehensive services, including medical homes, in the community. Community-based case management should be implemented for children and families.

• All immigrant children seeking safe haven should have comprehensive

health care and insurance coverage, which includes the right to access qualified medical interpretation covered by medical benefits, pending immigration proceedings.

• Children not connected to medical

homes may first present to nonprimary care settings. Pediatric providers and staff in these facilities, particularly urgent care and emergency departments, can support referral to the medical home and access to comprehensive services.

• Pediatric providers can refer

to the AAP Immigrant Health Toolkit (https://www.aap.org/ en-us/about-the-aap/CommitteesCouncils-Sections/Council-onCommunity-Pediatrics/Pages/ Immigrant-Child-Health-Toolkit. aspx) as a resource for care of immigrant children.

• Pediatric providers should

familiarize themselves with trauma-informed care and promote access to comprehensive mental health evaluation in the community. The AAP Trauma Toolbox for Primary Care (https:// www.aap.org/en-us/advocacyand-policy/aap-health-initiatives/ healthy-foster-care-america/ Pages/Trauma-Guide.aspx) offers an accessible resource for pediatricians to build these skills. Integrated behavioral health in the primary care setting is an optimal model for care of immigrant and other vulnerable children, minimizing the difficulty in navigating the health care system.

• Pediatric providers serving

previously detained immigrant children should elicit specific history of abuse, neglect, abandonment, persecution, trafficking, or violence to screen children for legal needs and subsequently refer these children for legal services. Integrated care strategies, such as

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medical–legal partnerships, may increase connectivity. Likewise, immigration lawyers should have opportunities to refer children to medical homes if children reach the legal system before seeking medical care.

• Pediatric practices should facilitate children’s enrollment in public educational services, essential to children’s development and future well-being.

• School facilities should be safe

settings for immigrant children to access education. School records and facilities should not be used in any immigration enforcement action.

• No child, whether accompanied

or unaccompanied, should ever represent himself or herself in court. After release into the community, all previously detained immigrant children should have access to legal services at no cost to the child or his or her sponsor.

• Child trafficking victims and other

unaccompanied children should be appointed independent child advocates, pursuant to TVPRA, to advocate for their best interests on all issues, including conditions of custody, release to family or sponsors, and relief from removal.

• Pediatricians everywhere should

advocate for comprehensive, highquality health care in a medical home for all children in the United States, including all immigrant children and those detained or otherwise in the care of the state.

CONCLUSIONS The AAP supports comprehensive health care in a medical home for all children in the United States, including all immigrant children and those detained or otherwise in the care of the state. Children deserve protection from additional traumatization in the United States and the identification and treatment of trauma that may have occurred in children’s country of origin, during migration, or during immigration processing or detention in the United States. The AAP endorses the humane treatment of all immigrant children seeking safe haven in the United States, whether unaccompanied or in family units, throughout the immigration pathway.

ACKNOWLEDGMENTS The authors thank Jennifer Nagda, JD, of the Young Center for Immigrant Children’s Rights, and Jennifer Podkul, JD, and Wendy Young, JD, of Kids in Need of Defense, for their expert contributions to this policy statement. The authors thank Benard Dreyer, MD, FAAP, James Duffee, MD, FAAP, Judy Dolins, MPH, and Tamar Magarik Haro for critical review of multiple drafts of this policy statement. LEAD AUTHORS Julie M. Linton, MD, FAAP Marsha Griffin, MD, FAAP Alan J. Shapiro, MD, FAAP

COUNCIL ON COMMUNITY PEDIATRICS EXECUTIVE COMMITTEE, 2016–2017 Lance A. Chilton, MD, FAAP, Chairperson Patricia J. Flanagan, MD, FAAP, Vice-Chairperson Kimberley J. Dilley, MD, MPH, FAAP James H. Duffee, MD, MPH, FAAP Andrea E. Green, MD, FAAP J. Raul Gutierrez, MD, MPH, FAAP Virginia A. Keane, MD, FAAP Scott D. Krugman, MD, MS, FAAP Julie M. Linton, MD, FAAP Carla D. McKelvey, MD, MPH, FAAP Jacqueline L. Nelson, MD, FAAP

LIAISONS Jacqueline R. Dougé, MD, MPH, FAAP – Chairperson, Public Health Special Interest Group Kathleen Rooney-Otero, MD, MPH – Section on Pediatric Trainees

STAFF Tamar Magarik Haro Camille Watson, MS

ABBREVIATIONS AAP: American Academy of Pediatrics CBP: Customs and Border Protection DHS: Department of Homeland Security FY: fiscal year HHS: US Department of Health and Human Services ICE: Immigration and Customs Enforcement INS: US Immigration and Naturalization Service ORR: Office of Refugee Resettlement TVPRA: Trafficking Victims Protection Reauthorization Act

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

REFERENCES 1. Rosenblum MR, Ruiz Soto AG. An Analysis of Unauthorized Immigrants in the United States by Country and Region of Birth. Washington, DC: Migration Policy Institute; 2015 2. US Customs and Border Protection; US Department of Homeland Security.

United States Border Patrol Southwest Family Unit and Unaccompanied Alien Children Apprehensions Fiscal Year 2016. Washington, DC: US Customs and Border Protection; 2016. Available at: https://www.cbp.gov/newsroom/stats/ southwest-border-unaccompanied-

children/fy-2016. Accessed December 21, 2016 3. Rosenblum M, Ball I. Trends in Unaccompanied Child and Family Migration From Central America. Washington, DC: Migration Policy Institute; 2016

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4. UN Refugee Agency. Children on the Run, Unaccompanied Children Leaving Central America and Mexico and the Need for International Protection. Washington, DC: UN Refugee Agency; 2014. Available at: www.unhcr.org/ en-us/children-on-the-run.html. Accessed December 21, 2016 5. Perreira KM, Ornelas I. Painful passages: traumatic experiences and post-traumatic stress among immigrant Latino adolescents and their primary caregivers. Int Migr Rev. 2013;47(4) 6. UN Refugee Agency. Women on the Run: First-Hand Accounts of Refugees Fleeing El Salvador, Guatemala, Honduras, and Mexico. Washington, DC: UN Refugee Agency; 2015. Available at: www.unhcr.org/5630f24c6.html. Accessed December 21, 2016 7. US Customs and Border Protection; US Department of Homeland Security. Fiscal Year 2015 CBP Border Security Report. Washington, DC: US Customs and Border Protection; 2015. Available at: https://www.dhs.gov/sites/default/ files/publications/CBP%20FY15%20 Border%20Security%20Report_12-21_ 0.pdf. Accessed December 21, 2016 8. Hiskey JT, Cordova A, Orces D, Malone MF. Understanding the Central American Refugee Crisis. Washington, DC: American Immigration Council; 2016. Available at: https://www. americanimmigrationcouncil.org/ research/understanding-centralamerican-refugee-crisis. Accessed December 21, 2016 9. Women’s Refugee Commission. Forced From Home: The Lost Boys and Girls of Central America. New York, NY: Women’s Refugee Commission; 2012. Available at: https://www. womensrefugeecommission.org/ uncategorized/2057-forced-from-homethe-lost-boys-and-girls-of-centralamerica-background-and-report. Accessed December 21, 2016 10. Cantor G. Hieleras (Iceboxes) in the Rio Grande Valley Sector. Washington, DC: American Immigration Council; 2015. Available at: www.immigrationpolicy. org/special-reports/hieleras-iceboxesrio-grande-valley-sector. Accessed December 21, 2016

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11. American Immigration Council. A Guide to Children Arriving at the Border: Laws, Policies and Responses. Washington, DC: American Immigration Council; 2015. Available at: http:// immigrationpolicy.org/special-reports/ guide-children-arriving-border-lawspolicies-and-responses. Accessed December 21, 2016 12. American Immigration Lawyers Association. Due Process Denied: Central Americans Seeking Asylum and Legal Protection in the United States. Washington, DC: American Immigration Lawyers Association; 2016. Available at: www.aila.org/infonet/report-dueprocess-denied. Accessed December 21, 2016 13. Council on Community Pediatrics. Providing care for immigrant, migrant, and border children. Pediatrics. 2013;131(6). Available at: www. pediatrics.org/cgi/content/full/131/6/ e2028 14. Garner AS, Shonkoff JP; Committee on Psychosocial Aspects of Child and Family Health; Committee on Early Childhood, Adoption, and Dependent Care; Section on Developmental and Behavioral Pediatrics. Early childhood adversity, toxic stress, and the role of the pediatrician: translating developmental science into lifelong health. Pediatrics. 2012;129(1). Available at: www.pediatrics.org/cgi/ content/full/129/1/e224 15. American Academy of Pediatrics; Council on Community Pediatrics. Community pediatrics: navigating the intersection of medicine, public health, and social determinants of children’s health. Pediatrics. 2013;131(3):623–628 16. Mahler S, Ugrina D. Central America: Crossroads of the Americas. Washington, DC: Migration Policy Institute; 2006. Available at: www. migrationpolicy.org/article/centralamerica-crossroads-americas/. Accessed December 21, 2016 17. The Flores Settlement Agreement, case no. CV 85-4544-RJK(Px), 1996 18. Lutheran Immigration and Refugee Service; Women’s Refugee Commission; Kids in Need of Defense. Flores Settlement Agreement & DHS Custody. Baltimore, MD: Lutheran Immigration and Refugee Service; 2014. Available at:

https://lirs.org/wp-content/uploads/ 2014/12/Flores-Family-DetentionBackgrounder-LIRS-WRC-KIND-FINAL1. pdf. Accessed December 21, 2016 19. Byrne O, Miller E. The Flow of Unaccompanied Children Through the Immigration System: A Resource for Practitioners, Policy Makers, and Researchers. New York, NY: Center on Immigration and Justice; 2012. Available at: http://immigrantchildren. org/PDF/03-01-12%20the-flow-ofunaccompanied-children-throughthe-immigration-system%20copy.pdf. Accessed December 21, 2016 20. US Immigration and Customs Enforcement. Overview. Available at: https://www.ice.gov/overview-2016. Accessed December 21, 2016 21. US Customs and Border Protection. About CBP. Available at: https://www. cbp.gov/about. Accessed December 21, 2016 22. US Administration for Children and Families. What we do. Available at: www.acf.hhs.gov/about/what-we-do. Accessed December 21, 2016 23. Office of Refugee Resettlement. About unaccompanied children’s services. Available at: www.acf.hhs.gov/ programs/orr/programs/ucs/about. Accessed December 21, 2016 24. Lutheran Immigration and Refugee Service. At the Crossroads for Unaccompanied Migrant Children: Policy, Practice, and Protection. Baltimore, MD: Lutheran Immigration and Refugee Service; 2015. Available at: http://lirs.org/wp-content/uploads/ 2015/07/LIRS_RoundtableReport_WEB. pdf. Accessed December 21, 2016 25. US Government Accountability Office. Unaccompanied Alien Children: Actions Needed to Ensure Children Receive Required Care in DHS Custody. Washington, DC: US Government Accountability Office; 2015. Available at: www.gao.gov/products/GAO-15-521. Accessed December 21, 2016 26. Roth J. DHS Inspector General memorandum re: oversight of unaccompanied alien children. Available at: https://www.oig.dhs. gov/assets/pr/2014/Sig_Mem_Over_ Unac_Alien_Child090214.pdf. Accessed December 21, 2016

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27. National Immigrant Justice Center. Fact Sheet: Children Detained by the Department of Homeland Security in Adult Detention Facilities. Chicago, IL: Heartland Alliance, National Immigrant Justice Center; 2013

Values, Again. Baltimore, MD: Lutheran Immigration and Refugee Service; 2014. Available at: http://lirs.org/ wp-content/uploads/2014/11/LIRSWRC_ LockingUpFamilyValuesAgain_Report_ 141114.pdf. Accessed December 21, 2016

28. US Department of Human Services; Administration for Children and Families; Office of Refugee Resettlement; Unaccompanied Children’s Program. Fact Sheet. Washington, DC: Office of Refugee Resettlement; 2016. Available at: https://www.acf.hhs.gov/sites/default/ files/orr/orr_uc_updated_fact_sheet_ 1416.pdf. Accessed December 21, 2016

34. Department of Homeland Security; Immigration and Customs Enforcement. Report of the ICE Advisory Committee on Family Residential Centers. Available at: https://www.ice.gov/sites/default/files/ documents/Report/2016/acfrc-reportfinal-102016.pdf. Accessed February 6, 2017

29. Office of Refugee Resettlement. Children Entering the United States Unaccompanied: Section 3. Washington, DC: Office of Refugee Resettlement; 2015. Available at: www.acf.hhs.gov/programs/orr/ resource/children-entering-the-unitedstates-unaccompanied-section-3#3.4. Accessed June 13, 2016

35. National Immigrant Justice Center. Background on Family Detention. Chicago, IL: Heartland Alliance, National Immigrant Justice Center; 2015. Available at: www.immigrantjustice. org/sites/immigrantjustice.org/files/ Background%20on%20Family%20 Detention.pdf. Accessed December 21, 2016

30. American Academy of Pediatrics; Council on Community Pediatrics. Immigrant Child Health Toolkit. Elk Grove Village, IL: American Academy of Pediatrics; 2015. Available at: https:// www.aap.org/en-us/about-the-aap/ Committees-Councils-Sections/Councilon-Community-Pediatrics/Pages/ Immigrant-Child-Health-Toolkit.aspx. Accessed December 21, 2016

36. Lutheran Immigration and Refugee Service; Women’s Refugee Commission. Family Detention & the Flores Settlement Agreement. Baltimore, MD: Lutheran Immigration and Refugee Service; 2015. Available at: http://lirs. org/wp-content/uploads/2015/10/LIRS_ FloresSettlementandFamilyDetention_ 1510.pdf. Accessed December 21, 2016

31. Office of Refugee Resettlement. Key Documents for the Unaccompanied Children Program. Washington, DC: Office of Refugee Resettlement; 2012. Available at: www.acf.hhs. gov/programs/orr/resource/ unaccompanied-childrens-services. Accessed December 21, 2016 32. CARA Family Detention Pro Bono Project. Letter of complaint from CARA to Office of Civil Rights and Civil Liberties and Office of Inspector General, Department of Homeland Security, Washington DC. March 28, 2016; AILA doc. no. 16032961. Available at: www.aila.org/advo-media/pressreleases/2016/cara-crcl-complaintconcerns-regarding-detention. Accessed December 21, 2016 33. Lutheran Immigration and Refugee Service; The Women’s Refugee Commission. Locking Up Family

37. Flores v Johnson: Plaintiffs’ response to order show cause. Case no. CV 85-4544 DMG (AGRx). August 13, 2015

care to mothers and children detained at the South Texas Family Residential Center. Available at: www.aila.org/ File/DownloadEmbeddedFile/66149. Accessed December 21, 2016 41. Dirksen W. Letter from Texas Pediatric Society re: proposed rule, chapter 748, sec. 748.7, minimum standards for general residential operations. Available at: https://txpeds.org/ sites/txpeds.org/files/documents/ newsletters/tps-comments-ondfps-detention-center-licensing.pdf. Accessed December 21, 2016 42. Brief for the American Academy of Child and Adolescent Psychiatry (AACAP) and the National Association of Social Workers (NASW) as amici curiae supporting appellees and in support of affirmance of district court judgement Flores el al v Lynch 15-56434 9th Circuit Feb 23 2016 AILA Doc No 16032961. Available at: www. humanrightsfirst.org/sites/default/ files/HRFFloresAmicusBrief.pdf. Accessed December 21, 2016 43. Zayas LH. Declaration of Luis H. Zayas. Available at: https://lofgren.house.gov/ uploadedfiles/declaration_of_luis_ zayas.pdf. Accessed December 21, 2016 44. Shapiro A. Declaration of Dr. Alan Shapiro, MD, dkt no. 187-7, case no. 2:85-cv-04544-DMG-AGR. Available at: www.humanrightsfirst.org/sites/ default/files/HRFFloresAmicusBrief.pdf. Accessed December 21, 2016

38. US Immigration and Customs Enforcement. ICE/DRO residential standard. Medical care. Available at: https://www.ice.gov/doclib/dro/familyresidential/pdf/rs_medical_care.pdf. Accessed December 21, 2016

45. Human Rights First. Long-term detention of mothers and children in Pennsylvania. Available at: www. humanrightsfirst.org/sites/default/ files/HRF-Long-Term-Detention-Brief. pdf. Accessed December 21, 2016

39. US Customs and Immigration Services. Credible fear FAQ. Available at: https:// www.uscis.gov/faq-page/credible-fearfaq#t12831n40211. Accessed December 21, 2016

46. Lustig SL, Kureshi S, Delucchi KL, Iacopino V, Morse SC. Asylum grant rates following medical evaluations of maltreatment among political asylum applicants in the United States. J Immigr Minor Health. 2008;10(1):7–15

40. American Immigration Council; American Immigration Lawyers Association; Catholic Legal Immigration Network I; Refugee and Immigrant Center for Education and Legal Services. Letter to Department of Homeland Security Office of Civil Rights and Civil Liberties re: ICE’s continued failure to provide adequate medical

47. Office of Refugee Resettlement. Children Entering the United States Unaccompanied: Section 2; Safe and Timely Release From ORR Care. Washington, DC: Office of Refugee Resettlement; 2015. Available at: https://www.acf.hhs.gov/orr/resource/ children-entering-the-united-states-

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unaccompanied. Accessed December 21, 2016 48. United States Conference of Catholic Bishops; Migration and Refugee Services; Lutheran Immigration and Refugee Service. Post-release services: family preservation services for immigrant children released from federal custody. Available at: www.usccb.org/about/children-andmigration/upload/LIRS-and-USCCBPost-Release-Services-FAQs-Final.pdf. Accessed December 21, 2016 49. Legal Information Institute. Definition of disability. 42 USC §12102 50. US Citizen and Immigration Services. Credible fear workload report summary. Available at: https://www. uscis.gov/sites/default/files/USCIS/ Outreach/Upcoming%20National%20 Engagements/CredibleFearReaso nableFearStatisticsNationalityReports. pdf. Accessed December 21, 2016 51. Society for Community Research and Action Division 27 of the American Psychological Association. Policy statement on the incarceration of undocumented migrant families. Am J Community Psychol. 2016;57(1–2):255–263 52. United Nations General Assembly. Convention on the Rights of the Child. Available at: www.ohchr.org/ Documents/ProfessionalInterest/crc. pdf. Accessed December 21, 2016 53. Haggerty RJ. The convention on the rights of the child: it’s time for the United States to ratify. Pediatrics. 1994;94(5):746–747 54. Subcommittee on Best Interests of the Interagency Working Group on Unaccompanied and Separated Children. Framework for considering the best interests of unaccompanied children. Available at: https:// www.gcir.org/sites/default/files/ resources/2016%20Young%20 Center%20Framework%20for%20 Considering%20Best%20Interests%20 of%20Unaccompanied%20Children.pdf. Accessed December 21, 2016 55. Lorek A, Ehntholt K, Nesbitt A, et al. The mental and physical health difficulties of children held within a British immigration detention center: a pilot study. Child Abuse Negl. 2009;33(9):573–585

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56. Kronick R, Rousseau C, Cleveland J. Asylum-seeking children’s experiences of detention in Canada: a qualitative study. Am J Orthopsychiatry. 2015;85(3):287–294 57. Mares S, Jureidini J. Psychiatric assessment of children and families in immigration detention–clinical, administrative and ethical issues. Aust N Z J Public Health. 2004;28(6):520–526 58. Dudley M, Steel Z, Mares S, Newman L. Children and young people in immigration detention. Curr Opin Psychiatry. 2012;25(4):285–292 59. Fazel M, Stein A. Mental health of refugee children: comparative study. BMJ. 2003;327(7407):134 60. Bailey C. The psychosocial context of mental health needs of unaccompanied children in United States immigration proceedings. Grad Stud J Psychol. 2011;13:4–11 61. Deans AK, Boerma CJ, Fordyce J, De Souza M, Palmer DJ, Davis JS. Use of Royal Darwin Hospital emergency department by immigration detainees in 2011. Med J Aust. 2013;199(11):776–778 62. Physicians for Human Rights; The Bellevue/NYU Program for Survivors of Torture. From Persecution to Prison: The Health Consequences of Detention for Asylum Seekers. New York, NY: Physicians for Human Rights; 2003. Available at: www. survivorsoftorture.org/files/pdf/ perstoprison2003.pdf. Accessed December 21, 2016 63. Porter M, Haslam N. Predisplacement and postdisplacement factors associated with mental health of refugees and internally displaced persons: a meta-analysis. JAMA. 2005;294(5):602–612 64. Momartin S, Steel Z, Coello M, Aroche J, Silove DM, Brooks R. A comparison of the mental health of refugees with temporary versus permanent protection visas. Med J Aust. 2006;185(7):357–361 65. Robjant K, Hassan R, Katona C. Mental health implications of detaining asylum seekers: systematic review. Br J Psychiatry. 2009;194(4):306–312 66. Coffey GJ, Kaplan I, Sampson RC, Tucci MM. The meaning and mental

health consequences of long-term immigration detention for people seeking asylum. Soc Sci Med. 2010;70(12):2070–2079 67. Dyer C. Measures to end child detention don’t go far enough, says children’s rights charity. BMJ. 2010;341:c7285 68. Weisleder A, Cates CB, Dreyer BP, et al. Promotion of positive parenting and prevention of socioemotional disparities. Pediatrics. 2016;137(2):e20153239 69. Centers for Disease Control and Prevention. Refugee health guidelines. Available at: www.cdc.gov/ immigrantrefugeehealth/guidelines/ refugee-guidelines.html. Accessed December 21, 2016 70. Substance Abuse and Mental Health Services Administration. Traumainformed approach and traumaspecific interventions. Available at: www.samhsa.gov/nctic/traumainterventions. Accessed December 21, 2016 71. American Academy of Pediatrics. Trauma Toolbox for Primary Care. Elk Grove Village, IL: American Academy of Pediatrics; 2014. Available at: https://www.aap.org/en-us/advocacyand-policy/aap-health-initiatives/ healthy-foster-care-america/Pages/ Trauma-Guide.aspx#trauma. Accessed December 21, 2016 72. National Child Traumatic Stress Network. Guidance for working with unaccompanied migrant children. Available at: http://nctsn.org/traumatypes/refugee-trauma/guidanceunaccompanied. Accessed December 21, 2016 73. The Henry J. Kaiser Family Foundation. Medicaid and CHIP Eligibility, Enrollment, Renewal, and Cost Sharing Policies as of January 2017: Findings From a 50-State Survey. Menlo Park, CA: The Henry J. Kaiser Family Foundation; 2017. Available at: http://files.kff.org/attachment/ Report-Medicaid-and-CHIP-Eligibilityas-of-Jan-2017. Accessed February 6, 2017 74. Plyler v Doe, US S Ct 80-15381982

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75. Immigration TRAC. Juveniles: immigration court deportation proceedings. Available at: http://trac.syr.edu/phptools/ immigration/juvenile/. Accessed December 21, 2016 76. Kids in Need of Defense; Women’s Refugee Commission. One year later:

where are the refugee mothers and children? Available at: https:// supportkind.org/wp-content/uploads/ 2015/07/One-Year-Later.pdf. Accessed December 21, 2016 77. Child Welfare Information Gateway. Child welfare and human trafficking. Available at: https://www.childwelfare.

gov/pubPDFs/trafficking.pdf. Accessed December 21, 2016 78. Greenbaum J, Crawford-Jakubiak JE; Committee on Child Abuse and Neglect. Child sex trafficking and commercial sexual exploitation: health care needs of victims. Pediatrics. 2015;135(3):566–574

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Diagnosis, Treatment, and Prevention of Congenital Toxoplasmosis in the United States • Technical Report

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TECHNICAL REPORT

Diagnosis, Treatment, and Prevention of Congenital Toxoplasmosis in the United States Yvonne A. Maldonado, MD, FAAP, Jennifer S. Read, MD, MS, MPH, DTM&H, FAAP, COMMITTEE ON INFECTIOUS DISEASES

EXECUTIVE SUMMARY Congenital toxoplasmosis (CT) is a parasitic disease that can cause significant fetal and neonatal harm. Coordinated efforts by pregnant women, researchers, physicians, and health policy makers regarding potential primary and secondary preventive measures for CT and their implementation may lead to a lower incidence of CT as well as lower morbidity and mortality rates associated with CT. In the United States, the age-adjusted seroprevalence of Toxoplasma gondii among women of childbearing age (15–44 years) has declined over time (15%, 11%, and 9% in 1988–1994, 1999–2004, and 2009–2010, respectively; among US-born women only, the seroprevalence rates during these time periods were 13%, 8%, and 6%, respectively). Thus, approximately 91% of women of childbearing age in the United States are susceptible to Toxoplasma infection. Should these women become infected during pregnancy and remain undiagnosed and untreated, they could deliver an infant with CT. However, the incidence of acute primary infection is likely very low in the current era and is probably much lower than the 1.1 in 1000 pregnant women originally reported in 1960s. There are 3 ways CT can occur. First, CT can develop through transmission of T gondii to the fetus from a previously seronegative, immunocompetent mother who acquired acute primary infection during pregnancy or within 3 months before conception. Second, CT can occur through reactivation of toxoplasmosis in a previously T gondii–immune pregnant woman who was severely immunocompromised during pregnancy. Third, CT can result after reinfection of a previously immune pregnant mother with a new, more virulent strain (eg, after international travel or after eating undercooked meat from areas where more virulent atypical strains predominate).

This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication. Technical reports from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, technical reports from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent. The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. All technical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time. DOI: 10.1542/peds.2016-3860 PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2017 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they do not have a financial relationship relevant to this article to disclose. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

To cite: Maldonado YA, Read JS, AAP COMMITTEE ON INFECTIOUS DISEASES. Diagnosis, Treatment, and Prevention of Congenital Toxoplasmosis in the United States. Pediatrics. 2017;139(2):e20163860

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In cohorts of women who have been screened routinely during pregnancy and treated accordingly once primary infection was diagnosed, the mother-to-child transmission (MTCT) rate was 50% of children and family members before, during, and after wartime deployments. This clinical report is for all pediatricians, both active duty and civilian, to aid in caring for children whose loved ones have been, are, or will be deployed. (5/13)

http://pediatrics.aappublications.org/content/131/6/e2002

HEALTH CARE FOR YOUTH IN THE JUVENILE JUSTICE SYSTEM Committee on Adolescence ABSTRACT. Youth in the juvenile correctional system are a high-risk population who, in many cases, have unmet physical, developmental, and mental health needs. Multiple studies have found that some of these health issues occur at higher rates than in the general adolescent population. Although some youth in the juvenile justice system have interfaced with health care providers in their community on a regular basis, others have had inconsistent or nonexistent care. The health needs of these youth are commonly identified when they are admitted to a juvenile

SECTION 5/CURRENT POLICIES

custodial facility. Pediatricians and other health care providers play an important role in the care of these youth, and continuity between the community and the correctional facility is crucial. This policy statement provides an overview of the health needs of youth in the juvenile correctional system, including existing resources and standards for care, financing of health care within correctional facilities, and evidence-based interventions. Recommendations are provided for the provision of health care services to youth in the juvenile correctional system as well as specific areas for advocacy efforts. (11/11, reaffirmed 5/15)

http://pediatrics.aappublications.org/content/128/6/1219

HEALTH CARE ISSUES FOR CHILDREN AND ADOLESCENTS IN FOSTER CARE AND KINSHIP CARE Council on Foster Care, Adoption, and Kinship Care; Committee on Adolescence; and Council on Early Childhood ABSTRACT. Children and adolescents who enter foster care often do so with complicated and serious medical, mental health, developmental, oral health, and psychosocial problems rooted in their history of childhood trauma. Ideally, health care for this population is provided in a pediatric medical home by physicians who are familiar with the sequelae of childhood trauma and adversity. As youth with special health care needs, children and adolescents in foster care require more frequent monitoring of their health status, and pediatricians have a critical role in ensuring the well-being of children in out-of-home care through the provision of high-quality pediatric health services, health care coordination, and advocacy on their behalves. (9/15)

http://pediatrics.aappublications.org/content/136/4/e1131

HEALTH CARE ISSUES FOR CHILDREN AND ADOLESCENTS IN FOSTER CARE AND KINSHIP CARE (TECHNICAL REPORT) Moira A. Szilagyi, MD, PhD; David S. Rosen, MD, MPH; David Rubin, MD, MSCE; Sarah Zlotnik, MSW, MSPH; Council on Foster Care, Adoption, and Kinship Care; Committee on Adolescence; and Council on Early Childhood ABSTRACT. Children and adolescents involved with child welfare, especially those who are removed from their family of origin and placed in out-of-home care, often present with complex and serious physical, mental health, developmental, and psychosocial problems rooted in childhood adversity and trauma. As such, they are designated as children with special health care needs. There are many barriers to providing highquality comprehensive health care services to children and adolescents whose lives are characterized by transience and uncertainty. Pediatricians have a critical role in ensuring the well-being of children in out-of-home care through the provision of high-quality pediatric health services in the context of a medical home, and health care coordination and advocacy on their behalf. This technical report supports the policy statement of the same title. (9/15)

http://pediatrics.aappublications.org/content/136/4/e1142

HEALTH CARE OF YOUTH AGING OUT OF FOSTER CARE Council on Foster Care, Adoption, and Kinship Care and Committee on Early Childhood ABSTRACT. Youth transitioning out of foster care face significant medical and mental health care needs. Unfortunately, these youth rarely receive the services they need because of lack of health insurance. Through many policies and programs, the federal government has taken steps to support older youth in foster care and those aging out. The Fostering Connections to Success and Increasing Adoptions Act of 2008 (Pub L No. 110354) requires states to work with youth to develop a transition plan that addresses issues such as health insurance. In addition, beginning in 2014, the Patient Protection and Affordable Care Act of 2010 (Pub L No. 111-148) makes youth aging out of foster

POLICY TITLES AND ABSTRACTS

care eligible for Medicaid coverage until age 26 years, regardless of income. Pediatricians can support youth aging out of foster care by working collaboratively with the child welfare agency in their state to ensure that the ongoing health needs of transitioning youth are met. (11/12, reaffirmed 7/17)

http://pediatrics.aappublications.org/content/130/6/1170

HEALTH CARE SUPERVISION FOR CHILDREN WITH WILLIAMS SYNDROME Committee on Genetics ABSTRACT. This set of guidelines is designed to assist the pediatrician to care for children with Williams syndrome diagnosed by clinical features and with regional chromosomal microdeletion confirmed by fluorescence in situ hybridization. (5/01, reaffirmed 5/05, 1/09)

http://pediatrics.aappublications.org/content/107/5/1192

HEALTH EQUITY AND CHILDREN’S RIGHTS Council on Community Pediatrics and Committee on Native American Child Health ABSTRACT. Many children in the United States fail to reach their full health and developmental potential. Disparities in their health and well-being result from the complex interplay of multiple social and environmental determinants that are not adequately addressed by current standards of pediatric practice or public policy. Integrating the principles and practice of child health equity—children’s rights, social justice, human capital investment, and health equity ethics—into pediatrics will address the root causes of child health disparities. Promoting the principles and practice of equity-based clinical care, child advocacy, and child- and family-centered public policy will help to ensure that social and environmental determinants contribute positively to the health and well-being of children. The American Academy of Pediatrics and pediatricians can move the national focus from documenting child health disparities to advancing the principles and practice of child health equity and, in so doing, influence the worldwide practice of pediatrics and child health. All pediatricians, including primary care practitioners and medical and surgical subspecialists, can incorporate these principles into their practice of pediatrics and child health. Integration of these principles into competencybased training and board certification will secure their assimilation into all levels of pediatric practice. (3/10, reaffirmed 10/13)

http://pediatrics.aappublications.org/content/125/4/838

HEALTH INFORMATION TECHNOLOGY AND THE MEDICAL HOME Council on Clinical Information Technology ABSTRACT. The American Academy of Pediatrics (AAP) supports development and universal implementation of a comprehensive electronic infrastructure to support pediatric information functions of the medical home. These functions include (1) timely and continuous management and tracking of health data and services over a patient’s lifetime for all providers, patients, families, and guardians, (2) comprehensive organization and secure transfer of health data during patient-care transitions between providers, institutions, and practices, (3) establishment and maintenance of central coordination of a patient’s health information among multiple repositories (including personal health records and information exchanges), (4) translation of evidence into actionable clinical decision support, and (5) reuse of archived clinical data for continuous quality improvement. The AAP supports universal, secure, and vendor-neutral portability of health information for all patients contained within the medical home across all care settings (ambulatory practices, inpatient settings, emergency departments, pharmacies, ­consultants,

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s­ upport service providers, and therapists) for multiple purposes including direct care, personal health records, public health, and registries. The AAP also supports financial incentives that promote the development of information tools that meet the needs of pediatric workflows and that appropriately recognize the added value of medical homes to pediatric care. (4/11, reaffirmed 7/15)

http://pediatrics.aappublications.org/content/127/5/978

HEALTH SUPERVISION FOR CHILDREN WITH ACHONDROPLASIA (CLINICAL REPORT) Tracy L. Trotter, MD; Judith G. Hall, OC, MD; and Committee on Genetics ABSTRACT. Achondroplasia is the most common condition associated with disproportionate short stature. Substantial information is available concerning the natural history and anticipatory health supervision needs in children with this dwarfing disorder. Most children with achondroplasia have delayed motor milestones, problems with persistent or recurrent middleear dysfunction, and bowing of the lower legs. Less often, infants and children may have serious health consequences related to hydrocephalus, craniocervical junction compression, upperairway obstruction, or thoracolumbar kyphosis. Anticipatory care should be directed at identifying children who are at high risk and intervening to prevent serious sequelae. This report is designed to help the pediatrician care for children with achondroplasia and their families. (9/05, reaffirmed 5/12)

http://pediatrics.aappublications.org/content/116/3/771

HEALTH SUPERVISION FOR CHILDREN WITH DOWN SYNDROME (CLINICAL REPORT) Marilyn J. Bull, MD, and Committee on Genetics ABSTRACT. These guidelines are designed to assist the pediatrician in caring for the child in whom a diagnosis of Down syndrome has been confirmed by chromosome analysis. Although a pediatrician’s initial contact with the child is usually during infancy, occasionally the pregnant woman who has been given a prenatal diagnosis of Down syndrome will be referred for review of the condition and the genetic counseling provided. Therefore, this report offers guidance for this situation as well. (7/11, reaffirmed 9/16)

http://pediatrics.aappublications.org/content/128/2/393

HEALTH SUPERVISION FOR CHILDREN WITH FRAGILE X SYNDROME (CLINICAL REPORT) Joseph H. Hersh, MD; Robert A. Saul, MD; and Committee on Genetics ABSTRACT. Fragile X syndrome (an FMR1–related disorder) is the most commonly inherited form of mental retardation. Early physical recognition is difficult, so boys with developmental delay should be strongly considered for molecular testing. The characteristic adult phenotype usually does not develop until the second decade of life. Girls can also be affected with developmental delay. Because multiple family members can be affected with mental retardation and other conditions (premature ovarian failure and tremor/ataxia), family history information is of critical importance for the diagnosis and management of affected patients and their families. This report summarizes issues for fragile X syndrome regarding clinical diagnosis, laboratory diagnosis, genetic counseling, related health problems, behavior management, and age-related health supervision guidelines. The diagnosis of fragile X syndrome not only involves the affected children but also potentially has significant health consequences for multiple generations in each family. (4/11)

http://pediatrics.aappublications.org/content/127/5/994

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HEALTH SUPERVISION FOR CHILDREN WITH MARFAN SYNDROME (CLINICAL REPORT) Brad T. Tinkle, MD, PhD; Howard M. Saal, MD; and Committee on Genetics ABSTRACT. Marfan syndrome is a systemic, heritable connective tissue disorder that affects many different organ systems and is best managed by using a multidisciplinary approach. The guidance in this report is designed to assist the pediatrician in recognizing the features of Marfan syndrome as well as caring for the individual with this disorder. (9/13)

http://pediatrics.aappublications.org/content/132/4/e1059

HEALTH SUPERVISION FOR CHILDREN WITH NEUROFIBROMATOSIS (CLINICAL REPORT) Joseph H. Hersh, MD, and Committee on Genetics ABSTRACT. Neurofibromatosis 1 is a multisystem disorder that primarily involves the skin and nervous system. Its population prevalence is 1 in 3500. The condition usually is recognized in early childhood, when cutaneous manifestations are apparent. Although neurofibromatosis 1 is associated with marked clinical variability, most affected children do well from the standpoint of their growth and development. Some features of neurofibromatosis 1 are present at birth, and others are age-related abnormalities of tissue proliferation, which necessitate periodic monitoring to address ongoing health and developmental needs and to minimize the risk of serious medical complications. This clinical report provides a review of the clinical criteria needed to establish a diagnosis, the inheritance pattern of neurofibromatosis 1, its major clinical and developmental manifestations, and guidelines for monitoring and providing intervention to maximize the growth, development, and health of an affected child. (3/08, reaffirmed 9/16)

http://pediatrics.aappublications.org/content/121/3/633

HEALTH SUPERVISION FOR CHILDREN WITH PRADERWILLI SYNDROME (CLINICAL REPORT) Shawn E. McCandless, MD, and Committee on Genetics ABSTRACT. This set of guidelines was designed to assist the pediatrician in caring for children with Prader-Willi syndrome diagnosed by clinical features and confirmed by molecular testing. Prader-Willi syndrome provides an excellent example of how early diagnosis and management can improve the longterm outcome for some genetic disorders. (12/10)

http://pediatrics.aappublications.org/content/127/1/195

HEALTH SUPERVISION FOR CHILDREN WITH SICKLE CELL DISEASE Section on Hematology/Oncology and Committee on Genetics ABSTRACT. Sickle cell disease (SCD) is a group of complex genetic disorders with multisystem manifestations. This statement provides pediatricians in primary care and subspecialty practice with an overview of the genetics, diagnosis, clinical manifestations, and treatment of SCD. Specialized comprehensive medical care decreases morbidity and mortality during childhood. The provision of comprehensive care is a time-intensive endeavor that includes ongoing patient and family education, periodic comprehensive evaluations and other disease-specific health maintenance services, psychosocial care, and genetic counseling. Timely and appropriate treatment of acute illness is critical, because life-threatening complications develop rapidly. It is essential that every child with SCD receive comprehensive care that is coordinated through a medical home with appropriate expertise. (3/02, reaffirmed 1/06, 1/11, 2/16)

http://pediatrics.aappublications.org/content/109/3/526

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HEARING ASSESSMENT IN INFANTS AND CHILDREN: RECOMMENDATIONS BEYOND NEONATAL SCREENING (CLINICAL REPORT) Allen D. “Buz” Harlor Jr, MD; Charles Bower, MD; Committee on Practice and Ambulatory Medicine; and Section on Otolaryngology–Head and Neck Surgery ABSTRACT. Congenital or acquired hearing loss in infants and children has been linked with lifelong deficits in speech and language acquisition, poor academic performance, personalsocial maladjustments, and emotional difficulties. Identification of hearing loss through neonatal hearing screening, regular surveillance of developmental milestones, auditory skills, parental concerns, and middle-ear status and objective hearing screening of all infants and children at critical developmental stages can prevent or reduce many of these adverse consequences. This report promotes a proactive, consistent, and explicit process for the early identification of children with hearing loss in the medical home. An algorithm of the recommended approach has been developed to assist in the detection and documentation of, and intervention for, hearing loss. (9/09)

http://pediatrics.aappublications.org/content/124/4/1252

HELPING CHILDREN AND FAMILIES DEAL WITH DIVORCE AND SEPARATION (CLINICAL REPORT) George J. Cohen, MD, FAAP; Carol C. Weitzman, MD, FAAP; Committee on Psychosocial Aspects of Child and Family Health; and Section on Developmental and Behavioral Pediatrics ABSTRACT. For the past several years in the United States, there have been more than 800 000 divorces and parent separations annually, with over 1 million children affected. Children and their parents can experience emotional trauma before, during, and after a separation or divorce. Pediatricians can be aware of their patients’ behavior and parental attitudes and behaviors that may indicate family dysfunction and that can indicate need for intervention. Age-appropriate explanation and counseling for the child and advice and guidance for the parents, as well as recommendation of reading material, may help reduce the potential negative effects of divorce. Often, referral to professionals with expertise in the social, emotional, and legal aspects of the separation and its aftermath may be helpful for these families. (11/16)

http://pediatrics.aappublications.org/content/138/6/e20163020

HIGH-DEDUCTIBLE HEALTH PLANS Committee on Child Health Financing ABSTRACT. High-deductible health plans (HDHPs) are insurance policies with higher deductibles than conventional plans. The Medicare Prescription Drug Improvement and Modernization Act of 2003 linked many HDHPs with taxadvantaged spending accounts. The 2010 Patient Protection and Affordable Care Act continues to provide for HDHPs in its lower-level plans on the health insurance marketplace and provides for them in employer-offered plans. HDHPs decrease the premium cost of insurance policies for purchasers and shift the risk of further payments to the individual subscriber. HDHPs reduce utilization and total medical costs, at least in the short term. Because HDHPs require out-of-pocket payment in the initial stages of care, primary care and other outpatient services as well as elective procedures are the services most affected, whereas higher-cost services in the health care system, incurred after the deductible is met, are unaffected. HDHPs promote adverse selection because healthier and wealthier patients tend to opt out of conventional plans in favor of HDHPs. Because the ill pay more than the healthy under HDHPs, families with children with special health care needs bear an increased cost burden in this model. HDHPs discourage use of nonpreventive

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primary care and thus are at odds with most recommendations for improving the organization of health care, which focus on strengthening primary care. This policy statement provides background information on HDHPs, discusses the implications for families and pediatric care providers, and suggests courses of action. (4/14)

http://pediatrics.aappublications.org/content/133/5/e1461

HIV TESTING AND PROPHYLAXIS TO PREVENT MOTHERTO-CHILD TRANSMISSION IN THE UNITED STATES Committee on Pediatric AIDS ABSTRACT. Universal HIV testing of pregnant women in the United States is the key to prevention of mother-to-child transmission of HIV. Repeat testing in the third trimester and rapid HIV testing at labor and delivery are additional strategies to further reduce the rate of perinatal HIV transmission. Prevention of mother-to-child transmission of HIV is most effective when antiretroviral drugs are received by the mother during her pregnancy and continued through delivery and then administered to the infant after birth. Antiretroviral drugs are effective in reducing the risk of mother-to-child transmission of HIV even when prophylaxis is started for the infant soon after birth. New rapid testing methods allow identification of HIV-infected women or HIV-exposed infants in 20 to 60 minutes. The American Academy of Pediatrics recommends documented, routine HIV testing for all pregnant women in the United States after notifying the patient that testing will be performed, unless the patient declines HIV testing (“opt-out” consent or “right of refusal”). For women in labor with undocumented HIV-infection status during the current pregnancy, immediate maternal HIV testing with opt-out consent, using a rapid HIV antibody test, is recommended. Positive HIV antibody screening test results should be confirmed with immunofluorescent antibody or Western blot assay. For women with a positive rapid HIV antibody test result, antiretroviral prophylaxis should be administered promptly to the mother and newborn infant on the basis of the positive result of the rapid antibody test without waiting for results of confirmatory HIV testing. If the confirmatory test result is negative, then prophylaxis should be discontinued. For a newborn infant whose mother’s HIV serostatus is unknown, the health care professional should perform rapid HIV antibody testing on the mother or on the newborn infant, with results reported to the health care professional no later than 12 hours after the infant’s birth. If the rapid HIV antibody test result is positive, antiretroviral prophylaxis should be instituted as soon as possible after birth but certainly by 12 hours after delivery, pending completion of confirmatory HIV testing. The mother should be counseled not to breastfeed the infant. Assistance with immediate initiation of hand and pump expression to stimulate milk production should be offered to the mother, given the possibility that the confirmatory test result may be negative. If the confirmatory test result is negative, then prophylaxis should be stopped and breastfeeding may be initiated. If the confirmatory test result is positive, infants should receive antiretroviral prophylaxis for 6 weeks after birth, and the mother should not breastfeed the infant. (11/08, reaffirmed 6/11, 11/14)

http://pediatrics.aappublications.org/content/122/5/1127

HOME, HOSPITAL, AND OTHER NON–SCHOOL-BASED INSTRUCTION FOR CHILDREN AND ADOLESCENTS WHO ARE MEDICALLY UNABLE TO ATTEND SCHOOL Committee on School Health ABSTRACT. The American Academy of Pediatrics recommends that school-aged children and adolescents obtain their education in school in the least restrictive setting, that is, the setting most conducive to learning for the particular student. However, at times, acute illness or injury and chronic medical conditions

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preclude school attendance. This statement is meant to assist evaluation and planning for children to receive non–schoolbased instruction and to return to school at the earliest possible date. (11/00, reaffirmed 6/03, 5/06)

http://pediatrics.aappublications.org/content/106/5/1154

HOME CARE OF CHILDREN AND YOUTH WITH COMPLEX HEALTH CARE NEEDS AND TECHNOLOGY DEPENDENCIES (CLINICAL REPORT) Ellen Roy Elias, MD; Nancy A. Murphy, MD; and Council on Children With Disabilities ABSTRACT. Children and youth with complex medical issues, especially those with technology dependencies, experience frequent and often lengthy hospitalizations. Hospital discharges for these children can be a complicated process that requires a deliberate, multistep approach. In addition to successful discharges to home, it is essential that pediatric providers develop and implement an interdisciplinary and coordinated plan of care that addresses the child’s ongoing health care needs. The goal is to ensure that each child remains healthy, thrives, and obtains optimal medical home and developmental supports that promote ongoing care at home and minimize recurrent hospitalizations. This clinical report presents an approach to discharging the child with complex medical needs with technology dependencies from hospital to home and then continually addressing the needs of the child and family in the home environment. (4/12, reaffirmed 5/17)

http://pediatrics.aappublications.org/content/129/5/996

HONORING DO-NOT-ATTEMPT-RESUSCITATION REQUESTS IN SCHOOLS Council on School Health and Committee on Bioethics ABSTRACT. Increasingly, children and adolescents with complex chronic conditions are living in the community. Federal legislation and regulations facilitate their participation in school. Some of these children and adolescents and their families may wish to forego life-sustaining medical treatment, including cardiopulmonary resuscitation, because they would be ineffective or because the risks outweigh the benefits. Honoring these requests in the school environment is complex because of the limited availability of school nurses and the frequent lack of supporting state legislation and regulations. Understanding and collaboration on the part of all parties is essential. Pediatricians have an important role in helping school nurses incorporate a specific action plan into the student’s individualized health care plan. The action plan should include both communication and comfort-care plans. Pediatricians who work directly with schools can also help implement policies, and professional organizations can advocate for regulations and legislation that enable students and their families to effectuate their preferences. (4/10, reaffirmed 7/13, 8/16)

http://pediatrics.aappublications.org/content/125/5/1073

HOSPITAL DISCHARGE OF THE HIGH-RISK NEONATE Committee on Fetus and Newborn ABSTRACT. This policy statement updates the guidelines on discharge of the high-risk neonate first published by the American Academy of Pediatrics in 1998. As with the earlier document, this statement is based, insofar as possible, on published, scientifically derived information. This updated statement incorporates new knowledge about risks and medical care of the high-risk neonate, the timing of discharge, and planning for care after discharge. It also refers to other American Academy of Pediatrics publications that are relevant to these issues. This statement draws on the previous classification of high-risk infants into 4 categories: (1) the preterm infant; (2) the infant with special health care needs or dependence on technology; (3)

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the infant at risk because of family issues; and (4) the infant with anticipated early death. The issues of deciding when discharge is appropriate, defining the specific needs for follow-up care, and the process of detailed discharge planning are addressed as they apply in general to all 4 categories; in addition, special attention is directed to the particular issues presented by the 4 individual categories. Recommendations are given to aid in deciding when discharge is appropriate and to ensure that all necessary care will be available and well coordinated after discharge. The need for individualized planning and physician judgment is emphasized. (11/08, reaffirmed 5/11)

http://pediatrics.aappublications.org/content/122/5/1119

THE HOSPITAL RECORD OF THE INJURED CHILD AND THE NEED FOR EXTERNAL CAUSE-OF-INJURY CODES Committee on Injury and Poison Prevention ABSTRACT. Proper record-keeping of emergency department visits and hospitalizations of injured children is vital for appropriate patient management. Determination and documentation of the circumstances surrounding the injury event are essential. This information not only is the basis for preventive counseling, but also provides clues about how similar injuries in other youth can be avoided. The hospital records have an important secondary purpose; namely, if sufficient information about the cause and mechanism of injury is documented, it can be subsequently coded, electronically compiled, and retrieved later to provide an epidemiologic profile of the injury, the first step in prevention at the population level. To be of greatest use, hospital records should indicate the “who, what, when, where, why, and how” of the injury occurrence and whether protective equipment (eg, a seat belt) was used. The pediatrician has two important roles in this area: to document fully the injury event and to advocate the use of standardized external cause-of-injury codes, which allow such data to be compiled and analyzed. (2/99, reaffirmed 5/02, 5/05, 10/08, 10/13)

http://pediatrics.aappublications.org/content/103/2/524

HOSPITAL STAY FOR HEALTHY TERM NEWBORN INFANTS William E. Benitz, MD, FAAP, and Committee on Fetus and Newborn ABSTRACT. The hospital stay of the mother and her healthy term newborn infant should be long enough to allow identification of problems and to ensure that the mother is sufficiently recovered and prepared to care for herself and her newborn at home. The length of stay should be based on the unique characteristics of each mother-infant dyad, including the health of the mother, the health and stability of the newborn, the ability and confidence of the mother to care for herself and her newborn, the adequacy of support systems at home, and access to appropriate follow-up care in a medical home. Input from the mother and her obstetrical care provider should be considered before a decision to discharge a newborn is made, and all efforts should be made to keep a mother and her newborn together to ensure simultaneous discharge. (4/15)

http://pediatrics.aappublications.org/content/135/5/948

HUMAN EMBRYONIC STEM CELL (HESC) AND HUMAN EMBRYO RESEARCH Committee on Pediatric Research and Committee on Bioethics ABSTRACT. Human embryonic stem cell research has emerged as an important platform for the understanding and treatment of pediatric diseases. From its inception, however, it has raised ethical concerns based not on the use of stem cells themselves but on objections to the source of the cells—specifically, the destruction of preimplantation human embryos. Despite differences in public opinion on this issue, a large majority of the public supports continued research using embryonic stem cells. Given the possible substantial benefit of stem cell research on child health and

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development, the American Academy of Pediatrics believes that funding and oversight for human embryo and embryonic stem cell research should continue. (10/12, reaffirmed 7/17)

http://pediatrics.aappublications.org/content/130/5/972

HUMAN IMMUNODEFICIENCY VIRUS AND OTHER BLOODBORNE VIRAL PATHOGENS IN THE ATHLETIC SETTING Committee on Sports Medicine and Fitness ABSTRACT. Because athletes and the staff of athletic programs can be exposed to blood during athletic activity, they have a very small risk of becoming infected with human immunodeficiency virus, hepatitis B virus, or hepatitis C virus. This statement, which updates a previous position statement of the American Academy of Pediatrics, discusses sports participation for athletes infected with these pathogens and the precautions needed to reduce the risk of infection to others in the athletic setting. Each of the recommendations in this statement is dependent upon and intended to be considered with reference to the other recommendations in this statement and not in isolation. (12/99, reaffirmed 1/05, 1/09, 11/11, 2/15)

http://pediatrics.aappublications.org/content/104/6/1400

HYPOTHERMIA AND NEONATAL ENCEPHALOPATHY (CLINICAL REPORT) Committee on Fetus and Newborn ABSTRACT. Data from large randomized clinical trials indicate that therapeutic hypothermia, using either selective head cooling or systemic cooling, is an effective therapy for neonatal encephalopathy. Infants selected for cooling must meet the criteria outlined in published clinical trials. The implementation of cooling needs to be performed at centers that have the capability to manage medically complex infants. Because the majority of infants who have neonatal encephalopathy are born at community hospitals, centers that perform cooling should work with their referring hospitals to implement education programs focused on increasing the awareness and identification of infants at risk for encephalopathy, and the initial clinical management of affected infants. (5/14)

http://pediatrics.aappublications.org/content/133/6/1146

IDENTIFICATION AND CARE OF HIV-EXPOSED AND HIVINFECTED INFANTS, CHILDREN, AND ADOLESCENTS IN FOSTER CARE Committee on Pediatric AIDS ABSTRACT. As a consequence of the expanding human immunodeficiency virus (HIV) epidemic and major advances in medical management of HIV-exposed and HIV-infected persons, revised recommendations are provided for HIV testing of infants, children, and adolescents in foster care. Updated recommendations also are provided for the care of HIV-exposed and HIV-infected persons who are in foster care. (7/00, reaffirmed 12/16)

http://pediatrics.aappublications.org/content/106/1/149

IDENTIFICATION AND EVALUATION OF CHILDREN WITH AUTISM SPECTRUM DISORDERS (CLINICAL REPORT) Chris Plauché Johnson, MD, MEd; Scott M. Myers, MD; and Council on Children With Disabilities ABSTRACT. Autism spectrum disorders are not rare; many primary care pediatricians care for several children with autism spectrum disorders. Pediatricians play an important role in early recognition of autism spectrum disorders, because they usually are the first point of contact for parents. Parents are now much more aware of the early signs of autism spectrum disorders because of frequent coverage in the media; if their child demonstrates any of the published signs, they will most likely

POLICY TITLES AND ABSTRACTS

raise their concerns to their child’s pediatrician. It is important that pediatricians be able to recognize the signs and symptoms of autism spectrum disorders and have a strategy for assessing them systematically. Pediatricians also must be aware of local resources that can assist in making a definitive diagnosis of, and in managing, autism spectrum disorders. The pediatrician must be familiar with developmental, educational, and community resources as well as medical subspecialty clinics. This clinical report is 1 of 2  documents that replace the original American Academy of Pediatrics policy statement and technical report published in 2001. This report addresses background information, including definition, history, epidemiology, diagnostic criteria, early signs, neuropathologic aspects, and etiologic possibilities in autism spectrum disorders. In addition, this report provides an algorithm to help the pediatrician develop a strategy for early identification of children with autism spectrum disorders. The accompanying clinical report addresses the management of children with autism spectrum disorders and follows this report on page 1162 [available at www.pediatrics. org/cgi/content/full/120/5/1162]. Both clinical reports are complemented by the toolkit titled “Autism: Caring for Children With Autism Spectrum Disorders: A Resource Toolkit for Clinicians,” which contains screening and surveillance tools, practical forms, tables, and parent handouts to assist the pediatrician in the identification, evaluation, and management of autism spectrum disorders in children. (11/07, reaffirmed 9/10, 8/14)

http://pediatrics.aappublications.org/content/120/5/1183

IDENTIFICATION AND MANAGEMENT OF EATING DISORDERS IN CHILDREN AND ADOLESCENTS (CLINICAL REPORT) David S. Rosen, MD, MPH, and Committee on Adolescence ABSTRACT. The incidence and prevalence of eating disorders in children and adolescents has increased significantly in recent decades, making it essential for pediatricians to consider these disorders in appropriate clinical settings, to evaluate patients suspected of having these disorders, and to manage (or refer) patients in whom eating disorders are diagnosed. This clinical report includes a discussion of diagnostic criteria and outlines the initial evaluation of the patient with disordered eating. Medical complications of eating disorders may affect any organ system, and careful monitoring for these complications is required. The range of treatment options, including pharmacotherapy, is described in this report. Pediatricians are encouraged to advocate for legislation and policies that ensure appropriate services for patients with eating disorders, including medical care, nutritional intervention, mental health treatment, and care coordination. (11/10)

http://pediatrics.aappublications.org/content/126/6/1240

IDENTIFYING INFANTS AND YOUNG CHILDREN WITH DEVELOPMENTAL DISORDERS IN THE MEDICAL HOME: AN ALGORITHM FOR DEVELOPMENTAL SURVEILLANCE AND SCREENING Council on Children With Disabilities, Section on Developmental and Behavioral Pediatrics, Bright Futures Steering Committee, and Medical Home Initiatives for Children With Special Needs Project Advisory Committee ABSTRACT. Early identification of developmental disorders is critical to the well-being of children and their families. It is an integral function of the primary care medical home and an appropriate responsibility of all pediatric health care professionals. This statement provides an algorithm as a strategy to support health care professionals in developing a pattern and practice for addressing developmental concerns in children from birth through 3 years of age. The authors recommend that developmental surveillance be incorporated at every well-child

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preventive care visit. Any concerns raised during surveillance should be promptly addressed with standardized developmental screening tests. In addition, screening tests should be administered regularly at the 9-, 18-, and 30-month visits. (Because the 30-month visit is not yet a part of the preventive care system and is often not reimbursable by third-party payers at this time, developmental screening can be performed at 24 months of age. In addition, because the frequency of regular pediatric visits decreases after 24  months of age, a pediatrician who expects that his or her patients will have difficulty attending a 30-month visit should conduct screening during the 24-month visit.) The early identification of developmental problems should lead to further developmental and medical evaluation, diagnosis, and treatment, including early developmental intervention. Children diagnosed with developmental disorders should be identified as children with special health care needs, and chronic-condition management should be initiated. Identification of a developmental disorder and its underlying etiology may also drive a range of treatment planning, from medical treatment of the child to family planning for his or her parents. (7/06, reaffirmed 12/09, 8/14)

http://pediatrics.aappublications.org/content/118/1/405

IMMERSION IN WATER DURING LABOR AND DELIVERY (CLINICAL REPORT) Committee on Fetus and Newborn (joint with American College of Obstetricians and Gynecologists Committee on Obstetric Practice) ABSTRACT. Immersion in water has been suggested as a beneficial alternative for labor, delivery, or both and over the past decades has gained popularity in many parts of the world. Immersion in water during the first stage of labor may be associated with decreased pain or use of anesthesia and decreased duration of labor. However, there is no evidence that immersion in water during the first stage of labor otherwise improves perinatal outcomes, and it should not prevent or inhibit other elements of care. The safety and efficacy of immersion in water during the second stage of labor have not been established, and immersion in water during the second stage of labor has not been associated with maternal or fetal benefit. Given these facts and case reports of rare but serious adverse effects in the newborn, the practice of immersion in the second stage of labor (underwater delivery) should be considered an experimental procedure that only should be performed within the context of an appropriately designed clinical trial with informed consent. Facilities that plan to offer immersion in the first stage of labor need to establish rigorous protocols for candidate selection, maintenance and cleaning of tubs and immersion pools, infection control procedures, monitoring of mothers and fetuses at appropriate intervals while immersed, and immediately and safely moving women out of the tubs if maternal or fetal concerns develop. (3/14)

http://pediatrics.aappublications.org/content/133/4/758

IMMUNIZATION FOR STREPTOCOCCUS PNEUMONIAE INFECTIONS IN HIGH-RISK CHILDREN Committee on Infectious Diseases ABSTACT. Routine use of the pneumococcal conjugate vaccines (PCV7 and PCV13), beginning in 2000, has resulted in a dramatic reduction in the incidence of invasive pneumococcal disease (IPD) attributable to serotypes of Streptococcus pneumoniae contained in the vaccines. The Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention and the American Academy of Pediatrics recommend the expanded use of PCV13 in children 6 through 18 years of age with certain conditions that place them at elevated risk of IPD. This statement provides recommendations for the use of PCV13 in children 6 through 18 years. A single dose of PCV13 should be administered to certain children in this age group who are at elevated risk of IPD. Recommendations for the use of

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PCV13 in healthy children and for pneumococcal polysaccharide vaccine (PPSV23) remain unchanged. (11/14)

change in legal status might influence the degree of marijuana use by adolescents in the future. (2/15)

IMMUNIZATION INFORMATION SYSTEMS Committee on Practice and Ambulatory Medicine ABSTRACT. The American Academy of Pediatrics continues to support the development and implementation of immunization information systems, previously referred to as immunization registries, and other systems for the benefit of children, pediatricians, and their communities. Pediatricians and others must be aware of the value that immunization information systems have for society, the potential fiscal influences on their practice, the costs and benefits, and areas for future improvement. (9/06, reaffirmed 10/11)

THE IMPACT OF MARIJUANA POLICIES ON YOUTH: CLINICAL, RESEARCH, AND LEGAL UPDATE (TECHNICAL REPORT) Seth Ammerman, MD, FAAP; Sheryl Ryan, MD, FAAP; William P. Adelman, MD, FAAP; Committee on Substance Abuse; and Committee on Adolescence ABSTRACT. This technical report updates the 2004 American Academy of Pediatrics technical report on the legalization of marijuana. Current epidemiology of marijuana use is presented, as are definitions and biology of marijuana compounds, side effects of marijuana use, and effects of use on adolescent brain development. Issues concerning medical marijuana specifically are also addressed. Concerning legalization of marijuana, 4 different approaches in the United States are discussed: legalization of marijuana solely for medical purposes, decriminalization of recreational use of marijuana, legalization of recreational use of marijuana, and criminal prosecution of recreational (and medical) use of marijuana. These approaches are compared, and the latest available data are presented to aid in forming public policy. The effects on youth of criminal penalties for marijuana use and possession are also addressed, as are the effects or potential effects of the other 3 policy approaches on adolescent marijuana use. Recommendations are included in the accompanying policy statement. (2/15)

http://pediatrics.aappublications.org/content/134/6/1230

http://pediatrics.aappublications.org/content/118/3/1293

IMMUNIZING PARENTS AND OTHER CLOSE FAMILY CONTACTS IN THE PEDIATRIC OFFICE SETTING (TECHNICAL REPORT) Herschel R. Lessin, MD; Kathryn M. Edwards, MD; Committee on Practice and Ambulatory Medicine; and Committee on Infectious Diseases ABSTRACT. Additional strategies are needed to protect children from vaccine-preventable diseases. In particular, very young infants, as well as children who are immunocompromised, are at especially high risk for developing the serious consequences of vaccine-preventable diseases and cannot be immunized completely. There is some evidence that children who become infected with these diseases are exposed to pathogens through household contacts, particularly from parents or other close family contacts. Such infections likely are attributable to adults who are not fully protected from these diseases, either because their immunity to vaccine-preventable diseases has waned over time or because they have not received a vaccine. There are many challenges that have added to low adult immunization rates in the United States. One option to increase immunization coverage for parents and close family contacts of infants and vulnerable children is to provide alternative locations for these adults to be immunized, such as the pediatric office setting. Ideally, adults should receive immunizations in their medical homes; however, to provide greater protection to these adults and reduce the exposure of children to pathogens, immunizing parents or other adult family contacts in the pediatric office setting could increase immunization coverage for this population to protect themselves as well as children to whom they provide care. (12/11, reaffirmed 8/16)

http://pediatrics.aappublications.org/content/129/1/e247

THE IMPACT OF MARIJUANA POLICIES ON YOUTH: CLINICAL, RESEARCH, AND LEGAL UPDATE Committee on Substance Abuse and Committee on Adolescence ABSTRACT. This policy statement is an update of the American Academy of Pediatrics policy statement “Legalization of Marijuana: Potential Impact on Youth,” published in 2004. Pediatricians have special expertise in the care of children and adolescents and may be called on to advise legislators about the potential impact of changes in the legal status of marijuana on adolescents. Parents also may look to pediatricians for advice as they consider whether to support state-level initiatives that propose to legalize the use of marijuana for medical and nonmedical purposes or to decriminalize the possession of small amounts of marijuana. This policy statement provides the position of the American Academy of Pediatrics on the issue of marijuana legalization. The accompanying technical report reviews what is currently known about the relationships of marijuana use with health and the developing brain and the legal status of marijuana and adolescents’ use of marijuana to better understand how

http://pediatrics.aappublications.org/content/135/3/584

http://pediatrics.aappublications.org/content/135/3/e769

THE IMPACT OF SOCIAL MEDIA ON CHILDREN, ADOLESCENTS, AND FAMILIES (CLINICAL REPORT) Gwenn Schurgin O’Keeffe, MD; Kathleen Clarke-Pearson, MD; and Council on Communications and Media ABSTRACT. Using social media Web sites is among the most common activity of today’s children and adolescents. Any Web site that allows social interaction is considered a social media site, including social networking sites such as Facebook, MySpace, and Twitter; gaming sites and virtual worlds such as Club Penguin, Second Life, and the Sims; video sites such as YouTube; and blogs. Such sites offer today’s youth a portal for entertainment and communication and have grown exponentially in recent years. For this reason, it is important that parents become aware of the nature of social media sites, given that not all of them are healthy environments for children and adolescents. Pediatricians are in a unique position to help families understand these sites and to encourage healthy use and urge parents to monitor for potential problems with cyberbullying, “Facebook depression,” sexting, and exposure to inappropriate content. (3/11)

http://pediatrics.aappublications.org/content/127/4/800

THE IMPORTANCE OF PLAY IN PROMOTING HEALTHY CHILD DEVELOPMENT AND MAINTAINING STRONG PARENT-CHILD BOND: FOCUS ON CHILDREN IN POVERTY (CLINICAL REPORT) Regina M. Milteer, MD; Kenneth R. Ginsburg, MD, MSEd; Council on Communications and Media; and Committee on Psychosocial Aspects of Child and Family Health ABSTRACT. Play is essential to the social, emotional, cognitive, and physical well-being of children beginning in early childhood. It is a natural tool for children to develop resiliency as they learn to cooperate, overcome challenges, and negotiate with others. Play also allows children to be creative. It provides time for parents to be fully engaged with their children, to bond with their children, and to see the world from the perspective of their child. However, children who live in poverty often face socioeconomic obstacles that impede their rights to have playtime, thus

POLICY TITLES AND ABSTRACTS

affecting their healthy social-emotional development. For children who are underresourced to reach their highest potential, it is essential that parents, educators, and pediatricians recognize the importance of lifelong benefits that children gain from play. (12/11, reaffirmed 9/15)

http://pediatrics.aappublications.org/content/129/1/e204

INCIDENTAL FINDINGS ON BRAIN AND SPINE IMAGING IN CHILDREN (CLINICAL REPORT) Cormac O. Maher, MD, FAAP; Joseph H. Piatt Jr, MD, FAAP; and Section on Neurologic Surgery ABSTRACT. In recent years, the utilization of diagnostic imaging of the brain and spine in children has increased dramatically, leading to a corresponding increase in the detection of incidental findings of the central nervous system. Patients with unexpected findings on imaging are often referred for subspecialty evaluation. Even with rational use of diagnostic imaging and subspecialty consultation, the diagnostic process will always generate unexpected findings that must be explained and managed. Familiarity with the most common findings that are discovered incidentally on diagnostic imaging of the brain and spine will assist the pediatrician in providing counseling to families and in making recommendations in conjunction with a neurosurgeon, when needed, regarding additional treatments and prognosis. (3/15)

http://pediatrics.aappublications.org/content/135/4/e1084

INCORPORATING RECOGNITION AND MANAGEMENT OF PERINATAL AND POSTPARTUM DEPRESSION INTO PEDIATRIC PRACTICE (CLINICAL REPORT) Marian F. Earls, MD, and Committee on Psychosocial Aspects of Child and Family Health ABSTRACT. Every year, more than 400 000 infants are born to mothers who are depressed, which makes perinatal depression the most underdiagnosed obstetric complication in America. Postpartum depression leads to increased costs of medical care, inappropriate medical care, child abuse and neglect, discontinuation of breastfeeding, and family dysfunction and adversely affects early brain development. Pediatric practices, as medical homes, can establish a system to implement postpartum depression screening and to identify and use community resources for the treatment and referral of the depressed mother and support for the mother-child (dyad) relationship. This system would have a positive effect on the health and well-being of the infant and family. State chapters of the American Academy of Pediatrics, working with state Early Periodic Screening, Diagnosis, and Treatment (EPSDT) and maternal and child health programs, can increase awareness of the need for perinatal depression screening in the obstetric and pediatric periodicity of care schedules and ensure payment. Pediatricians must advocate for workforce development for professionals who care for very young children and for promotion of evidence-based interventions focused on healthy attachment and parent-child relationships. (10/10, reaffirmed 12/14)

http://pediatrics.aappublications.org/content/126/5/1032

INCREASING ANTIRETROVIRAL DRUG ACCESS FOR CHILDREN WITH HIV INFECTION Committee on Pediatric AIDS and Section on International Child Health ABSTRACT. Although there have been great gains in the prevention of pediatric HIV infection and provision of antiretroviral therapy for children with HIV infection in resource-rich countries, many barriers remain to scaling up HIV prevention and treatment for children in resource-limited areas of the world. Appropriate testing technologies need to be made more widely available to identify HIV infection in infants. Training of practitioners in the skills required to care for children with HIV

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infection is required to increase the number of children receiving antiretroviral therapy. Lack of availability of appropriate antiretroviral drug formulations that are easily usable and inexpensive is a major impediment to optimal care for children with HIV. The time and energy spent trying to develop liquid antiretroviral formulations might be better used in the manufacture of smaller pill sizes or crushable tablets, which are easier to dispense, transport, store, and administer to children. (4/07, reaffirmed 4/10, 4/16)

http://pediatrics.aappublications.org/content/119/4/838

INCREASING IMMUNIZATION COVERAGE Committee on Practice and Ambulatory Medicine and Council on Community Pediatrics ABSTRACT. In 1977, the American Academy of Pediatrics issued a statement calling for universal immunization of all children for whom vaccines are not contraindicated. In 1995, the policy statement “Implementation of the Immunization Policy” was published by the American Academy of Pediatrics, followed in 2003 with publication of the first version of this statement, “Increasing Immunization Coverage.” Since 2003, there have continued to be improvements in immunization coverage, with progress toward meeting the goals set forth in Healthy People 2010. Data from the 2007 National Immunization Survey showed that 90% of children 19 to 35 months of age have received recommended doses of each of the following vaccines: inactivated poliovirus (IPV), measles-mumps-rubella (MMR), varicella-zoster virus (VZB), hepatitis B virus (HBV), and Haemophilus influenzae type b (Hib). For diphtheria and tetanus and acellular pertussis (DTaP) vaccine, 84.5% have received the recommended 4 doses by 35 months of age. Nevertheless, the Healthy People 2010 goal of at least 80% coverage for the full series (at least 4 doses of DTaP, 3 doses of IPV, 1 dose of MMR, 3 doses of Hib, 3 doses of HBV, and 1 dose of varicella-zoster virus vaccine) has not yet been met, and immunization coverage of adolescents continues to lag behind the goals set forth in Healthy People 2010. Despite these encouraging data, a vast number of new challenges that threaten continued success toward the goal of universal immunization coverage have emerged. These challenges include an increase in new vaccines and new vaccine combinations as well as a significant number of vaccines currently under development; a dramatic increase in the acquisition cost of vaccines, coupled with a lack of adequate payment to practitioners to buy and administer vaccines; unanticipated manufacturing and delivery problems that have caused significant shortages of various vaccine products; and the rise of a public antivaccination movement that uses the Internet as well as standard media outlets to advance a position, wholly unsupported by any scientific evidence, linking vaccines with various childhood conditions, particularly autism. Much remains to be accomplished by physician organizations; vaccine manufacturers; third-party payers; the media; and local, state, and federal governments to ensure dependable vaccine supply and payments that are sufficient to continue to provide immunizations in public and private settings and to promote effective strategies to combat unjustified misstatements by the antivaccination movement. Pediatricians should work individually and collectively at the local, state, and national levels to ensure that all children without a valid contraindication receive all childhood immunizations on time. Pediatricians and pediatric organizations, in conjunction with government agencies such as the Centers for Disease Control and Prevention, must communicate effectively with parents to maximize their understanding of the overall safety and efficacy of vaccines. Most parents and children have not experienced many of the vaccine-preventable diseases, and the general public is not well informed about the risks and sequelae of these conditions. A number of recommendations are included for pediatricians, individually and collectively, to support further

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progress toward the goal of universal immunization coverage of all children for whom vaccines are not contraindicated. (5/10)

http://pediatrics.aappublications.org/content/125/6/1295

THE INDIVIDUALS WITH DISABILITIES EDUCATION ACT (IDEA) FOR CHILDREN WITH SPECIAL EDUCATIONAL NEEDS (CLINICAL REPORT) Paul H. Lipkin, MD, FAAP; Jeffrey Okamoto, MD, FAAP; Council on Children With Disabilities; and Council on School Health ABSTRACT. The pediatric health care provider has a critical role in supporting the health and well-being of children and adolescents in all settings, including early intervention (EI), preschool, and school environments. It is estimated that 15% of children in the United States have a disability. The Individuals with Disabilities Education Act entitles every affected child in the United States from infancy to young adulthood to a free appropriate public education through EI and special education services. These services bolster development and learning of children with various disabilities. This clinical report provides the pediatric health care provider with a summary of key components of the most recent version of this law. Guidance is also provided to ensure that every child in need receives the EI and special education services to which he or she is entitled. (11/15)

http://pediatrics.aappublications.org/content/136/6/e1650

INDOOR ENVIRONMENTAL CONTROL PRACTICES AND ASTHMA MANAGEMENT (CLINICAL REPORT) Elizabeth C. Matsui, MD, MHS, FAAP; Stuart L. Abramson, MD, PhD, AE-C, FAAP; Megan T. Sandel, MD, MPH, FAAP; Section on Allergy and Immunology; and Council on Environmental Health ABSTRACT. Indoor environmental exposures, particularly allergens and pollutants, are major contributors to asthma morbidity in children; environmental control practices aimed at reducing these exposures are an integral component of asthma management. Some individually tailored environmental control practices that have been shown to reduce asthma symptoms and exacerbations are similar in efficacy and cost to controller medications. As a part of developing tailored strategies regarding environmental control measures, an environmental history can be obtained to evaluate the key indoor environmental exposures that are known to trigger asthma symptoms and exacerbations, including both indoor pollutants and allergens. An environmental history includes questions regarding the presence of pets or pests or evidence of pests in the home, as well as knowledge regarding whether the climatic characteristics in the community favor dust mites. In addition, the history focuses on sources of indoor air pollution, including the presence of smokers who live in the home or care for children and the use of gas stoves and appliances in the home. Serum allergen-specific immunoglobulin E antibody tests can be performed or the patient can be referred for allergy skin testing to identify indoor allergens that are most likely to be clinically relevant. Environmental control strategies are tailored to each potentially relevant indoor exposure and are based on knowledge of the sources and underlying characteristics of the exposure. Strategies include source removal, source control, and mitigation strategies, such as high-efficiency particulate air purifiers and allergen-proof mattress and pillow encasements, as well as education, which can be delivered by primary care pediatricians, allergists, pediatric pulmonologists, other health care workers, or community health workers trained in asthma environmental control and asthma education. (10/16)

http://pediatrics.aappublications.org/content/138/5/e20162589

SECTION 5/CURRENT POLICIES

INFANT FEEDING AND TRANSMISSION OF HUMAN IMMUNODEFICIENCY VIRUS IN THE UNITED STATES Committee on Pediatric AIDS ABSTRACT. Physicians caring for infants born to women infected with HIV are likely to be involved in providing guidance to HIVinfected mothers on appropriate infant feeding practices. It is critical that physicians are aware of the HIV transmission risk from human milk and the current recommendations for feeding HIV-exposed infants in the United States. Because the only intervention to completely prevent HIV transmission via human milk is not to breastfeed, in the United States, where clean water and affordable replacement feeding are available, the American Academy of Pediatrics recommends that HIV-infected mothers not breastfeed their infants, regardless of maternal viral load and antiretroviral therapy. (1/13, reaffirmed 4/16)

http://pediatrics.aappublications.org/content/131/2/391

INFANT METHEMOGLOBINEMIA: THE ROLE OF DIETARY NITRATE IN FOOD AND WATER (CLINICAL REPORT) Frank R. Greer, MD; Michael Shannon, MD; Committee on Nutrition; and Committee on Environmental Health ABSTRACT. Infants for whom formula may be prepared with well water remain a high-risk group for nitrate poisoning. This clinical report reinforces the need for testing of well water for nitrate content. There seems to be little or no risk of nitrate poisoning from commercially prepared infant foods in the United States. However, reports of nitrate poisoning from home-prepared vegetable foods for infants continue to occur. Breastfeeding infants are not at risk of methemoglobinemia even when mothers ingest water with very high concentrations of nitrate nitrogen (100 ppm). (9/05, reaffirmed 4/09)

http://pediatrics.aappublications.org/content/116/3/784

INFECTION PREVENTION AND CONTROL IN PEDIATRIC AMBULATORY SETTINGS Mobeen H. Rathore, MD, FAAP; Mary Anne Jackson, MD, FAAP; and Committee on Infectious Diseases ABSTRACT. Since the American Academy of Pediatrics published its statement titled “Infection Prevention and Control in Pediatric Ambulatory Settings” in 2007, there have been significant changes that prompted this updated statement. Infection prevention and control is an integral part of pediatric practice in ambulatory medical settings as well as in hospitals. Infection prevention and control practices should begin at the time the ambulatory visit is scheduled. All health care personnel should be educated regarding the routes of transmission and techniques used to prevent the transmission of infectious agents. Policies for infection prevention and control should be written, readily available, updated every 2 years, and enforced. Many of the recommendations for infection control and prevention from the Centers for Disease Control and Prevention for hospitalized patients are also applicable in the ambulatory setting. These recommendations include requirements for pediatricians to take precautions to identify and protect employees likely to be exposed to blood or other potentially infectious materials while on the job. In addition to emphasizing the key principles of infection prevention and control in this policy, we update those that are relevant to the ambulatory care patient. These guidelines emphasize the role of hand hygiene and the implementation of diagnosis- and syndrome-specific isolation precautions, with the exemption of the use of gloves for routine diaper changes and wiping a well child’s nose or tears for most patient encounters. Additional topics include respiratory hygiene and cough etiquette strategies for patients with a respiratory tract infection, including those relevant for special populations like patients

POLICY TITLES AND ABSTRACTS

with cystic fibrosis or those in short-term residential facilities; separation of infected, contagious children from uninfected children when feasible; safe handling and disposal of needles and other sharp medical devices; appropriate use of personal protective equipment, such as gloves, gowns, masks, and eye protection; and appropriate use of sterilization, disinfection, and antisepsis. Lastly, in this policy, we emphasize the importance of public health interventions, including vaccination for patients and health care personnel, and outline the responsibilities of the health care provider related to prompt public health notification for specific reportable diseases and communication with colleagues who may be providing subsequent care of an infected patient to optimize the use of isolation precautions and limit the spread of contagions. (10/17) See full text on page 835.

http://pediatrics.aappublications.org/content/140/5/e20172857

INFECTIOUS COMPLICATIONS WITH THE USE OF BIOLOGIC RESPONSE MODIFIERS IN INFANTS AND CHILDREN (CLINICAL REPORT) H. Dele Davies, MD, FAAP, and Committee on Infectious Diseases ABSTRACT. Biologic response modifiers (BRMs) are substances that interact with and modify the host immune system. BRMs that dampen the immune system are used to treat conditions such as juvenile idiopathic arthritis, psoriatic arthritis, or inflammatory bowel disease and often in combination with other immunosuppressive agents, such as methotrexate and corticosteroids. Cytokines that are targeted include tumor necrosis factor á; interleukins (ILs) 6, 12, and 23; and the receptors for IL-1α(IL-1A) and IL-1β (IL-1B) as well as other molecules. Although the risk varies with the class of BRM, patients receiving immune-dampening BRMs generally are at increased risk of infection or reactivation with mycobacterial infections (Mycobacterium tuberculosis and nontuberculous mycobacteria), some viral (herpes simplex virus, varicella-zoster virus, Epstein-Barr virus, hepatitis B) and fungal (histoplasmosis, coccidioidomycosis) infections, as well as other opportunistic infections. The use of BRMs warrants careful determination of infectious risk on the basis of history (including exposure, residence, and travel and immunization history) and selected baseline screening test results. Routine immunizations should be given at least 2 weeks (inactivated or subunit vaccines) or 4 weeks (live vaccines) before initiation of BRMs whenever feasible, and inactivated influenza vaccine should be given annually. Inactivated and subunit vaccines should be given when needed while taking BRMs, but live vaccines should be avoided unless under special circumstances in consultation with an infectious diseases specialist. If the patient develops a febrile or serious respiratory illness during BRM therapy, consideration should be given to stopping the BRM while actively searching for and treating possible infectious causes. (7/16)

http://pediatrics.aappublications.org/content/138/2/e20161209

INFECTIOUS DISEASES ASSOCIATED WITH ORGANIZED SPORTS AND OUTBREAK CONTROL (CLINICAL REPORT) H. Dele Davies, MD, MS, MHCM, FAAP; Mary Anne Jackson, MD, FAAP; Stephen G. Rice, MD, PhD, MPH, FAAP; Committee on Infectious Diseases; and Council on Sports Medicine and Fitness ABSTRACT. Participation in organized sports has a variety of health benefits but also has the potential to expose the athlete to a variety of infectious diseases, some of which may produce outbreaks. Major risk factors for infection include skin-to-skin contact with athletes who have active skin infections, environmental exposures and physical trauma, and sharing of equipment and contact with contaminated fomites. Close contact that is intrinsic to team sports and psychosocial factors associated with adolescence are additional risks. Minimizing risk requires leadership by the organized sports community (including the athlete’s

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primary care provider) and depends on outlining key hygiene behaviors, recognition, diagnosis, and treatment of common sports-related infections, and the implementation of preventive interventions. (9/17) See full text on page 861.

http://pediatrics.aappublications.org/content/140/4/e20172477

INFLUENZA IMMUNIZATION FOR ALL HEALTH CARE PERSONNEL: KEEP IT MANDATORY Committee on Infectious Diseases ABSTRACT. The purpose of this statement is to reaffirm the American Academy of Pediatrics’ support for a mandatory influenza immunization policy for all health care personnel. With an increasing number of organizations requiring influenza vaccination, coverage among health care personnel has risen to 75% in the 2013 to 2014 influenza season but still remains below the Healthy People 2020 objective of 90%. Mandatory influenza immunization for all health care personnel is ethical, just, and necessary to improve patient safety. It is a crucial step in efforts to reduce health care–associated influenza infections. (9/15)

http://pediatrics.aappublications.org/content/136/4/809

INFORMED CONSENT IN DECISION-MAKING IN PEDIATRIC PRACTICE Committee on Bioethics ABSTRACT. Informed consent should be seen as an essential part of health care practice; parental permission and childhood assent is an active process that engages patients, both adults and children, in health care. Pediatric practice is unique in that developmental maturation allows, over time, for increasing inclusion of the child’s and adolescent’s opinion in medical decisionmaking in clinical practice and research. (7/16)

http://pediatrics.aappublications.org/content/138/2/e20161484

INFORMED CONSENT IN DECISION-MAKING IN PEDIATRIC PRACTICE (TECHNICAL REPORT) Aviva L. Katz, MD, FAAP; Sally A. Webb, MD, FAAP; and Committee on Bioethics ABSTRACT. Informed consent should be seen as an essential part of health care practice; parental permission and childhood assent is an active process that engages patients, both adults and children, in their health care. Pediatric practice is unique in that developmental maturation allows, over time, for increasing inclusion of the child’s and adolescent’s opinion in medical decision-making in clinical practice and research. This technical report, which accompanies the policy statement “Informed Consent in Decision-Making in Pediatric Practice,” was written to provide a broader background on the nature of informed consent, surrogate decision-making in pediatric practice, information on child and adolescent decision-making, and special issues in adolescent informed consent, assent, and refusal. It is anticipated that this information will help provide support for the recommendations included in the policy statement. (7/16)

http://pediatrics.aappublications.org/content/138/2/e20161485

INJURIES ASSOCIATED WITH INFANT WALKERS Committee on Injury and Poison Prevention ABSTRACT. In 1999, an estimated 8800 children younger than 15 months were treated in hospital emergency departments in the United States for injuries associated with infant walkers. Thirty-four infant walker-related deaths were reported from 1973 through 1998. The vast majority of injuries occur from falls down stairs, and head injuries are common. Walkers do not help a child learn to walk; indeed, they can delay normal motor and mental development. The use of warning labels, public education, adult supervision during walker use, and stair gates have all been demonstrated to be insufficient strategies to prevent injuries associated with infant walkers. To comply with the

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revised voluntary standard (ASTM F977-96), walkers manufactured after June 30, 1997, must be wider than a 36-in doorway or must have a braking mechanism designed to stop the walker if 1 or more wheels drop off the riding surface, such as at the top of a stairway. Because data indicate a considerable risk of major and minor injury and even death from the use of infant walkers, and because there is no clear benefit from their use, the American Academy of Pediatrics recommends a ban on the manufacture and sale of mobile infant walkers. If a parent insists on using a mobile infant walker, it is vital that they choose a walker that meets the performance standards of ASTM F977-96 to prevent falls down stairs. Stationary activity centers should be promoted as a safer alternative to mobile infant walkers. (9/01, reaffirmed 1/05, 2/08, 10/11, 11/14)

http://pediatrics.aappublications.org/content/108/3/790

INJURIES IN YOUTH SOCCER (CLINICAL REPORT) Chris G. Koutures, MD; Andrew J. M. Gregory, MD; and Council on Sports Medicine and Fitness ABSTRACT. Injury rates in youth soccer, known as football outside the United States, are higher than in many other contact/ collision sports and have greater relative numbers in younger, preadolescent players. With regard to musculoskeletal injuries, young females tend to suffer more knee injuries, and young males suffer more ankle injuries. Concussions are fairly prevalent in soccer as a result of contact/collision rather than purposeful attempts at heading the ball. Appropriate rule enforcement and emphasis on safe play can reduce the risk of soccer-related injuries. This report serves as a basis for encouraging safe participation in soccer for children and adolescents. (1/10, reaffirmed 5/13, 4/17)

http://pediatrics.aappublications.org/content/125/2/410

INJURY RISK OF NONPOWDER GUNS (TECHNICAL REPORT) Committee on Injury, Violence, and Poison Prevention ABSTRACT. Nonpowder guns (ball-bearing [BB] guns, pellet guns, air rifles, paintball guns) continue to cause serious injuries to children and adolescents. The muzzle velocity of these guns can range from approximately 150 ft/second to 1200 ft/second (the muzzle velocities of traditional firearm pistols are 750 ft/ second to 1450 ft/second). Both low- and high-velocity nonpowder guns are associated with serious injuries, and fatalities can result from high-velocity guns. A persisting problem is the lack of medical recognition of the severity of injuries that can result from these guns, including penetration of the eye, skin, internal organs, and bone. Nationally, in 2000, there were an estimated 21840 (coefficient of variation: 0.0821) injuries related to nonpowder guns, with approximately 4% resulting in hospitalization. Between 1990 and 2000, the US Consumer Product Safety Commission reported 39 nonpowder gun–related deaths, of which 32 were children younger than 15 years. The introduction of high-powered air rifles in the 1970s has been associated with approximately 4 deaths per year. The advent of war games and the use of paintball guns have resulted in a number of reports of injuries, especially to the eye. Injuries associated with nonpowder guns should receive prompt medical management similar to the management of firearm-related injuries, and nonpowder guns should never be characterized as toys. (11/04, reaffirmed 2/08, 10/11)

http://pediatrics.aappublications.org/content/114/5/1357

SECTION 5/CURRENT POLICIES

IN-LINE SKATING INJURIES IN CHILDREN AND ADOLESCENTS Committee on Injury and Poison Prevention and Committee on Sports Medicine and Fitness ABSTRACT. In-line skating has become one of the fastestgrowing recreational sports in the United States. Recent studies emphasize the value of protective gear in reducing the incidence of injuries. Recommendations are provided for parents and pediatricians, with special emphasis on the novice or inexperienced skater. (4/98, reaffirmed 1/02, 1/06, 1/09, 11/11)

http://pediatrics.aappublications.org/content/101/4/720

INSTITUTIONAL ETHICS COMMITTEES Committee on Bioethics ABSTRACT. In hospitals throughout the United States, institutional ethics committees (IECs) have become a standard vehicle for the education of health professionals about biomedical ethics, for the drafting and review of hospital policy, and for clinical ethics case consultation. In addition, there is increasing interest in a role for the IEC in organizational ethics. Recommendations are made about the membership and structure of an IEC, and guidelines are provided for those serving on an ethics committee. (1/01, reaffirmed 1/04, 1/09, 10/12, 7/14)

http://pediatrics.aappublications.org/content/107/1/205

INSTRUMENT-BASED PEDIATRIC VISION SCREENING POLICY STATEMENT Section on Ophthalmology and Committee on Practice and Ambulatory Medicine (joint with American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, and American Association of Certified Orthoptists) ABSTRACT. A policy statement describing the use of automated vision screening technology (instrument-based vision screening) is presented. Screening for amblyogenic refractive error with instrument-based screening is not dependent on behavioral responses of children, as when visual acuity is measured. Instrument-based screening is quick, requires minimal cooperation of the child, and is especially useful in the preverbal, preliterate, or developmentally delayed child. Children younger than 4 years can benefit from instrument-based screening, and visual acuity testing can be used reliably in older children. Adoption of this new technology is highly dependent on third-party payment policies, which could present a significant barrier to adoption. (10/12)

http://pediatrics.aappublications.org/content/130/5/983

INSUFFICIENT SLEEP IN ADOLESCENTS AND YOUNG ADULTS: AN UPDATE ON CAUSES AND CONSEQUENCES (TECHNICAL REPORT) Judith Owens, MD, MPH, FAAP; Adolescent Sleep Working Group; and Committee on Adolescence ABSTRACT. Chronic sleep loss and associated sleepiness and daytime impairments in adolescence are a serious threat to the academic success, health, and safety of our nation’s youth and an important public health issue. Understanding the extent and potential short- and long-term repercussions of sleep restriction, as well as the unhealthy sleep practices and environmental factors that contribute to sleep loss in adolescents, is key in setting public policies to mitigate these effects and in counseling patients and families in the clinical setting. This report reviews the current literature on sleep patterns in adolescents, factors contributing to chronic sleep loss (ie, electronic media use, caffeine consumption), and health-related consequences, such as depression, increased obesity risk, and higher rates of drowsy

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driving accidents. The report also discusses the potential role of later school start times as a means of reducing adolescent sleepiness. (8/14)

http://pediatrics.aappublications.org/content/134/3/e921 INSURANCE COVERAGE OF MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES FOR CHILDREN AND ADOLESCENTS: A CONSENSUS STATEMENT American Academy of Pediatrics and Others (10/00)

http://pediatrics.aappublications.org/content/106/4/860 INTENSIVE TRAINING AND SPORTS SPECIALIZATION IN YOUNG ATHLETES Committee on Sports Medicine and Fitness ABSTRACT. Children involved in sports should be encouraged to participate in a variety of different activities and develop a wide range of skills. Young athletes who specialize in just one sport may be denied the benefits of varied activity while facing additional physical, physiologic, and psychologic demands from intense training and competition. This statement reviews the potential risks of high-intensity training and sports specialization in young athletes. Pediatricians who recognize these risks can have a key role in monitoring the health of these young athletes and helping reduce risks associated with high-level sports participation. (7/00, reaffirmed 11/04, 1/06, 5/09, 10/14)

http://pediatrics.aappublications.org/content/106/1/154

INTERFERON-γ RELEASE ASSAYS FOR DIAGNOSIS OF TUBERCULOSIS INFECTION AND DISEASE IN CHILDREN (TECHNICAL REPORT) Jeffrey R. Starke, MD, FAAP, and Committee on Infectious Diseases ABSTRACT. Tuberculosis (TB) remains an important problem among children in the United States and throughout the world. Although diagnosis and treatment of infection with Mycobacterium tuberculosis (also referred to as latent tuberculosis infection [LTBI] or TB infection) remain the lynchpins of TB prevention, there is no diagnostic reference standard for LTBI. The tuberculin skin test (TST) has many limitations, including difficulty in administration and interpretation, the need for a return visit by the patient, and false-positive results caused by significant cross-reaction with Mycobacterium bovis–bacille CalmetteGuérin (BCG) vaccines and many nontuberculous mycobacteria. Interferon-g release assays (IGRAs) are blood tests that measure ex vivo T-lymphocyte release of interferon-g after stimulation by antigens specific for M  tuberculosis. Because these antigens are not found on M bovis–BCG or most nontuberculous mycobacteria, IGRAs are more specific tests than the TST, yielding fewer false-positive results. However, IGRAs have little advantage over the TST in sensitivity, and both methods have reduced sensitivity in immunocompromised children, including children with severe TB disease. Both methods have a higher positive predictive value when applied to children with risk factors for LTBI. Unfortunately, neither method distinguishes between TB infection and TB disease. The objective of this technical report is to review what IGRAs are most useful for: (1) increasing test specificity in children who have received a BCG vaccine and may have a false-positive TST result; (2) using with the TST to increase sensitivity for finding LTBI in patients at high risk of developing progression from LTBI to disease; and (3) helping to diagnose TB disease. (11/14)

http://pediatrics.aappublications.org/content/134/6/e1763

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INTIMATE PARTNER VIOLENCE: THE ROLE OF THE PEDIATRICIAN (CLINICAL REPORT) Jonathan D. Thackeray, MD; Roberta Hibbard, MD; M. Denise Dowd, MD, MPH; Committee on Child Abuse and Neglect; and Committee on Injury, Violence, and Poison Prevention ABSTRACT. The American Academy of Pediatrics and its members recognize the importance of improving the physician’s ability to recognize intimate partner violence (IPV) and understand its effects on child health and development and its role in the continuum of family violence. Pediatricians are in a unique position to identify abused caregivers in pediatric settings and to evaluate and treat children raised in homes in which IPV may occur. Children exposed to IPV are at increased risk of being abused and neglected and are more likely to develop adverse health, behavioral, psychological, and social disorders later in life. Identifying IPV, therefore, may be one of the most effective means of preventing child abuse and identifying caregivers and children who may be in need of treatment and/or therapy. Pediatricians should be aware of the profound effects of exposure to IPV on children. (4/10, reaffirmed 1/14)

http://pediatrics.aappublications.org/content/125/5/1094

IODINE DEFICIENCY, POLLUTANT CHEMICALS, AND THE THYROID: NEW INFORMATION ON AN OLD PROBLEM Council on Environmental Health ABSTRACT. Many women of reproductive age in the United States are marginally iodine deficient, perhaps because the salt in processed foods is not iodized. Iodine deficiency, per se, can interfere with normal brain development in their offspring; in addition, it increases vulnerability to the effects of certain environmental pollutants, such as nitrate, thiocyanate, and perchlorate. Although pregnant and lactating women should take a supplement containing adequate iodide, only about 15% do so. Such supplements, however, may not contain enough iodide and may not be labeled accurately. The American Thyroid Association recommends that pregnant and lactating women take a supplement with adequate iodide. The American Academy of Pediatrics recommends that pregnant and lactating women also avoid exposure to excess nitrate, which would usually occur from contaminated well water, and thiocyanate, which is in cigarette smoke. Perchlorate is currently a candidate for regulation as a water pollutant. The Environmental Protection Agency should proceed with appropriate regulation, and the Food and Drug Administration should address the mislabeling of the iodine content of prenatal/lactation supplements. (5/14)

http://pediatrics.aappublications.org/content/133/6/1163

LACTOSE INTOLERANCE IN INFANTS, CHILDREN, AND ADOLESCENTS (CLINICAL REPORT) Melvin B. Heyman, MD, MPH, for Committee on Nutrition ABSTRACT. The American Academy of Pediatrics Committee on Nutrition presents an updated review of lactose intolerance in infants, children, and adolescents. Differences between primary, secondary, congenital, and developmental lactase deficiency that may result in lactose intolerance are discussed. Children with suspected lactose intolerance can be assessed clinically by dietary lactose elimination or by tests including noninvasive hydrogen breath testing or invasive intestinal biopsy determination of lactase (and other disaccharidase) concentrations. Treatment consists of use of lactase-treated dairy products or oral lactase supplementation, limitation of lactose-containing foods, or dairy elimination. The American Academy of Pediatrics supports use of dairy foods as an important source of calcium for bone mineral health and of other nutrients that facilitate growth in children and adolescents. If dairy products are eliminated, other dietary sources of calcium or calcium supplements need to be provided. (9/06, reaffirmed 8/12)

http://pediatrics.aappublications.org/content/118/3/1279

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“LATE-PRETERM” INFANTS: A POPULATION AT RISK (CLINICAL REPORT) William A. Engle, MD; Kay M. Tomashek, MD; Carol Wallman, MSN; and Committee on Fetus and Newborn ABSTRACT. Late-preterm infants, defined by birth at 340⁄7 through 366⁄7 weeks’ gestation, are less physiologically and metabolically mature than term infants. Thus, they are at higher risk of morbidity and mortality than term infants. The purpose of this report is to define “late preterm,” recommend a change in terminology from “near term” to “late preterm,” present the characteristics of late-preterm infants that predispose them to a higher risk of morbidity and mortality than term infants, and propose guidelines for the evaluation and management of these infants after birth. (12/07, reaffirmed 5/10)

http://pediatrics.aappublications.org/content/120/6/1390

LAWN MOWER-RELATED INJURIES TO CHILDREN Committee on Injury and Poison Prevention ABSTRACT. Lawn mower-related injuries to children are relatively common and can result in severe injury or death. Many amputations during childhood are caused by power mowers. Pediatricians have an important role as advocates and educators to promote the prevention of these injuries. (6/01, reaffirmed 10/04, 5/07, 6/10)

http://pediatrics.aappublications.org/content/107/6/1480

LAWN MOWER-RELATED INJURIES TO CHILDREN (TECHNICAL REPORT) Committee on Injury and Poison Prevention ABSTRACT. In the United States, approximately 9400  children younger than 18 years receive emergency treatment annually for lawn mower-related injuries. More than 7% of these children require hospitalization, and power mowers cause a large proportion of the amputations during childhood. Prevention of lawn mower-related injuries can be achieved by design changes of lawn mowers, guidelines for mower operation, and education of parents, child caregivers, and children. Pediatricians have an important role as advocates and educators to promote the prevention of these injuries. (6/01, reaffirmed 10/04, 5/07, 6/10)

http://pediatrics.aappublications.org/content/107/6/e106

LEARNING DISABILITIES, DYSLEXIA, AND VISION Section on Ophthalmology and Council on Children With Disabilities (joint with American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, and American Association of Certified Orthoptists) ABSTRACT. Learning disabilities, including reading disabilities, are commonly diagnosed in children. Their etiologies are multifactorial, reflecting genetic influences and dysfunction of brain systems. Learning disabilities are complex problems that require complex solutions. Early recognition and referral to qualified educational professionals for evidence-based evaluations and treatments seem necessary to achieve the best possible outcome. Most experts believe that dyslexia is a language-based disorder. Vision problems can interfere with the process of learning; however, vision problems are not the cause of primary dyslexia or learning disabilities. Scientific evidence does not support the efficacy of eye exercises, behavioral vision therapy, or special tinted filters or lenses for improving the long-term educational performance in these complex pediatric neurocognitive conditions. Diagnostic and treatment approaches that lack scientific evidence of efficacy, including eye exercises, behavioral vision therapy, or special tinted filters or lenses, are not endorsed and should not be recommended. (7/09, reaffirmed 7/14)

http://pediatrics.aappublications.org/content/127/3/e818

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LEARNING DISABILITIES, DYSLEXIA, AND VISION (TECHNICAL REPORT) Sheryl M. Handler, MD; Walter M. Fierson, MD; and Section on Ophthalmology and Council on Children With Disabilities (joint with American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, and American Association of Certified Orthoptists) ABSTRACT. Learning disabilities constitute a diverse group of disorders in which children who generally possess at least average intelligence have problems processing information or generating output. Their etiologies are multifactorial and reflect genetic influences and dysfunction of brain systems. Reading disability, or dyslexia, is the most common learning disability. It is a receptive language-based learning disability that is characterized by difficulties with decoding, fluent word recognition, rapid automatic naming, and/or reading-comprehension skills. These difficulties typically result from a deficit in the phonologic component of language that makes it difficult to use the alphabetic code to decode the written word. Early recognition and referral to qualified professionals for evidence-based evaluations and treatments are necessary to achieve the best possible outcome. Because dyslexia is a language-based disorder, treatment should be directed at this etiology. Remedial programs should include specific instruction in decoding, fluency training, vocabulary, and comprehension. Most programs include daily intensive individualized instruction that explicitly teaches phonemic awareness and the application of phonics. Vision problems can interfere with the process of reading, but children with dyslexia or related learning disabilities have the same visual function and ocular health as children without such conditions. Currently, there is inadequate scientific evidence to support the view that subtle eye or visual problems cause or increase the  severity of learning disabilities. Because they are difficult for the public to understand and for educators to treat, learning disabilities have spawned a wide variety of scientifically unsupported vision-based diagnostic and treatment procedures. Scientific evidence does not support the claims that visual training, muscle exercises, ocular pursuit-and-tracking exercises, behavioral/perceptual vision therapy, “training” glasses, prisms, and colored lenses and filters are effective direct or indirect treatments for learning disabilities. There is no valid evidence that children who participate in vision therapy are more responsive to educational instruction than children who do not participate. (3/11)

http://pediatrics.aappublications.org/content/127/3/e818

LEVELS OF NEONATAL CARE Committee on Fetus and Newborn ABSTRACT. Provision of risk-appropriate care for newborn infants and mothers was first proposed in 1976. This updated policy statement provides a review of data supporting evidence for a tiered provision of care and reaffirms the need for uniform, nationally applicable definitions and consistent standards of service for public health to improve neonatal outcomes. Facilities that provide hospital care for newborn infants should be classified on the basis of functional capabilities, and these facilities should be organized within a regionalized system of perinatal care. (8/12, reaffirmed 9/15)

http://pediatrics.aappublications.org/content/130/3/587

THE LIFELONG EFFECTS OF EARLY CHILDHOOD ADVERSITY AND TOXIC STRESS (TECHNICAL REPORT) Jack P. Shonkoff, MD; Andrew S. Garner, MD, PhD; Committee on Psychosocial Aspects of Child and Family Health; Committee on Early Childhood, Adoption, and Dependent Care; and Section on Developmental and Behavioral Pediatrics ABSTRACT. Advances in fields of inquiry as diverse as neuroscience, molecular biology, genomics, developmental ­psychology,

POLICY TITLES AND ABSTRACTS

epidemiology, sociology, and economics are catalyzing an important paradigm shift in our understanding of health and disease across the lifespan. This converging, multidisciplinary science of human development has profound implications for our ability to enhance the life prospects of children and to strengthen the social and economic fabric of society. Drawing on these multiple streams of investigation, this report presents an ecobiodevelopmental framework that illustrates how early experiences and environmental influences can leave a lasting signature on the genetic predispositions that affect emerging brain architecture and long-term health. The report also examines extensive evidence of the disruptive impacts of toxic stress, offering intriguing insights into causal mechanisms that link early adversity to later impairments in learning, behavior, and both physical and mental well-being. The implications of this framework for the practice of medicine, in general, and pediatrics, specifically, are potentially transformational. They suggest that many adult diseases should be viewed as developmental disorders that begin early in life and that persistent health disparities associated with poverty, discrimination, or maltreatment could be reduced by the alleviation of toxic stress in childhood. An ecobiodevelopmental framework also underscores the need for new thinking about the focus and boundaries of pediatric practice. It calls for pediatricians to serve as both front-line guardians of healthy child development and strategically positioned, community leaders to inform new science-based strategies that build strong foundations for educational achievement, economic productivity, responsible citizenship, and lifelong health. (12/11, reaffirmed 7/16)

http://pediatrics.aappublications.org/content/129/1/e232

LITERACY PROMOTION: AN ESSENTIAL COMPONENT OF PRIMARY CARE PEDIATRIC PRACTICE Council on Early Childhood ABSTRACT. Reading regularly with young children stimulates optimal patterns of brain development and strengthens parentchild relationships at a critical time in child development, which, in turn, builds language, literacy, and social-emotional skills that last a lifetime. Pediatric providers have a unique opportunity to encourage parents to engage in this important and enjoyable activity with their children beginning in infancy. Research has revealed that parents listen and children learn as a result of literacy promotion by pediatricians, which provides a practical and evidence-based opportunity to support early brain development in primary care practice. The American Academy of Pediatrics (AAP) recommends that pediatric providers promote early literacy development for children beginning in infancy and continuing at least until the age of kindergarten entry by (1) advising all parents that reading aloud with young children can enhance parent-child relationships and prepare young minds to learn language and early literacy skills; (2) counseling all parents about developmentally appropriate shared-reading activities that are enjoyable for children and their parents and offer language-rich exposure to books, pictures, and the written word; (3) providing developmentally appropriate books given at health supervision visits for all high-risk, low-income young children; (4) using a robust spectrum of options to support and promote these efforts; and (5) partnering with other child advocates to influence national messaging and policies that support and promote these key early shared-reading experiences. The AAP supports federal and state funding for children’s books to be provided at pediatric health supervision visits to children at high risk living at or near the poverty threshold and the integration of literacy promotion, an essential component of pediatric primary care, into pediatric resident education. This policy statement is supported by the AAP technical report “School Readiness” and supports the AAP

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policy statement “Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science Into Lifelong Health.” (7/14)

http://pediatrics.aappublications.org/content/134/2/404

LONG-TERM FOLLOW-UP CARE FOR PEDIATRIC CANCER SURVIVORS (CLINICAL REPORT) Section on Hematology/Oncology (joint with Children’s Oncology Group) ABSTRACT. Progress in therapy has made survival into adulthood a reality for most children, adolescents, and young adults diagnosed with cancer today. Notably, this growing population remains vulnerable to a variety of long-term therapy-related sequelae. Systematic ongoing follow-up of these patients, therefore, is important for providing for early detection of and intervention for potentially serious late-onset complications. In addition, health counseling and promotion of healthy lifestyles are important aspects of long-term follow-up care to promote risk reduction for health problems that commonly present during adulthood. Both general and subspecialty pediatric health care providers are playing an increasingly important role in the ongoing care of childhood cancer survivors, beyond the routine preventive care, health supervision, and anticipatory guidance provided to all patients. This report is based on the guidelines that have been developed by the Children’s Oncology Group to facilitate comprehensive long-term follow-up of childhood cancer survivors (www.survivorshipguidelines.org). (3/09, reaffirmed 4/13)

http://pediatrics.aappublications.org/content/123/3/906

MAINTAINING AND IMPROVING THE ORAL HEALTH OF YOUNG CHILDREN Section on Oral Health ABSTRACT. Oral health is an integral part of the overall health of children. Dental caries is a common and chronic disease process with significant short- and long-term consequences. The prevalence of dental caries for the youngest of children has not decreased over the past decade, despite improvements for older children. As health care professionals responsible for the overall health of children, pediatricians frequently confront morbidity associated with dental caries. Because the youngest children visit the pediatrician more often than they visit the dentist, it is important that pediatricians be knowledgeable about the disease process of dental caries, prevention of the disease, and interventions available to the pediatrician and the family to maintain and restore health. (11/14)

http://pediatrics.aappublications.org/content/134/6/1224

MALE ADOLESCENT SEXUAL AND REPRODUCTIVE HEALTH CARE (CLINICAL REPORT) Arik V. Marcell, MD, MPH; Charles Wibbelsman, MD; Warren M. Seigel, MD; and Committee on Adolescence ABSTRACT. Male adolescents’ sexual and reproductive health needs often go unmet in the primary care setting. This report discusses specific issues related to male adolescents’ sexual and reproductive health care in the context of primary care, including pubertal and sexual development, sexual behavior, consequences of sexual behavior, and methods of preventing sexually transmitted infections (including HIV) and pregnancy. Pediatricians are encouraged to address male adolescent sexual and reproductive health on a regular basis, including taking a sexual history, performing an appropriate examination, providing patient-centered and age-appropriate anticipatory guidance, and delivering appropriate vaccinations. Pediatricians should provide these services to male adolescent patients in a confidential and culturally appropriate manner, promote healthy sexual relationships and responsibility, and involve parents in

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age-appropriate discussions about sexual health with their sons. (11/11)

http://pediatrics.aappublications.org/content/128/6/e1658

MALE CIRCUMCISION (TECHNICAL REPORT) Task Force on Circumcision ABSTRACT. Male circumcision consists of the surgical removal of some, or all, of the foreskin (or prepuce) from the penis. It is one of the most common procedures in the world. In the United States, the procedure is commonly performed during the newborn period. In 2007, the American Academy of Pediatrics (AAP) convened a multidisciplinary workgroup of AAP members and other stakeholders to evaluate the evidence regarding male circumcision and update the AAP’s 1999 recommendations in this area. The Task Force included AAP representatives from specialty areas as well as members of the AAP Board of Directors and liaisons representing the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, and the Centers for Disease Control and Prevention. The Task Force members identified selected topics relevant to male circumcision and conducted a critical review of peer-reviewed literature by using the American Heart Association’s template for evidence evaluation. Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks; furthermore, the benefits of newborn male circumcision justify access to this procedure for families who choose it. Specific benefits from male circumcision were identified for the prevention of urinary tract infections, acquisition of HIV, transmission of some sexually transmitted infections, and penile cancer. Male circumcision does not appear to adversely affect penile sexual function/sensitivity or sexual satisfaction. It is imperative that those providing circumcision are adequately trained and that both sterile techniques and effective pain management are used. Significant acute complications are rare. In general, untrained providers who perform circumcisions have more complications than well-trained providers who perform the procedure, regardless of whether the former are physicians, nurses, or traditional religious providers. Parents are entitled to factually correct, nonbiased information about circumcision and should receive this information from clinicians before conception or early in pregnancy, which is when parents typically make circumcision decisions. Parents should determine what is in the best interest of their child. Physicians who counsel families about this decision should provide assistance by explaining the potential benefits and risks and ensuring that parents understand that circumcision is an elective procedure. The Task Force strongly recommends the creation, revision, and enhancement of educational materials to assist parents of male infants with the care of circumcised and uncircumcised penises. The Task Force also strongly recommends the development of educational materials for providers to enhance practitioners’ competency in discussing circumcision’s benefits and risks with parents. The Task Force made the following recommendations: • Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks, and the benefits of newborn male circumcision justify access to this procedure for those families who choose it. • Parents are entitled to factually correct, nonbiased information about circumcision that should be provided before conception and early in pregnancy, when parents are most likely to be weighing the option of circumcision of a male child. • Physicians counseling families about elective male circumcision should assist parents by explaining, in a nonbiased manner, the potential benefits and risks and by ensuring that they understand the elective nature of the procedure.

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• Parents should weigh the health benefits and risks in light of their own religious, cultural, and personal preferences, as the medical benefits alone may not outweigh these other considerations for individual families. • Parents of newborn boys should be instructed in the care of the penis, regardless of whether the newborn has been circumcised or not. • Elective circumcision should be performed only if the infant’s condition is stable and healthy. • Male circumcision should be performed by trained and competent practitioners, by using sterile techniques and effective pain management. • Analgesia is safe and effective in reducing the procedural pain associated with newborn circumcision; thus, adequate analgesia should be provided whenever newborn circumcision is performed. —— Nonpharmacologic techniques (eg, positioning, sucrose pacifiers) alone are insufficient to prevent procedural and postprocedural pain and are not recommended as the sole method of analgesia. They should be used only as analgesic adjuncts to improve infant comfort during circumcision. —— If used, topical creams may cause a higher incidence of skin irritation in low birth weight infants, compared with infants of normal weight; penile nerve block techniques should therefore be chosen for this group of newborns. • Key professional organizations (AAP, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, the American Society of Anesthesiologists, the American College of Nurse Midwives, and other midlevel clinicians such as nurse practitioners) should work collaboratively to: —— Develop standards of trainee proficiency in the performance of anesthetic and procedure techniques, including suturing; —— Teach the procedure and analgesic techniques during postgraduate training programs; —— Develop educational materials for clinicians to enhance their own competency in discussing the benefits and risks of circumcision with parents; —— Offer educational materials to assist parents of male infants with the care of both circumcised and uncircumcised penises. • The preventive and public health benefits associated with newborn male circumcision warrant third-party reimbursement of the procedure. The American College of Obstetricians and Gynecologists has endorsed this technical report. (8/12)

http://pediatrics.aappublications.org/content/130/3/e756

MALTREATMENT OF CHILDREN WITH DISABILITIES (CLINICAL REPORT) Roberta A. Hibbard, MD; Larry W. Desch, MD; Committee on Child Abuse and Neglect; and Council on Children With Disabilities ABSTRACT. Widespread efforts are being made to increase awareness and provide education to pediatricians regarding risk factors of child abuse and neglect. The purpose of this clinical report is to ensure that children with disabilities are recognized as a population that is also at risk of maltreatment. Some conditions related to a disability can be confused with maltreatment. The need for early recognition and intervention of child abuse and neglect in this population, as well as the ways that a medical home can facilitate the prevention and early detection of child

POLICY TITLES AND ABSTRACTS

maltreatment, are the subject of this report. (5/07, reaffirmed 1/11, 4/16)

http://pediatrics.aappublications.org/content/119/5/1018

MANAGEMENT OF CHILDREN WITH AUTISM SPECTRUM DISORDERS (CLINICAL REPORT) Scott M. Myers, MD; Chris Plauché Johnson, MD, MEd; and Council on Children With Disabilities ABSTRACT. Pediatricians have an important role not only in early recognition and evaluation of autism spectrum disorders but also in chronic management of these disorders. The primary goals of treatment are to maximize the child’s ultimate functional independence and quality of life by minimizing the core autism spectrum disorder features, facilitating development and learning, promoting socialization, reducing maladaptive behaviors, and educating and supporting families. To assist pediatricians in educating families and guiding them toward empirically supported interventions for their children, this report reviews the educational strategies and associated therapies that are the primary treatments for children with autism spectrum disorders. Optimization of health care is likely to have a positive effect on habilitative progress, functional outcome, and quality of life; therefore, important issues, such as management of associated medical problems, pharmacologic and nonpharmacologic intervention for challenging behaviors or coexisting mental health conditions, and use of complementary and alternative medical treatments, are also addressed. (11/07, reaffirmed 9/10, 8/14)

http://pediatrics.aappublications.org/content/120/5/1162

MANAGEMENT OF DENTAL TRAUMA IN A PRIMARY CARE SETTING (CLINICAL REPORT) Martha Ann Keels, DDS, PhD, and Section on Oral Health ABSTRACT. The American Academy of Pediatrics and its Section on Oral Health have developed this clinical report for pediatricians and primary care physicians regarding the diagnosis, evaluation, and management of dental trauma in children aged 1 to 21 years. This report was developed through a comprehensive search and analysis of the medical and dental literature and expert consensus. Guidelines published and updated by the International Association of Dental Traumatology (www.­ dentaltraumaguide.com) are an excellent resource for both dental and nondental health care providers. (1/14)

http://pediatrics.aappublications.org/content/133/2/e466

MANAGEMENT OF FOOD ALLERGY IN THE SCHOOL SETTING (CLINICAL REPORT) Scott H. Sicherer, MD; Todd Mahr, MD; and Section on Allergy and Immunology ABSTRACT. Food allergy is estimated to affect approximately 1 in 25 school-aged children and is the most common trigger of anaphylaxis in this age group. School food-allergy management requires strategies to reduce the risk of ingestion of the allergen as well as procedures to recognize and treat allergic reactions and anaphylaxis. The role of the pediatrician or pediatric health care provider may include diagnosing and documenting a poteninjectable tially life-threatening food allergy, prescribing self-­ epinephrine, helping the child learn how to store and use the medication in a responsible manner, educating the parents of their responsibility to implement prevention strategies within and outside the home environment, and working with families, schools, and students in developing written plans to reduce the risk of anaphylaxis and to implement emergency treatment in the event of a reaction. This clinical report highlights the role of the pediatrician and pediatric health care provider in managing students with food allergies. (11/10)

http://pediatrics.aappublications.org/content/126/6/1232

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MANAGEMENT OF NEONATES WITH SUSPECTED OR PROVEN EARLY-ONSET BACTERIAL SEPSIS (CLINICAL REPORT) Richard A. Polin, MD, and Committee on Fetus and Newborn ABSTRACT. With improved obstetrical management and evidence-based use of intrapartum antimicrobial therapy, earlyonset neonatal sepsis is becoming less frequent. However, early-onset sepsis remains one of the most common causes of neonatal morbidity and mortality in the preterm population. The identification of neonates at risk for early-onset sepsis is frequently based on a constellation of perinatal risk factors that are neither sensitive nor specific. Furthermore, diagnostic tests for neonatal sepsis have a poor positive predictive accuracy. As a result, clinicians often treat well-appearing infants for extended periods of time, even when bacterial cultures are negative. The optimal treatment of infants with suspected early-onset sepsis is broad-spectrum antimicrobial agents (ampicillin and an aminoglycoside). Once a pathogen is identified, antimicrobial therapy should be narrowed (unless synergism is needed). Recent data suggest an association between prolonged empirical treatment of preterm infants (≥5 days) with broad-spectrum antibiotics and higher risks of late onset sepsis, necrotizing enterocolitis, and mortality. To reduce these risks, antimicrobial therapy should be discontinued at 48 hours in clinical situations in which the probability of sepsis is low. The purpose of this clinical report is to provide a practical and, when possible, evidence-based approach to the management of infants with suspected or proven early-onset sepsis. (4/12, reaffirmed 2/16)

http://pediatrics.aappublications.org/content/129/5/1006

MANAGEMENT OF PEDIATRIC TRAUMA Committee on Pediatric Emergency Medicine; Council on Injury, Violence, and Poison Prevention; Section on Critical Care; Section on Orthopaedics; Section on Surgery; and Section on Transport Medicine (joint with Pediatric Trauma Society and Society of Trauma Nurses Pediatric Committee) ABSTRACT. Injury is still the number 1 killer of children ages 1 to 18 years in the United States (http://www.cdc.gov/nchs/ fastats/children.htm). Children who sustain injuries with resulting disabilities incur significant costs not only for their health care but also for productivity lost to the economy. The families of children who survive childhood injury with disability face years of emotional and financial hardship, along with a significant societal burden. The entire process of managing childhood injury is enormously complex and varies by region. Only the comprehensive cooperation of a broadly diverse trauma team will have a significant effect on improving the care of injured children. (7/16)

http://pediatrics.aappublications.org/content/138/2/e20161569

MANAGEMENT OF TYPE 2 DIABETES MELLITUS IN CHILDREN AND ADOLESCENTS (TECHNICAL REPORT) Shelley C. Springer, MD, MBA, MSc, JD; Janet Silverstein, MD; Kenneth Copeland, MD; Kelly R. Moore, MD; Greg E. Prazar, MD; Terry Raymer, MD, CDE; Richard N. Shiffman, MD; Vidhu V. Thaker, MD; Meaghan Anderson, MS, RD, LD, CDE; Stephen J. Spann, MD, MBA; and Susan K. Flinn, MA ABSTRACT. Objective. Over the last 3 decades, the prevalence of childhood obesity has increased dramatically in North America, ushering in a variety of health problems, including type 2 diabetes mellitus (T2DM), which previously was not typically seen until much later in life. This technical report describes, in detail, the procedures undertaken to develop the recommendations given in the accompanying clinical practice guideline, “Management of Type 2 Diabetes Mellitus in Children and

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Adolescents,” and provides in-depth information about the rationale for the recommendations and the studies used to make the clinical practice guideline’s recommendations. Methods. A primary literature search was conducted relating to the treatment of T2DM in children and adolescents, and a secondary literature search was conducted relating to the screening and treatment of T2DM’s comorbidities in children and adolescents. Inclusion criteria were prospectively and unanimously agreed on by members of the committee. An article was eligible for inclusion if it addressed treatment (primary search) or 1 of 4 comorbidities (secondary search) of T2DM, was published in 1990 or later, was written in English, and included an abstract. Only primary research inquiries were considered; review articles were considered if they included primary data or opinion. The research population had to constitute children and/or adolescents with an existing diagnosis of T2DM; studies of adult patients were considered if at least 10% of the study population was younger than 35 years. All retrieved titles, abstracts, and articles were reviewed by the consulting epidemiologist. Results. Thousands of articles were retrieved and considered in both searches on the basis of the aforementioned criteria. From those, in the primary search, 199 abstracts were identified for possible inclusion, 58 of which were retained for systematic review. Five of these studies were classified as grade A studies, 1 as grade B, 20 as grade C, and 32 as grade D. Articles regarding treatment of T2DM selected for inclusion were divided into 4 major subcategories on the basis of type of treatment being discussed: (1) medical treatments (32 studies); (2) nonmedical treatments (9 studies); (3) provider behaviors (8 studies); and (4) social issues (9 studies). From the secondary search, an additional 336 abstracts relating to comorbidities were identified for possible inclusion, of which 26 were retained for systematic review. These articles included the following: 1 systematic review of literature regarding comorbidities of T2DM in adolescents; 5 expert opinions presenting global recommendations not based on evidence; 5 cohort studies reporting natural history of disease and comorbidities; 3 with specific attention to comorbidity patterns in specific ethnic groups (case-control, cohort, and clinical report using adult literature); 3 reporting an association between microalbuminuria and retinopathy (2 case-control, 1 cohort); 3 reporting the prevalence of nephropathy (cohort); 1 reporting peripheral vascular disease (case series); 2 discussing retinopathy (1 case-control, 1 position statement); and 3 addressing hyperlipidemia (American Heart Association position statement on cardiovascular risks; American Diabetes Association consensus statement; case series). A breakdown of grade of recommendation shows no grade A studies, 10 grade B studies, 6 grade C studies, and 10 grade D studies. With regard to screening and treatment recommendations for comorbidities, data in children are scarce, and the available literature is conflicting. Therapeutic recommendations for hypertension, dyslipidemia, retinopathy, microalbuminuria, and depression were summarized from expert guideline documents and are presented in detail in the guideline. The references are provided, but the committee did not independently assess the supporting evidence. Screening tools are provided in the Supplemental Information. (1/13)

http://pediatrics.aappublications.org/content/131/2/e648

MATERNAL PHENYLKETONURIA Committee on Genetics ABSTRACT. Elevated maternal phenylalanine concentrations during pregnancy are teratogenic and may result in growth retardation, microcephaly, significant developmental delays, and birth defects in the offspring of women with poorly controlled phenylketonuria during pregnancy. Women of childbearing

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age with all forms of phenylketonuria, including mild variants such as mild hyperphenylalaninemia, should receive counseling concerning their risks for adverse fetal effects, optimally before conceiving. The best outcomes occur when strict control of maternal phenylalanine concentration is achieved before conception and continued throughout pregnancy. Included are brief descriptions of novel treatments for phenylketonuria. (8/08, reaffirmed 1/13)

http://pediatrics.aappublications.org/content/122/2/445

MATERNAL-FETAL INTERVENTION AND FETAL CARE CENTERS (CLINICAL REPORT) Committee on Bioethics (joint with American College of Obstetricians and Gynecologists Committee on Ethics) ABSTRACT. The past 2 decades have yielded profound advances in the fields of prenatal diagnosis and fetal intervention. Although fetal interventions are driven by a beneficence-based motivation to improve fetal and neonatal outcomes, advancement in fetal therapies raises ethical issues surrounding maternal autonomy and decision-making, concepts of innovation versus research, and organizational aspects within institutions in the development of fetal care centers. To safeguard the interests of both the pregnant woman and the fetus, the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics make recommendations regarding informed consent, the role of research subject advocates and other independent advocates, the availability of support services, the multidisciplinary nature of fetal intervention teams, the oversight of centers, and the need to accumulate maternal and fetal outcome data. (7/11)

http://pediatrics.aappublications.org/content/128/2/e473

MEDIA AND YOUNG MINDS Council on Communications and Media ABSTRACT. Infants, toddlers, and preschoolers are now growing up in environments saturated with a variety of traditional and new technologies, which they are adopting at increasing rates. Although there has been much hope for the educational potential of interactive media for young children, accompanied by fears about their overuse during this crucial period of rapid brain development, research in this area still remains limited. This policy statement reviews the existing literature on television, videos, and mobile/interactive technologies; their potential for educational benefit; and related health concerns for young children (0 to 5 years of age). The statement also highlights areas in which pediatric providers can offer specific guidance to families in managing their young children’s media use, not only in terms of content or time limits, but also emphasizing the importance of parent-child shared media use and allowing the child time to take part in other developmentally healthy activities. (10/16)

http://pediatrics.aappublications.org/content/138/5/e20162591

MEDIA EDUCATION Committee on Communications and Media ABSTRACT. The American Academy of Pediatrics recognizes that exposure to mass media (eg, television, movies, video and computer games, the Internet, music lyrics and videos, newspapers, magazines, books, advertising) presents health risks for children and adolescents but can provide benefits as well. Media education has the potential to reduce the harmful effects of media and accentuate the positive effects. By understanding and supporting media education, pediatricians can play an important role in reducing harmful effects of media on children and adolescents. (9/10)

http://pediatrics.aappublications.org/content/126/5/1012

POLICY TITLES AND ABSTRACTS

MEDIA USE IN SCHOOL-AGED CHILDREN AND ADOLESCENTS Council on Communications and Media ABSTRACT. This policy statement focuses on children and adolescents 5 through 18 years of age. Research suggests both benefits and risks of media use for the health of children and teenagers. Benefits include exposure to new ideas and knowledge acquisition, increased opportunities for social contact and support, and new opportunities to access health-promotion messages and information. Risks include negative health effects on weight and sleep; exposure to inaccurate, inappropriate, or unsafe content and contacts; and compromised privacy and confidentiality. Parents face challenges in monitoring their children’s and their own media use and in serving as positive role models. In this new era, evidence regarding healthy media use does not support a one-size-fits-all approach. Parents and pediatricians can work together to develop a Family Media Use Plan (www.healthychildren.org/MediaUsePlan) that considers their children’s developmental stages to individualize an appropriate balance for media time and consistent rules about media use, to mentor their children, to set boundaries for accessing content and displaying personal information, and to implement open family communication about media. (10/16)

http://pediatrics.aappublications.org/content/138/5/e20162592

MEDIATORS AND ADVERSE EFFECTS OF CHILD POVERTY IN THE UNITED STATES (TECHNICAL REPORT) John M. Pascoe, MD, MPH, FAAP; David L. Wood, MD, MPH, FAAP; James H. Duffee, MD, MPH, FAAP; Alice Kuo, MD, PhD, MEd, FAAP; Committee on Psychosocial Aspects of Child and Family Health; and Council on Community Pediatrics ABSTRACT. The link between poverty and children’s health is well recognized. Even temporary poverty may have an adverse effect on children’s health, and data consistently support the observation that poverty in childhood continues to have a negative effect on health into adulthood. In addition to childhood morbidity being related to child poverty, epidemiologic studies have documented a mortality gradient for children aged 1 to 15 years (and adults), with poor children experiencing a higher mortality rate than children from higher-income families. The global great recession is only now very slowly abating for millions of America’s children and their families. At this difficult time in the history of our nation’s families and immediately after the 50th anniversary year of President Lyndon Johnson’s War on Poverty, it is particularly germane for the American Academy of Pediatrics, which is “dedicated to the health of all children,” to publish a research-supported technical report that examines the mediators associated with the long-recognized adverse effects of child poverty on children and their families. This technical report draws on research from a number of disciplines, including physiology, sociology, psychology, economics, and epidemiology, to describe the present state of knowledge regarding poverty’s negative impact on children’s health and development. Children inherit not only their parents’ genes but also the family ecology and its social milieu. Thus, parenting skills, housing, neighborhood, schools, and other factors (eg, medical care) all have complex relations to each other and influence how each child’s genetic canvas is expressed. Accompanying this technical report is a policy statement that describes specific actions that pediatricians and other child advocates can take to attenuate the negative effects of the mediators identified in this technical report and improve the well-being of our nation’s children and their families. (3/16)

http://pediatrics.aappublications.org/content/137/4/e20160340

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MEDICAID POLICY STATEMENT Committee on Child Health Financing ABSTRACT. Medicaid insures 39% of the children in the United States. This revision of the 2005 Medicaid Policy Statement of the American Academy of Pediatrics reflects opportunities for changes in state Medicaid programs resulting from the 2010 Patient Protection and Affordable Care Act as upheld in 2012 by the Supreme Court. Policy recommendations focus on the areas of benefit coverage, financing and payment, eligibility, outreach and enrollment, managed care, and quality improvement. (4/13)

http://pediatrics.aappublications.org/content/131/5/e1697

MEDICAL CONDITIONS AFFECTING SPORTS PARTICIPATION (CLINICAL REPORT) Stephen G. Rice, MD, PhD, MPH, and Council on Sports Medicine and Fitness ABSTRACT. Children and adolescents with medical conditions present special issues with respect to participation in athletic activities. The pediatrician can play an important role in determining whether a child with a health condition should participate in certain sports by assessing the child’s health status, suggesting appropriate equipment or modifications of sports to decrease the risk of injury, and educating the athlete, parent(s) or guardian, and coach regarding the risks of injury as they relate to the child’s condition. This report updates a previous policy statement and provides information for pediatricians on sports participation for children and adolescents with medical conditions. (4/08, reaffirmed 5/11, 6/14)

http://pediatrics.aappublications.org/content/121/4/841

MEDICAL COUNTERMEASURES FOR CHILDREN IN PUBLIC HEALTH EMERGENCIES, DISASTERS, OR TERRORISM Disaster Preparedness Advisory Council ABSTRACT. Significant strides have been made over the past 10 to 15 years to develop medical countermeasures (MCMs) to address potential disaster hazards, including chemical, biological, radiologic, and nuclear threats. Significant and effective collaboration between the pediatric health community, including the American Academy of Pediatrics, and federal partners, such as the Office of the Assistant Secretary for Preparedness and Response, Centers for Disease Control and Prevention, Federal Emergency Management Agency, National Institutes of Health, Food and Drug Administration, and other federal agencies, over the past 5 years has resulted in substantial gains in addressing the needs of children related to disaster preparedness in general and MCMs in particular. Yet, major gaps still remain related to MCMs for children, a population highly vulnerable to the effects of exposure to such threats, because many vaccines and pharmaceuticals approved for use by adults as MCMs do not yet have pediatric formulations, dosing information, or safety information. As a result, the nation’s stockpiles and other caches (designated supply of MCMs) where pharmacotherapeutic and other MCMs are stored are less prepared to address the needs of children compared with those of adults in the event of a disaster. This policy statement provides recommendations to close the remaining gaps for the development and use of MCMs in children during public health emergencies or disasters. The progress made by federal agencies to date to address the needs of children and the shared commitment of collaboration that characterizes the current relationship between the pediatric health community and the federal agencies responsible for MCMs should encourage all child advocates to invest the necessary energy and resources now to complete the process of remedying the remaining significant gaps in preparedness. (1/16)

http://pediatrics.aappublications.org/content/137/2/e20154273

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MEDICAL EMERGENCIES OCCURRING AT SCHOOL Council on School Health ABSTRACT. Children and adults might experience medical emergency situations because of injuries, complications of chronic health conditions, or unexpected major illnesses that occur in schools. In February 2001, the American Academy of Pediatrics issued a policy statement titled “Guidelines for Emergency Medical Care in Schools” (available at: http://aappolicy.­ aappublications.org/cgi/content/full/­pediatrics;107/2/435). Since the release of that statement, the spectrum of potential individual student emergencies has changed significantly. The increase in the number of children with special health care needs and chronic medical conditions attending schools and the challenges associated with ensuring that schools have access to onsite licensed health care professionals on an ongoing basis have added to increasing the risks of medical emergencies in schools. The goal of this statement is to increase pediatricians’ awareness of schools’ roles in preparing for individual student emergencies and to provide recommendations for primary care and school physicians on how to assist and support school personnel. (10/08, reaffirmed 9/11, 4/17)

http://pediatrics.aappublications.org/content/122/4/887

THE MEDICAL HOME Medical Home Initiatives for Children With Special Needs Project Advisory Committee (7/02, reaffirmed 5/08)

http://pediatrics.aappublications.org/content/110/1/184

MEDICAL STAFF APPOINTMENT AND DELINEATION OF PEDIATRIC PRIVILEGES IN HOSPITALS (CLINICAL REPORT) Daniel A. Rauch, MD; Committee on Hospital Care; and Section on Hospital Medicine ABSTRACT. The review and verification of credentials and the granting of clinical privileges are required of every hospital to ensure that members of the medical staff are competent and qualified to provide specified levels of patient care. The credentialing process involves the following: (1) assessment of the professional and personal background of each practitioner seeking privileges; (2)  assignment of privileges appropriate for the clinician’s training and experience; (3) ongoing monitoring of the professional activities of each staff member; and (4) periodic reappointment to the medical staff on the basis of objectively measured performance. We examine the essential elements of a credentials review for initial and renewed medical staff appointments along with suggested criteria for the delineation of clinical privileges. Sample forms for the delineation of privileges can be found on the American Academy of Pediatrics Committee on Hospital Care Web site (http://www.aap.org/ visit/cmte19.htm). Because of differences among individual hospitals, no 1 method for credentialing is universally applicable. The medical staff of each hospital must, therefore, establish its own process based on the general principles reviewed in this report. The issues of medical staff membership and credentialing have become very complex, and institutions and medical staffs are vulnerable to legal action. Consequently, it is advisable for hospitals and medical staffs to obtain expert legal advice when medical staff bylaws are constructed or revised. (3/12, reaffirmed 2/16)

http://pediatrics.aappublications.org/content/129/4/797

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MEDICAL VERSUS NONMEDICAL IMMUNIZATION EXEMPTIONS FOR CHILD CARE AND SCHOOL ATTENDANCE Committee on Practice and Ambulatory Medicine, Committee on Infectious Diseases, Committee on State Government Affairs, Council on School Health, and Section on Administration and Practice Management ABSTRACT. Routine childhood immunizations against infectious diseases are an integral part of our public health infrastructure. They provide direct protection to the immunized individual and indirect protection to children and adults unable to be immunized via the effect of community immunity. All 50 states, the District of Columbia, and Puerto Rico have regulations requiring proof of immunization for child care and school attendance as a public health strategy to protect children in these settings and to secondarily serve as a mechanism to promote timely immunization of children by their caregivers. Although all states and the District of Columbia have mechanisms to exempt school attendees from specific immunization requirements for medical reasons, the majority also have a heterogeneous collection of regulations and laws that allow nonmedical exemptions from childhood immunizations otherwise required for child care and school attendance. The American Academy of Pediatrics (AAP) supports regulations and laws requiring certification of immunization to attend child care and school as a sound means of providing a safe environment for attendees and employees of these settings. The AAP also supports medically indicated exemptions to specific immunizations as determined for each individual child. The AAP views nonmedical exemptions to school-required immunizations as inappropriate for individual, public health, and ethical reasons and advocates for their elimination. (8/16)

http://pediatrics.aappublications.org/content/138/3/e20162145

MEDICATION-ASSISTED TREATMENT OF ADOLESCENTS WITH OPIOID USE DISORDERS Committee on Substance Use and Prevention ABSTRACT. Opioid use disorder is a leading cause of morbidity and mortality among US youth. Effective treatments, both medications and substance use disorder counseling, are available but underused, and access to developmentally appropriate treatment is severely restricted for adolescents and young adults. Resources to disseminate available therapies and to develop new treatments specifically for this age group are needed to save and improve lives of youth with opioid addiction. (8/16)

http://pediatrics.aappublications.org/content/138/3/e20161893

MENSTRUAL MANAGEMENT FOR ADOLESCENTS WITH DISABILITIES (CLINICAL REPORT) Elisabeth H. Quint, MD; Rebecca F. O’Brien, MD; and Committee on Adolescence (joint with the North American Society for Pediatric and Adolescent Gynecology) ABSTRACT. The onset of menses for adolescents with physical or intellectual disabilities can affect their independence and add additional concerns for families at home, in schools, and in other settings. The pediatrician is the primary health care provider to explore and assist with the pubertal transition and menstrual management. Menstrual management of both normal and abnormal cycles may be requested to minimize hygiene issues, premenstrual symptoms, dysmenorrhea, heavy or irregular bleeding, contraception, and conditions exacerbated by the menstrual cycle. Several options are available for menstrual management, depending on the outcome that is desired, ranging from cycle regulation to complete amenorrhea. The use of medications or the request for surgeries to help with the menstrual cycles in teenagers with disabilities has medical, social, legal, and ethical

POLICY TITLES AND ABSTRACTS

implications. This clinical report is designed to help guide pediatricians in assisting adolescent females with intellectual and/ or physical disabilities and their families in making decisions related to successfully navigating menarche and subsequent menstrual cycles. (6/16)

http://pediatrics.aappublications.org/content/138/1/e20160295

THE METABOLIC SYNDROME IN CHILDREN AND ADOLESCENTS: SHIFTING THE FOCUS TO CARDIOMETABOLIC RISK FACTOR CLUSTERING (CLINICAL REPORT) Sheela N. Magge, MD, MSCE, FAAP; Elizabeth Goodman, MD, MBA, FAAP; Sarah C. Armstrong, MD, FAAP; Committee on Nutrition; Section on Endocrinology; and Section on Obesity ABSTRACT. Metabolic syndrome (MetS) was developed by the National Cholesterol Education Program Adult Treatment Panel III, identifying adults with at least 3 of 5 cardiometabolic risk factors (hyperglycemia, increased central adiposity, elevated triglycerides, decreased high-density lipoprotein cholesterol, and elevated blood pressure) who are at increased risk of diabetes and cardiovascular disease. The constellation of MetS component risk factors has a shared pathophysiology and many common treatment approaches grounded in lifestyle modification. Several attempts have been made to define MetS in the pediatric population. However, in children, the construct is difficult to define and has unclear implications for clinical care. In this Clinical Report, we focus on the importance of screening for and treating the individual risk factor components of MetS. Focusing attention on children with cardiometabolic risk factor clustering is emphasized over the need to define a pediatric MetS. (7/17) See full text on page 887.

http://pediatrics.aappublications.org/content/140/2/e20171603

METRIC UNITS AND THE PREFERRED DOSING OF ORALLY ADMINISTERED LIQUID MEDICATIONS Committee on Drugs ABSTRACT. Medication overdoses are a common, but preventable, problem among children. Volumetric dosing errors and the use of incorrect dosing delivery devices are 2 common sources of these preventable errors for orally administered liquid medications. To reduce errors and increase precision of drug administration, milliliter-based dosing should be used exclusively when prescribing and administering liquid medications. Teaspoonand tablespoon-based dosing should not be used. Devices that allow for precise dose administration (preferably syringes with metric markings) should be used instead of household spoons and should be distributed with the medication. (3/15)

http://pediatrics.aappublications.org/content/135/4/784

MIND-BODY THERAPIES IN CHILDREN AND YOUTH (CLINICAL REPORT) Section on Integrative Medicine ABSTRACT. Mind-body therapies are popular and are ranked among the top 10 complementary and integrative medicine practices reportedly used by adults and children in the 2007–2012 National Health Interview Survey. A growing body of evidence supports the effectiveness and safety of mind-body therapies in pediatrics. This clinical report outlines popular mind-body therapies for children and youth and examines the best-available evidence for a variety of mind-body therapies and practices, including biofeedback, clinical hypnosis, guided imagery, meditation, and yoga. The report is intended to help health care professionals guide their patients to nonpharmacologic approaches to improve concentration, help decrease pain, control discomfort, or ease anxiety. (8/16)

http://pediatrics.aappublications.org/content/138/3/e20161896

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MINORS AS LIVING SOLID-ORGAN DONORS (CLINICAL REPORT) Lainie Friedman Ross, MD, PhD; J. Richard Thistlethwaite Jr, MD, PhD; and Committee on Bioethics ABSTRACT. In the past half-century, solid-organ transplantation has become standard treatment for a variety of diseases in children and adults. The major limitation for all transplantation is the availability of donors, and the gap between demand and supply continues to grow despite the increase in living donors. Although rare, children do serve as living donors, and these donations raise serious ethical issues. This clinical report includes a discussion of the ethical considerations regarding minors serving as living donors, using the traditional benefit/ burden calculus from the perspectives of both the donor and the recipient. The report also includes an examination of the circumstances under which a minor may morally participate as a living donor, how to minimize risks, and what the informed-consent process should entail. The American Academy of Pediatrics holds that minors can morally serve as living organ donors but only in exceptional circumstances when specific criteria are fulfilled. (8/08, reaffirmed 5/11)

http://pediatrics.aappublications.org/content/122/2/454

MODEL CONTRACTUAL LANGUAGE FOR MEDICAL NECESSITY FOR CHILDREN Committee on Child Health Financing ABSTRACT. The term “medical necessity” is used by Medicare and Medicaid and in insurance contracts to refer to medical services that are generally recognized as appropriate for the diagnosis, prevention, or treatment of disease and injury. There is no consensus on how to define and apply the term and the accompanying rules and regulations, and as a result there has been substantial variation in medical-necessity definitions and interpretations. With this policy statement, the American Academy of Pediatrics hopes to encourage insurers to adopt more consistent medical-necessity definitions that take into account the needs of children. (7/05, reaffirmed 10/11)

http://pediatrics.aappublications.org/content/116/1/261

MOTOR DELAYS: EARLY IDENTIFICATION AND EVALUATION (CLINICAL REPORT) Garey H. Noritz, MD; Nancy A. Murphy, MD; and Neuromotor Screening Expert Panel ABSTRACT. Pediatricians often encounter children with delays of motor development in their clinical practices. Earlier identification of motor delays allows for timely referral for developmental interventions as well as diagnostic evaluations and treatment planning. A multidisciplinary expert panel developed an algorithm for the surveillance and screening of children for motor delays within the medical home, offering guidance for the initial workup and referral of the child with possible delays in motor development. Highlights of this clinical report include suggestions for formal developmental screening at the 9-, 18-, 30-, and 48-month well-child visits; approaches to the neurologic examination, with emphasis on the assessment of muscle tone; and initial diagnostic approaches for medical home providers. Use of diagnostic tests to evaluate children with motor delays are described, including brain MRI for children with high muscle tone, and measuring serum creatine kinase concentration of those with decreased muscle tone. The importance of pursuing diagnostic tests while concurrently referring patients to early intervention programs is emphasized. (5/13, reaffirmed 5/17)

http://pediatrics.aappublications.org/content/131/6/e2016

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THE NEED TO OPTIMIZE ADOLESCENT IMMUNIZATION (CLINICAL REPORT) Henry H. Bernstein, DO, MHCM, FAAP; Joseph A. Bocchini Jr, MD, FAAP; and Committee on Infectious Diseases ABSTRACT. The adolescent period heralds the pediatric patient’s transition into adulthood. It is a time of dynamic development during which effective preventive care measures can promote safe behaviors and the development of lifelong health habits. One of the foundations of preventive adolescent health care is timely vaccination, and every visit can be viewed as an opportunity to update and complete an adolescent’s immunizations. In the past decade, the adolescent immunization schedule has expanded to include 2 doses of quadrivalent meningococcal conjugate vaccine; 1 dose of tetanus, diphtheria, acellular pertussis, absorbed vaccine; 2 or 3 doses of human papillomavirus vaccine, depending on the child’s age; and an annual influenza vaccine. In addition, during adolescent visits, health care providers can determine whether catch-up vaccination is needed to meet early childhood recommendations for hepatitis B; hepatitis A; measles, mumps, rubella; poliovirus; and varicella vaccines. New serogroup B meningococcal vaccines are now available for those at increased risk for meningococcal disease; in addition, these serogroup B meningococcal vaccines received a Category B recommendation for healthy adolescents, where individual counseling and risk–benefit evaluation based on health care provider judgements and patient preferences are indicated. This clinical report focuses on the epidemiology of adolescent vaccine-preventable diseases by reviewing the rationale for the annual universally recommended adolescent immunization schedule of the American Academy of Pediatrics, the American Academy of Family Physicians, the Centers for Disease Control and Prevention, and the American Congress of Obstetricians and Gynecologists. In addition, the barriers that negatively influence adherence to this current adolescent immunization schedule will be highlighted. (2/17) See full text on page 901.

http://pediatrics.aappublications.org/content/139/3/e20164186

NEEDS OF KINSHIP CARE FAMILIES AND PEDIATRIC PRACTICE David Rubin, MD, FAAP; Sarah H. Springer, MD, FAAP; Sarah Zlotnik, MSW, MSPH; Christina D. Kang-Yi, PhD; and Council on Foster Care, Adoption, and Kinship Care ABSTRACT. As many as 3% of children in the United States live in kinship care arrangements with caregivers who are relatives but not the biological parents of the child. A growing body of evidence suggests that children who cannot live with their biological parents fare better, overall, when living with extended family than with nonrelated foster parents. Acknowledging this, federal laws and public policies increasingly favor kinship care over nonrelative foster care when children are unable to live with their biological parents. Despite overall better outcomes, families providing kinship care experience many hardships, and the children experience many of the same adversities of children in traditional foster care. This policy statement reviews both the strengths and vulnerabilities of kinship families and suggests strategies for pediatricians to use to address the needs of individual patients and families. Strategies are also outlined for community, state, and federal advocacy on behalf of these children and their families. (3/17) See full text on page 919.

http://pediatrics.aappublications.org/content/139/4/e20170099

NEONATAL DRUG WITHDRAWAL (CLINICAL REPORT) Mark L. Hudak, MD; Rosemarie C. Tan, MD, PhD; Committee on Drugs; and Committee on Fetus and Newborn ABSTRACT. Maternal use of certain drugs during pregnancy can result in transient neonatal signs consistent with withdrawal

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or acute toxicity or cause sustained signs consistent with a lasting drug effect. In addition, hospitalized infants who are treated with opioids or benzodiazepines to provide analgesia or sedation may be at risk for manifesting signs of withdrawal. This statement updates information about the clinical presentation of infants exposed to intrauterine drugs and the therapeutic options for treatment of withdrawal and is expanded to include evidence-based approaches to the management of the hospitalized infant who requires weaning from analgesics or sedatives. (1/12, reaffirmed 2/16)

http://pediatrics.aappublications.org/content/129/2/e540

A NEW ERA IN QUALITY MEASUREMENT: THE DEVELOPMENT AND APPLICATION OF QUALITY MEASURES Terry Adirim, MD, MPH, FAAP; Kelley Meade, MD, FAAP; Kamila Mistry, PhD, MPH; Council on Quality Improvement and Patient Safety; and Committee on Practice and Ambulatory Medicine ABSTRACT. Quality measures are used for a variety of purposes in health care, including clinical care improvement, regulation, accreditation, public reporting, surveillance, and maintenance of certification. Most quality measures are 1 of 3 types: structure, process, or outcome. Health care quality measures should address the domains of quality across the continuum of care and reflect patient and family experience. Measure development for pediatric health care has a number of important challenges, including gaps in the evidence base; the fact that measures for most conditions must be age-specific; the long, resource-­ intensive development process; and the national focus on measure development for adult conditions. Numerous national organizations focus on the development and application of quality measures, including the Pediatric Quality Measures Program, which is focused solely on the development and implementation of pediatric-specific measures. Once a quality measure is developed for use in national measurement programs, the organization that develops and/or “stewards” the measure may submit the measure or set of measures for endorsement, which is recognition of the scientific soundness, usability, and relevance of the measure. Quality measures must then be disseminated and applied to improve care. Although pediatric health care providers and child health care institutions alike must continually balance time and resources needed to address multiple reporting requirements, quality measurement is an important tool for advancing high-quality and safe health care for children. This policy statement provides an overview of quality measurement and describes the opportunities for pediatric health care providers to apply quality measures to improve clinical quality and performance in the delivery of pediatric health care services. (12/16) See full text on page 931.

http://pediatrics.aappublications.org/content/139/1/e20163442

NEWBORN SCREENING EXPANDS: RECOMMENDATIONS FOR PEDIATRICIANS AND MEDICAL HOMES—IMPLICATIONS FOR THE SYSTEM (CLINICAL REPORT) Newborn Screening Authoring Committee ABSTRACT. Advances in newborn screening technology, coupled with recent advances in the diagnosis and treatment of rare but serious congenital conditions that affect newborn infants, provide increased opportunities for positively affecting the lives of children and their families. These advantages also pose new challenges to primary care pediatricians, both educationally and in response to the management of affected infants. Primary care pediatricians require immediate access to clinical and diagnostic information and guidance and have a proactive role to play in

POLICY TITLES AND ABSTRACTS

supporting the performance of the newborn screening system. Primary care pediatricians must develop office policies and procedures to ensure that newborn screening is conducted and that results are transmitted to them in a timely fashion; they must also develop strategies to use should these systems fail. In addition, collaboration with local, state, and national partners is essential for promoting actions and policies that will optimize the function of the newborn screening systems and ensure that families receive the full benefit of them. (1/08, reaffirmed 9/16)

http://pediatrics.aappublications.org/content/121/1/192

NEWBORN SCREENING FOR BILIARY ATRESIA (TECHNICAL REPORT) Kasper S. Wang, MD, FAAP, FACS; Section on Surgery; and Committee on Fetus and Newborn (joint with Childhood Liver Disease Research Network) ABSTRACT. Biliary atresia is the most common cause of pediatric end-stage liver disease and the leading indication for pediatric liver transplantation. Affected infants exhibit evidence of biliary obstruction within the first few weeks after birth. Early diagnosis and successful surgical drainage of bile are associated with greater survival with the child’s native liver. Unfortunately, because noncholestatic jaundice is extremely common in early infancy, it is difficult to identify the rare infant with cholestatic jaundice who has biliary atresia. Hence, the need for timely diagnosis of this disease warrants a discussion of the feasibility of screening for biliary atresia to improve outcomes. Herein, newborn screening for biliary atresia in the United States is assessed by using criteria established by the Discretionary Advisory Committee on Heritable Disorders in Newborns and Children. Published analyses indicate that newborn screening for biliary atresia by using serum bilirubin concentrations or stool color cards is potentially life-saving and cost-effective. Further studies are necessary to evaluate the feasibility, effectiveness, and costs of potential screening strategies for early identification of biliary atresia in the United States. (11/15)

http://pediatrics.aappublications.org/content/136/6/e1663

NICOTINE AND TOBACCO AS SUBSTANCES OF ABUSE IN CHILDREN AND ADOLESCENTS (TECHNICAL REPORT) Lorena M. Siqueira, MD, MSPH, FAAP, FSAHM, and Committee on Substance Use and Prevention ABSTRACT. Nicotine is the primary pharmacologic component of tobacco, and users of tobacco products seek out its effects. The highly addictive nature of nicotine is responsible for its widespread use and difficulty with quitting. This technical report focuses on nicotine and discusses the stages of use in progression to dependence on nicotine-containing products; the physiologic characteristics, neurobiology, metabolism, pharmacogenetics, and health effects of nicotine; and acute nicotine toxicity. Finally, some newer approaches to cessation are noted. (12/16) See full text on page 945.

http://pediatrics.aappublications.org/content/139/1/e20163436

NONDISCRIMINATION IN PEDIATRIC HEALTH CARE Committee on Pediatric Workforce ABSTRACT. This policy statement is a revision of a 2001 statement and articulates the positions of the American Academy of Pediatrics on nondiscrimination in pediatric health care. It addresses both pediatricians who provide health care and the infants, children, adolescents, and young adults whom they serve. (10/07, reaffirmed 6/11, 1/15)

http://pediatrics.aappublications.org/content/120/4/922

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NONEMERGENCY ACUTE CARE: WHEN IT’S NOT THE MEDICAL HOME Gregory P. Conners, MD, MPH, MBA, FAAP; Susan J. Kressly, MD, FAAP; James M. Perrin, MD, FAAP; Julia E. Richerson, MD, FAAP; Usha M. Sankrithi, MBBS, MPH, FAAP; Committee on Practice and Ambulatory Medicine; Committee on Pediatric Emergency Medicine; Section on Telehealth Care; Section on Emergency Medicine; Subcommittee on Urgent Care; and Task Force on Pediatric Practice Change ABSTRACT. The American Academy of Pediatrics (AAP) affirms that the optimal location for children to receive care for acute, nonemergency health concerns is the medical home. The medical home is characterized by the AAP as a care model that “must be accessible, family centered, continuous, comprehensive, coordinated, compassionate, and culturally effective.” However, some children and families use acute care services outside the medical home because there is a perceived or real benefit related to accessibility, convenience, or cost of care. Examples of such acute care entities include urgent care facilities, retail-based clinics, and commercial telemedicine services. Children deserve high-quality, appropriate, and safe acute care services wherever they access the health care system, with timely and complete communication with the medical home, to ensure coordinated and continuous care. Treatment of children under established, new, and evolving practice arrangements in acute care entities should adhere to the core principles of continuity of care and communication, best practices within a defined scope of services, pediatric-trained staff, safe transitions of care, and continuous improvement. In support of the medical home, the AAP urges stakeholders, including payers, to avoid any incentives (eg, reduced copays) that encourage visits to external entities for acute issues as a preference over the medical home. (4/17) See full text on page 961.

http://pediatrics.aappublications.org/content/139/5/e20170629

NONINITIATION OR WITHDRAWAL OF INTENSIVE CARE FOR HIGH-RISK NEWBORNS Committee on Fetus and Newborn ABSTRACT. Advances in medical technology have led to dilemmas in initiation and withdrawal of intensive care of newborn infants with a very poor prognosis. Physicians and parents together must make difficult decisions guided by their understanding of the child’s best interest. The foundation for these decisions consists of several key elements: (1) direct and open communication between the health care team and the parents of the child with regard to the medical status, prognosis, and treatment options; (2) inclusion of the parents as active participants in the decision process; (3) continuation of comfort care even when intensive care is not being provided; and (4) treatment decisions that are guided primarily by the best interest of the child. (2/07, reaffirmed 5/10, 6/15)

http://pediatrics.aappublications.org/content/119/2/401

NONINVASIVE RESPIRATORY SUPPORT (CLINICAL REPORT) James J. Cummings, MD, FAAP; Richard A. Polin, MD, FAAP; and Committee on Fetus and Newborn ABSTRACT. Mechanical ventilation is associated with increased survival of preterm infants but is also associated with an increased incidence of chronic lung disease (bronchopulmonary dysplasia) in survivors. Nasal continuous positive airway pressure (nCPAP) is a form of noninvasive ventilation that reduces the need for mechanical ventilation and decreases the combined outcome of death or bronchopulmonary dysplasia. Other modes of noninvasive ventilation, including nasal intermittent positive pressure ventilation, biphasic positive airway pressure, and high-flow nasal cannula, have recently been introduced into the

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NICU setting as potential alternatives to mechanical ventilation or nCPAP. Randomized controlled trials suggest that these newer modalities may be effective alternatives to nCPAP and may offer some advantages over nCPAP, but efficacy and safety data are limited. (12/15)

http://pediatrics.aappublications.org/content/137/1/e20153758

NONORAL FEEDING FOR CHILDREN AND YOUTH WITH DEVELOPMENTAL OR ACQUIRED DISABILITIES (CLINICAL REPORT) Richard C. Adams, MD, FAAP; Ellen Roy Elias, MD, FAAP; and Council on Children With Disabilities ABSTRACT. The decision to initiate enteral feedings is multifaceted, involving medical, financial, cultural, and emotional considerations. Children who have developmental or acquired disabilities are at risk for having primary and secondary conditions that affect growth and nutritional well-being. This clinical report provides (1) an overview of clinical issues in children who have developmental or acquired disabilities that may prompt a need to consider nonoral feedings, (2) a systematic way to support the child and family in clinical decisions related to initiating nonoral feeding, (3) information on surgical options that the family may need to consider in that decision-making process, and (4) pediatric guidance for ongoing care after initiation of nonoral feeding intervention, including care of the gastrostomy tube and skin site. Ongoing medical and psychosocial support is needed after initiation of nonoral feedings and is best provided through the collaborative efforts of the family and a team of professionals that may include the pediatrician, dietitian, social worker, and/ or therapists. (11/14)

http://pediatrics.aappublications.org/content/134/6/e1745

NONTHERAPEUTIC USE OF ANTIMICROBIAL AGENTS IN ANIMAL AGRICULTURE: IMPLICATIONS FOR PEDIATRICS (TECHNICAL REPORT) Jerome A. Paulson, MD, FAAP; Theoklis E. Zaoutis, MD, MSCE, FAAP; Council on Environmental Health; and Committee on Infectious Diseases ABSTRACT. Antimicrobial resistance is one of the most serious threats to public health globally and threatens our ability to treat infectious diseases. Antimicrobial-resistant infections are associated with increased morbidity, mortality, and health care costs. Infants and children are affected by transmission of susceptible and resistant food zoonotic pathogens through the food supply, direct contact with animals, and environmental pathways. The overuse and misuse of antimicrobial agents in veterinary and human medicine is, in large part, responsible for the emergence of antibiotic resistance. Approximately 80% of the overall tonnage of antimicrobial agents sold in the United States in 2012 was for animal use, and approximately 60% of those agents are considered important for human medicine. Most of the use involves the addition of low doses of antimicrobial agents to the feed of healthy animals over prolonged periods to promote growth and increase feed efficiency or at a range of doses to prevent disease. These nontherapeutic uses contribute to resistance and create new health dangers for humans. This report describes how antimicrobial agents are used in animal agriculture, reviews the mechanisms of how such use contributes to development of resistance, and discusses US and global initiatives to curb the use of antimicrobial agents in agriculture. (11/15)

http://pediatrics.aappublications.org/content/136/6/e1670

OFFICE-BASED CARE FOR LESBIAN, GAY, BISEXUAL, TRANSGENDER, AND QUESTIONING YOUTH Committee on Adolescence ABSTRACT. The American Academy of Pediatrics issued its last statement on homosexuality and adolescents in 2004. Although most lesbian, gay, bisexual, transgender, and questioning

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(LGBTQ) youth are quite resilient and emerge from adolescence as healthy adults, the effects of homophobia and heterosexism can contribute to health disparities in mental health with higher rates of depression and suicidal ideation, higher rates of substance abuse, and more sexually transmitted and HIV infections. Pediatricians should have offices that are teen-friendly and welcoming to sexual minority youth. Obtaining a comprehensive, confidential, developmentally appropriate adolescent psychosocial history allows for the discovery of strengths and assets as well as risks. Referrals for mental health or substance abuse may be warranted. Sexually active LGBTQ youth should have sexually transmitted infection/HIV testing according to recommendations of the Sexually Transmitted Diseases Treatment Guidelines of the Centers for Disease Control and Prevention based on sexual behaviors. With appropriate assistance and care, sexual minority youth should live healthy, productive lives while transitioning through adolescence and young adulthood. (6/13)

http://pediatrics.aappublications.org/content/132/1/198

OFFICE-BASED CARE FOR LESBIAN, GAY, BISEXUAL, TRANSGENDER, AND QUESTIONING YOUTH (TECHNICAL REPORT) David A. Levine, MD, and Committee on Adolescence ABSTRACT. The American Academy of Pediatrics issued its last statement on homosexuality and adolescents in 2004. This technical report reflects the rapidly expanding medical and psychosocial literature about sexual minority youth. Pediatricians should be aware that some youth in their care may have concerns or questions about their sexual orientation or that of siblings, friends, parents, relatives, or others and should provide factual, current, nonjudgmental information in a confidential manner. Although most lesbian, gay, bisexual, transgender, and questioning (LGBTQ) youth are quite resilient and emerge from adolescence as healthy adults, the effects of homophobia and heterosexism can contribute to increased mental health issues for sexual minority youth. LGBTQ and MSM/WSW (men having sex with men and women having sex with women) adolescents, in comparison with heterosexual adolescents, have higher rates of depression and suicidal ideation, higher rates of substance abuse, and more risky sexual behaviors. Obtaining a comprehensive, confidential, developmentally appropriate adolescent psychosocial history allows for the discovery of strengths and assets as well as risks. Pediatricians should have offices that are teen-friendly and welcoming to sexual minority youth. This includes having supportive, engaging office staff members who ensure that there are no barriers to care. For transgender youth, pediatricians should provide the opportunity to acknowledge and affirm their feelings of gender dysphoria and desires to transition to the opposite gender. Referral of transgender youth to a qualified mental health professional is critical to assist with the dysphoria, to educate them, and to assess their readiness for transition. With appropriate assistance and care, sexual minority youth should live healthy, productive lives while transitioning through adolescence and young adulthood. (6/13)

http://pediatrics.aappublications.org/content/132/1/e297

OFFICE-BASED COUNSELING FOR UNINTENTIONAL INJURY PREVENTION (CLINICAL REPORT) H. Garry Gardner, MD, and Committee on Injury, Violence, and Poison Prevention ABSTRACT. Unintentional injuries are the leading cause of death for children older than 1 year. Pediatricians should include unintentional injury prevention as a major component of anticipatory guidance for infants, children, and adolescents. The content of injury-prevention counseling varies for infants, preschool-aged children, school-aged children, and adolescents.

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This report ­provides guidance on the content of unintentional injury-prevention counseling for each of those age groups. (1/07)

http://pediatrics.aappublications.org/content/119/1/202

OFF-LABEL USE OF DRUGS IN CHILDREN Committee on Drugs ABSTRACT. The passage of the Best Pharmaceuticals for Children Act and the Pediatric Research Equity Act has collectively resulted in an improvement in rational prescribing for children, including more than 500 labeling changes. However, off-label drug use remains an important public health issue for infants, children, and adolescents, because an overwhelming number of drugs still have no information in the labeling for use in pediatrics. The purpose of off-label use is to benefit the individual patient. Practitioners use their professional judgment to determine these uses. As such, the term “off-label” does not imply an improper, illegal, contraindicated, or investigational use. Therapeutic decision-making must always rely on the best available evidence and the importance of the benefit for the individual patient. (2/14)

http://pediatrics.aappublications.org/content/133/3/563

OFF-LABEL USE OF MEDICAL DEVICES IN CHILDREN Section on Cardiology and Cardiac Surgery and Section on Orthopaedics ABSTRACT. Despite widespread therapeutic needs, the majority of medical and surgical devices used in children do not have approval or clearance from the Food and Drug Administration (FDA) for use in pediatric populations. The clinical need for devices to diagnose and treat diseases or conditions occurring in children has led to the widespread and necessary practice in pediatric medicine and surgery of using approved devices for “off-label” or “physician-directed” applications that are not included in FDA-approved labeling. This practice is common and often appropriate, even with the highest-risk (class III) devices. The legal and regulatory framework used by the FDA for devices is complex, and economic or market barriers to medical and surgical device development for children are significant. Given the need for pediatric medical and surgical devices and the challenges to pediatric device development, off-label use is a necessary and appropriate part of care. In addition, because of the relatively uncommon nature of pediatric conditions, FDA clearance or approval often requires other regulatory pathways (eg, Humanitarian Device Exemption), which can cause confusion among pediatricians and payers about whether a specific use, even of an approved device, is considered experimental. This policy statement describes the appropriateness of off-label use of devices in children; the use of devices approved or cleared through the FDA regulatory processes, including through the Humanitarian Device Exemption; and the important need to increase pediatric device labeling information for all devices and especially those that pose the highest risk to children. (12/16) See full text on page 973.

http://pediatrics.aappublications.org/content/139/1/e20163439

OPHTHALMOLOGIC EXAMINATIONS IN CHILDREN WITH JUVENILE RHEUMATOID ARTHRITIS (CLINICAL REPORT) James Cassidy, MD; Jane Kivlin, MD; Carol Lindsley, MD; James Nocton, MD; Section on Rheumatology; and Section on Ophthalmology ABSTRACT. Unlike the joints, ocular involvement with juvenile rheumatoid arthritis is most often asymptomatic; yet, the inflammation can cause serious morbidity with loss of vision. Scheduled slit-lamp examinations by an ophthalmologist at specific intervals can detect ocular disease early, and prompt treatment can prevent vision loss. (5/06, reaffirmed 10/12)

http://pediatrics.aappublications.org/content/117/5/1843

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OPTIMIZING BONE HEALTH IN CHILDREN AND ADOLESCENTS (CLINICAL REPORT) Neville H. Golden, MD; Steven A. Abrams, MD; and Committee on Nutrition ABSTRACT. The pediatrician plays a major role in helping optimize bone health in children and adolescents. This clinical report reviews normal bone acquisition in infants, children, and adolescents and discusses factors affecting bone health in this age group. Previous recommended daily allowances for calcium and vitamin D are updated, and clinical guidance is provided regarding weight-bearing activities and recommendations for calcium and vitamin D intake and supplementation. Routine calcium supplementation is not recommended for healthy children and adolescents, but increased dietary intake to meet daily requirements is encouraged. The American Academy of Pediatrics endorses the higher recommended dietary allowances for vitamin D advised by the Institute of Medicine and supports testing for vitamin D deficiency in children and adolescents with conditions associated with increased bone fragility. Universal screening for vitamin D deficiency is not routinely recommended in healthy children or in children with dark skin or obesity because there is insufficient evidence of the cost–benefit of such a practice in reducing fracture risk. The preferred test to assess bone health is dual-energy x-ray absorptiometry, but caution is advised when interpreting results in children and adolescents who may not yet have achieved peak bone mass. For analyses, z scores should be used instead of T scores, and corrections should be made for size. Office-based strategies for the pediatrician to optimize bone health are provided. This clinical report has been endorsed by American Bone Health. (9/14)

http://pediatrics.aappublications.org/content/134/4/e1229

OPTIONS COUNSELING FOR THE PREGNANT ADOLESCENT PATIENT Laurie L. Hornberger, MD, MPH, FAAP, and Committee on Adolescence ABSTRACT. Each year, more than 500 000 girls and young women younger than 20 years become pregnant. It is important for pediatricians to have the ability and the resources in their offices to make a timely pregnancy diagnosis in their adolescent patients and provide them with nonjudgmental pregnancy options counseling. Counseling includes an unbiased discussion of the adolescent’s legal options to either continue or terminate her pregnancy, supporting the adolescent in the decisionmaking process, and referring the adolescent to appropriate resources and services. Pediatricians who choose not to provide such discussions should promptly refer pregnant adolescent patients to a health care professional who will offer developmentally appropriate pregnancy options counseling. This approach to pregnancy options counseling has not changed since the original 1989 American Academy of Pediatrics statement on this issue. (8/17) See full text on page 979.

http://pediatrics.aappublications.org/content/140/3/e20172274

ORAL AND DENTAL ASPECTS OF CHILD ABUSE AND NEGLECT (CLINICAL REPORT) Susan A. Fisher-Owens, MD, MPH, FAAP; James L. Lukefahr, MD, FAAP; Anupama Rao Tate, DMD, MPH; Section on Oral Health; and Committee on Child Abuse and Neglect (joint with American Academy of Pediatric Dentistry Council on Clinical Affairs, Council on Scientific Affairs, and Ad Hoc Work Group on Child Abuse and Neglect) ABSTRACT. In all 50 states, health care providers (including dentists) are mandated to report suspected cases of abuse and neglect to social service or law enforcement agencies. The purpose of this report is to review the oral and dental aspects of

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physical and sexual abuse and dental neglect in children and the role of pediatric care providers and dental providers in evaluating such conditions. This report addresses the evaluation of bite marks as well as perioral and intraoral injuries, infections, and diseases that may raise suspicion for child abuse or neglect. Oral health issues can also be associated with bullying and are commonly seen in human trafficking victims. Some medical providers may receive less education pertaining to oral health and dental injury and disease and may not detect the mouth and gum findings that are related to abuse or neglect as readily as they detect those involving other areas of the body. Therefore, pediatric care providers and dental providers are encouraged to collaborate to increase the prevention, detection, and treatment of these conditions in children. (7/17) See full text on page 987.

http://pediatrics.aappublications.org/content/140/2/e20171487

ORAL HEALTH CARE FOR CHILDREN WITH DEVELOPMENTAL DISABILITIES (CLINICAL REPORT) Kenneth W. Norwood Jr, MD; Rebecca L. Slayton, DDS, PhD; Council on Children With Disabilities; and Section on Oral Health ABSTRACT. Children with developmental disabilities often have unmet complex health care needs as well as significant physical and cognitive limitations. Children with more severe conditions and from low-income families are particularly at risk with high dental needs and poor access to care. In addition, children with developmental disabilities are living longer, requiring continued oral health care. This clinical report describes the effect that poor oral health has on children with developmental disabilities as well as the importance of partnerships between the pediatric medical and dental homes. Basic knowledge of the oral health risk factors affecting children with developmental disabilities is provided. Pediatricians may use the report to guide their incorporation of oral health assessments and education into their well-child examinations for children with developmental disabilities. This report has medical, legal, educational, and operational implications for practicing pediatricians. (2/13)

http://pediatrics.aappublications.org/content/131/3/614

ORGANIC FOODS: HEALTH AND ENVIRONMENTAL ADVANTAGES AND DISADVANTAGES (CLINICAL REPORT) Joel Forman, MD; Janet Silverstein, MD; Committee on Nutrition; and Council on Environmental Health ABSTRACT. The US market for organic foods has grown from $3.5 billion in 1996 to $28.6 billion in 2010, according to the Organic Trade Association. Organic products are now sold in specialty stores and conventional supermarkets. Organic products contain numerous marketing claims and terms, only some of which are standardized and regulated. In terms of health advantages, organic diets have been convincingly demonstrated to expose consumers to fewer pesticides associated with human disease. Organic farming has been demonstrated to have less environmental impact than conventional approaches. However, current evidence does not support any meaningful nutritional benefits or deficits from eating organic compared with conventionally grown foods, and there are no well-powered human studies that directly demonstrate health benefits or disease protection as a result of consuming an organic diet. Studies also have not demonstrated any detrimental or disease-promoting effects from an organic diet. Although organic foods regularly command a significant price premium, welldesigned farming studies demonstrate that costs can be competitive and yields comparable to those of conventional farming

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techniques. Pediatricians should incorporate this evidence when discussing the health and environmental impact of organic foods and organic farming while continuing to encourage all patients and their families to attain optimal nutrition and dietary variety consistent with the US Department of Agriculture’s MyPlate recommendations. This clinical report reviews the health and environmental issues related to organic food production and consumption. It defines the term “organic,” reviews organic food-labeling standards, describes organic and conventional farming practices, and explores the cost and environmental implications of organic production techniques. It examines the evidence available on nutritional quality and production contaminants in conventionally produced and organic foods. Finally, this report provides guidance for pediatricians to assist them in advising their patients regarding organic and conventionally produced food choices. (10/12)

http://pediatrics.aappublications.org/content/130/5/e1406

ORGANIZED SPORTS FOR CHILDREN AND PREADOLESCENTS Committee on Sports Medicine and Fitness and Committee on School Health ABSTRACT. Participation in organized sports provides an opportunity for young people to increase their physical activity and develop physical and social skills. However, when the demands and expectations of organized sports exceed the maturation and readiness of the participant, the positive aspects of participation can be negated. The nature of parental or adult involvement can also influence the degree to which participation in organized sports is a positive experience for preadolescents. This updates a previous policy statement on athletics for preadolescents and incorporates guidelines for sports participation for preschool children. Recommendations are offered on how pediatricians can help determine a child’s readiness to participate, how risks can be minimized, and how child-oriented goals can be maximized. (6/01, reaffirmed 8/16)

http://pediatrics.aappublications.org/content/107/6/1459

OUT-OF-HOME PLACEMENT FOR CHILDREN AND ADOLESCENTS WITH DISABILITIES (CLINICAL REPORT) Sandra L. Friedman, MD, MPH; Miriam A. Kalichman, MD; and Council on Children With Disabilities ABSTRACT. The vast majority of children and youth with chronic and complex health conditions who also have intellectual and developmental disabilities are cared for in their homes. Social, legal, policy, and medical changes through the years have allowed for an increase in needed support within the community. However, there continues to be a relatively small group of children who live in various types of congregate care settings. This clinical report describes these settings and the care and services that are provided in them. The report also discusses reasons families choose out-of-home placement for their children, barriers to placement, and potential effects of this decision on family members. We examine the pediatrician’s role in caring for children with severe intellectual and developmental disabilities and complex medical problems in the context of responding to parental inquiries about out-of-home placement and understanding factors affecting these types of decisions. Common medical problems and care issues for children residing outside the family home are reviewed. Variations in state and federal regulations, challenges in understanding local systems, and access to services are also discussed. (9/14)

http://pediatrics.aappublications.org/content/134/4/836

POLICY TITLES AND ABSTRACTS

OUT-OF-HOME PLACEMENT FOR CHILDREN AND ADOLESCENTS WITH DISABILITIES—ADDENDUM: CARE OPTIONS FOR CHILDREN AND ADOLESCENTS WITH DISABILITIES AND MEDICAL COMPLEXITY (CLINICAL REPORT) Sandra L. Friedman, MD, MPH, FAAP; Kenneth W. Norwood Jr, MD, FAAP; and Council on Children With Disabilities ABSTRACT. Children and adolescents with significant intellectual and developmental disabilities and complex medical problems require safe and comprehensive care to meet their medical and psychosocial needs. Ideally, such children and youth should be cared for by their families in their home environments. When this type of arrangement is not possible, there should be exploration of appropriate, alternative noncongregate community-based settings, especially alternative family homes. Government funding sources exist to support care in the community, although there is variability among states with regard to the availability of community programs and resources. It is important that families are supported in learning about options of care. Pediatricians can serve as advocates for their patients and their families to access community-based services and to increase the availability of resources to ensure that the option to live in a family home is available to all children with complex medical needs. (11/16)

http://pediatrics.aappublications.org/content/138/6/e20163216

OUT-OF-SCHOOL SUSPENSION AND EXPULSION Council on School Health ABSTRACT. The primary mission of any school system is to educate students. To achieve this goal, the school district must maintain a culture and environment where all students feel safe, nurtured, and valued and where order and civility are expected standards of behavior. Schools cannot allow unacceptable behavior to interfere with the school district’s primary mission. To this end, school districts adopt codes of conduct for expected behaviors and policies to address unacceptable behavior. In developing these policies, school boards must weigh the severity of the offense and the consequences of the punishment and the balance between individual and institutional rights and responsibilities. Out-of-school suspension and expulsion are the most severe consequences that a school district can impose for unacceptable behavior. Traditionally, these consequences have been reserved for offenses deemed especially severe or dangerous and/or for recalcitrant offenders. However, the implications and consequences of out-of-school suspension and expulsion and “zero-tolerance” are of such severity that their application and appropriateness for a developing child require periodic review. The indications and effectiveness of exclusionary discipline policies that demand automatic or rigorous application are increasingly questionable. The impact of these policies on offenders, other children, school districts, and communities is broad. Periodic scrutiny of policies should be placed not only on the need for a better understanding of the educational, emotional, and social impact of out-of-school suspension and expulsion on the individual student but also on the greater societal costs of such rigid policies. Pediatricians should be prepared to assist students and families affected by out-of-school suspension and expulsion and should be willing to guide school districts in their communities to find more effective and appropriate alternatives to exclusionary discipline policies for the developing child. A discussion of preventive strategies and alternatives to out-of-school suspension and expulsion, as well as recommendations for the role of the physician in matters of out-of-school suspension and expulsion are included. School-wide positive behavior support/positive behavior intervention and support is discussed as an effective alternative. (2/13)

http://pediatrics.aappublications.org/content/131/3/e1000

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OVERCROWDING CRISIS IN OUR NATION’S EMERGENCY DEPARTMENTS: IS OUR SAFETY NET UNRAVELING? Committee on Pediatric Emergency Medicine ABSTRACT. Emergency departments (EDs) are a vital component in our health care safety net, available 24 hours a day, 7 days a week, for all who require care. There has been a steady increase in the volume and acuity of patient visits to EDs, now with well over 100 million Americans (30 million children) receiving emergency care annually. This rise in ED utilization has effectively saturated the capacity of EDs and emergency medical services in many communities. The resulting phenomenon, commonly referred to as ED overcrowding, now threatens access to emergency services for those who need them the most. As managers of the pediatric medical home and advocates for children and optimal pediatric health care, there is a very important role for pediatricians and the American Academy of Pediatrics in guiding health policy decision-makers toward effective solutions that promote the medical home and timely access to emergency care. (9/04, reaffirmed 5/07, 6/11, 7/16)

http://pediatrics.aappublications.org/content/114/3/878

OVERUSE INJURIES, OVERTRAINING, AND BURNOUT IN CHILD AND ADOLESCENT ATHLETES (CLINICAL REPORT) Joel S. Brenner, MD, MPH, and Council on Sports Medicine and Fitness ABSTRACT. Overuse is one of the most common etiologic factors that lead to injuries in the pediatric and adolescent athlete. As more children are becoming involved in organized and recreational athletics, the incidence of overuse injuries is increasing. Many children are participating in sports year-round and sometimes on multiple teams simultaneously. This overtraining can lead to burnout, which may have a detrimental effect on the child participating in sports as a lifelong healthy activity. One contributing factor to overtraining may be parental pressure to compete and succeed. The purpose of this clinical report is to assist pediatricians in identifying and counseling at-risk children and their families. This report supports the American Academy of Pediatrics policy statement on intensive training and sport specialization. (6/07, reaffirmed 3/11, 6/14)

http://pediatrics.aappublications.org/content/119/6/1242

OXYGEN TARGETING IN EXTREMELY LOW BIRTH WEIGHT INFANTS (CLINICAL REPORT) James J. Cummings, MD, FAAP; Richard A. Polin, MD, FAAP; and Committee on Fetus and Newborn ABSTRACT. The use of supplemental oxygen plays a vital role in the care of the critically ill preterm infant, but the unrestricted use of oxygen can lead to unintended harms, such as chronic lung disease and retinopathy of prematurity. An overly restricted use of supplemental oxygen may have adverse effects as well. Ideally, continuous monitoring of tissue and cellular oxygen delivery would allow clinicians to better titrate the use of supplemental oxygen, but such monitoring is not currently feasible in the clinical setting. The introduction of pulse oximetry has greatly aided the clinician by providing a relatively easy and continuous estimate of arterial oxygen saturation, but pulse oximetry has several practical, technical, and physiologic limitations. Recent randomized clinical trials comparing different pulse oximetry targets have been conducted to better inform the practice of supplemental oxygen use. This clinical report discusses the benefits and limitations of pulse oximetry for assessing oxygenation, summarizes randomized clinical trials of oxygen saturation targeting, and addresses implications for practice. (7/16)

http://pediatrics.aappublications.org/content/138/2/e20161576

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PAIN ASSESSMENT AND TREATMENT IN CHILDREN WITH SIGNIFICANT IMPAIRMENT OF THE CENTRAL NERVOUS SYSTEM (CLINICAL REPORT) Julie Hauer, MD, FAAP; Amy J. Houtrow, MD, PhD, MPH, FAAP; Section on Hospice and Palliative Medicine; and Council on Children With Disabilities ABSTRACT. Pain is a frequent and significant problem for children with impairment of the central nervous system, with the highest frequency and severity occurring in children with the greatest impairment. Despite the significance of the problem, this population remains vulnerable to underrecognition and undertreatment of pain. Barriers to treatment may include uncertainty in identifying pain along with limited experience and fear with the use of medications for pain treatment. Behavioral pain-assessment tools are reviewed in this clinical report, along with other strategies for monitoring pain after an intervention. Sources of pain in this population include acute-onset pain attributable to tissue injury or inflammation resulting in nociceptive pain, with pain then expected to resolve after treatment directed at the source. Other sources can result in chronic intermittent pain that, for many, occurs on a weekly to daily basis, commonly attributed to gastroesophageal reflux, spasticity, and hip subluxation. Most challenging are pain sources attributable to the impaired central nervous system, requiring empirical medication trials directed at causes that cannot be identified by diagnostic tests, such as central neuropathic pain. Interventions reviewed include integrative therapies and medications, such as gabapentinoids, tricyclic antidepressants, α-agonists, and opioids. This clinical report aims to address, with evidence-based guidance, the inherent challenges with the goal to improve comfort throughout life in this vulnerable group of children. (5/17) See full text on page 997.

http://pediatrics.aappublications.org/content/139/6/e20171002

PARENTAL LEAVE FOR RESIDENTS AND PEDIATRIC TRAINING PROGRAMS Section on Medical Students, Residents, and Fellowship Trainees and Committee on Early Childhood ABSTRACT. The American Academy of Pediatrics (AAP) is committed to the development of rational, equitable, and effective parental leave policies that are sensitive to the needs of pediatric residents, families, and developing infants and that enable parents to spend adequate and good-quality time with their young children. It is important for each residency program to have a policy for parental leave that is written, that is accessible to residents, and that clearly delineates program practices regarding parental leave. At a minimum, a parental leave policy for residents and fellows should conform legally with the Family Medical Leave Act as well as with respective state laws and should meet institutional requirements of the Accreditation Council for Graduate Medical Education for accredited programs. Policies should be well formulated and communicated in a culturally sensitive manner. The AAP advocates for extension of benefits consistent with the Family Medical Leave Act to all residents and interns beginning at the time that pediatric residency training begins. The AAP recommends that regardless of gender, residents who become parents should be guaranteed 6 to 8 weeks, at a minimum, of parental leave with pay after the infant’s birth. In addition, in conformance with federal law, the resident should be allowed to extend the leave time when necessary by using paid vacation time or leave without pay. Coparenting, adopting, or fostering of a child should entitle the resident, regardless of gender, to the same amount of paid leave (6–8 weeks) as a person who takes maternity/paternity leave. Flexibility, creativity, and advanced planning are ­necessary to

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arrange schedules that optimize resident education and experience, cultivate equity in sharing workloads, and protect pregnant residents from overly strenuous work experiences at critical times of their pregnancies. (1/13)

http://pediatrics.aappublications.org/content/131/2/387

PARENTAL PRESENCE DURING TREATMENT OF EBOLA OR OTHER HIGHLY CONSEQUENTIAL INFECTION (CLINICAL REPORT) H. Dele Davies, MD, MS, MHCM, FAAP; Carrie L. Byington, MD, FAAP; and Committee on Infectious Diseases ABSTRACT. This clinical report offers guidance to health care providers and hospitals on options to consider regarding parental presence at the bedside while caring for a child with suspected or proven Ebola virus disease (Ebola) or other highly consequential infection. Options are presented to help meet the needs of the patient and the family while also posing the least risk to providers and health care organizations. The optimal way to minimize risk is to limit contact between the person under investigation or treatment and family members/caregivers whenever possible while working to meet the emotional support needs of both patient and family. At times, caregiver presence may be deemed to be in the best interest of the patient, and in such situations, a strong effort should be made to limit potential risks of exposure to the caregiver, health care providers, and the community. The decision to allow parental/caregiver presence should be made in consultation with a team including an infectious diseases expert and state and/or local public health authorities and should involve consideration of many factors, depending on the stage of investigation and management, including (1) a careful history, physical examination, and investigations to elucidate the likelihood of the diagnosis of Ebola or other highly consequential infection; (2) ability of the facility to offer appropriate isolation for the person under investigation and family members and to manage Ebola; (3) ability to recognize and exclude people at increased risk of worse outcomes (eg, pregnant women); and (4) ability of parent/caregiver to follow instructions, including appropriate donning and doffing of personal protective equipment. (8/16)

http://pediatrics.aappublications.org/content/138/3/e20161891

PARENT-PROVIDER-COMMUNITY PARTNERSHIPS: OPTIMIZING OUTCOMES FOR CHILDREN WITH DISABILITIES (CLINICAL REPORT) Nancy A. Murphy, MD; Paul S. Carbone, MD; and Council on Children With Disabilities ABSTRACT. Children with disabilities and their families have multifaceted medical, developmental, educational, and habilitative needs that are best addressed through strong partnerships among parents, providers, and communities. However, traditional health care systems are designed to address acute rather than chronic conditions. Children with disabilities require high-quality medical homes that provide care coordination and transitional care, and their families require social and financial supports. Integrated community systems of care that promote participation of all children are needed. The purpose of this clinical report is to explore the challenges of developing effective community-based systems of care and to offer suggestions to pediatricians and policy-makers regarding the development of partnerships among children with disabilities, their families, and health care and other providers to maximize health and well-being of these children and their families. (9/11, reaffirmed 5/17)

http://pediatrics.aappublications.org/content/128/4/795

POLICY TITLES AND ABSTRACTS

PATENT DUCTUS ARTERIOSUS IN PRETERM INFANTS William E. Benitz, MD, FAAP, and Committee on Fetus and Newborn ABSTRACT. Despite a large body of basic science and clinical research and clinical experience with thousands of infants over nearly 6 decades, there is still uncertainty and controversy about the significance, evaluation, and management of patent ductus arteriosus in preterm infants, resulting in substantial heterogeneity in clinical practice. The purpose of this clinical report is to summarize the evidence available to guide evaluation and treatment of preterm infants with prolonged ductal patency in the first few weeks after birth. (12/15)

http://pediatrics.aappublications.org/content/137/1/e20153730

PATIENT- AND FAMILY-CENTERED CARE AND THE PEDIATRICIAN’S ROLE Committee on Hospital Care and Institute for Patient- and FamilyCentered Care ABSTRACT. Drawing on several decades of work with families, pediatricians, other health care professionals, and policy makers, the American Academy of Pediatrics provides a definition of patient- and family-centered care. In pediatrics, patient- and family-centered care is based on the understanding that the family is the child’s primary source of strength and support. Further, this approach to care recognizes that the perspectives and information provided by families, children, and young adults are essential components of high-quality clinical decision-making, and that patients and family are integral partners with the health care team. This policy statement outlines the core principles of patient- and family-centered care, summarizes some of the recent literature linking patient- and family-centered care to improved health outcomes, and lists various other benefits to be expected when engaging in patient- and family-centered pediatric practice. The statement concludes with specific recommendations for how pediatricians can integrate patient- and family-centered care in hospitals, clinics, and community settings, and in broader systems of care, as well. (1/12)

http://pediatrics.aappublications.org/content/129/2/394

PATIENT- AND FAMILY-CENTERED CARE AND THE ROLE OF THE EMERGENCY PHYSICIAN PROVIDING CARE TO A CHILD IN THE EMERGENCY DEPARTMENT Committee on Pediatric Emergency Medicine (joint with American College of Emergency Physicians) ABSTRACT. Patient- and family-centered care is an approach to health care that recognizes the role of the family in providing medical care; encourages collaboration between the patient, family, and health care professionals; and honors individual and family strengths, cultures, traditions, and expertise. Although there are many opportunities for providing patient- and familycentered care in the emergency department, there are also challenges to doing so. The American Academy of Pediatrics and the American College of Emergency Physicians support promoting patient dignity, comfort, and autonomy; recognizing the patient and family as key decision-makers in the patient’s medical care; recognizing the patient’s experience and perspective in a culturally sensitive manner; acknowledging the interdependence of child and parent as well as the pediatric patient’s evolving independence; encouraging family-member presence; providing information to the family during interventions; encouraging collaboration with other health care professionals; acknowledging the importance of the patient’s medical home; and encouraging institutional policies for patient- and family-centered care. (11/06, reaffirmed 6/09, 10/11, 9/15)

http://pediatrics.aappublications.org/content/118/5/2242

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PATIENT- AND FAMILY-CENTERED CARE COORDINATION: A FRAMEWORK FOR INTEGRATING CARE FOR CHILDREN AND YOUTH ACROSS MULTIPLE SYSTEMS Council on Children With Disabilities and Medical Home Implementation Project Advisory Committee ABSTRACT. Understanding a care coordination framework, its functions, and its effects on children and families is critical for patients and families themselves, as well as for pediatricians, pediatric medical subspecialists/surgical specialists, and anyone providing services to children and families. Care coordination is an essential element of a transformed American health care delivery system that emphasizes optimal quality and cost outcomes, addresses family-centered care, and calls for partnership across various settings and communities. High-quality, costeffective health care requires that the delivery system include elements for the provision of services supporting the coordination of care across settings and professionals. This requirement of supporting coordination of care is generally true for health systems providing care for all children and youth but especially for those with special health care needs. At the foundation of an efficient and effective system of care delivery is the patient-/ family-centered medical home. From its inception, the medical home has had care coordination as a core element. In general, optimal outcomes for children and youth, especially those with special health care needs, require interfacing among multiple care systems and individuals, including the following: medical, social, and behavioral professionals; the educational system; payers; medical equipment providers; home care agencies; advocacy groups; needed supportive therapies/services; and families. Coordination of care across settings permits an integration of services that is centered on the comprehensive needs of the patient and family, leading to decreased health care costs, reduction in fragmented care, and improvement in the patient/ family experience of care. (4/14)

http://pediatrics.aappublications.org/content/133/5/e1451

PATIENT- AND FAMILY-CENTERED CARE OF CHILDREN IN THE EMERGENCY DEPARTMENT (TECHNICAL REPORT) Nanette Dudley, MD; Alice Ackerman, MD, MBA; Kathleen M. Brown, MD; Sally K. Snow, BSN, RN; and Committee on Pediatric Emergency Medicine (joint with American College of Emergency Physicians Pediatric Emergency Medicine Committee and Emergency Nurses Association Pediatric Committee) ABSTRACT. Patient- and family-centered care is an approach to the planning, delivery, and evaluation of health care that is grounded in a mutually beneficial partnership among patients, families, and health care professionals. Providing patient- and family-centered care to children in the emergency department setting presents many opportunities and challenges. This revised technical report draws on previously published policy statements and reports, reviews the current literature, and describes the present state of practice and research regarding patient- and family-centered care for children in the emergency department setting as well as some of the complexities of providing such care. (12/14)

http://pediatrics.aappublications.org/content/135/1/e255

PATIENT SAFETY IN THE PEDIATRIC EMERGENCY CARE SETTING Committee on Pediatric Emergency Medicine ABSTRACT. Patient safety is a priority for all health care professionals, including those who work in emergency care. Unique aspects of pediatric care may increase the risk of medical error and harm to patients, especially in the emergency care setting. Although errors can happen despite the best human efforts, given the right set of circumstances, health care professionals must work proactively to improve safety in the pediatric

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e­ mergency care system. Specific recommendations to improve pediatric patient safety in the emergency department are provided in this policy statement. (12/07, reaffirmed 6/11, 7/14)

http://pediatrics.aappublications.org/content/120/6/1367

PEDESTRIAN SAFETY Committee on Injury, Violence, and Poison Prevention ABSTRACT. Each year, approximately 900 pediatric pedestrians younger than 19 years are killed. In addition, 51000 children are injured as pedestrians, and 5300 of them are hospitalized because of their injuries. Parents should be warned that young children often do not have the cognitive, perceptual, and behavioral abilities to negotiate traffic independently. Parents should also be informed about the danger of vehicle back-over injuries to toddlers playing in driveways. Because posttraumatic stress syndrome commonly follows even minor pedestrian injury, pediatricians should screen and refer for this condition as necessary. The American Academy of Pediatrics supports community- and school-based strategies that minimize a child’s exposure to traffic, especially to high-speed, high-volume traffic. Furthermore, the American Academy of Pediatrics supports governmental and industry action that would lead to improvements in vehicle design, driver manuals, driver education, and data collection for the purpose of reducing pediatric pedestrian injury. (7/09, reaffirmed 8/13)

http://pediatrics.aappublications.org/content/124/2/802

PEDIATRIC AND ADOLESCENT MENTAL HEALTH EMERGENCIES IN THE EMERGENCY MEDICAL SERVICES SYSTEM (TECHNICAL REPORT) Margaret A. Dolan, MD; Joel A. Fein, MD, MPH; and Committee on Pediatric Emergency Medicine ABSTRACT. Emergency department (ED) health care professionals often care for patients with previously diagnosed psychiatric illnesses who are ill, injured, or having a behavioral crisis. In addition, ED personnel encounter children with psychiatric illnesses who may not present to the ED with overt mental health symptoms. Staff education and training regarding identification and management of pediatric mental health illness can help EDs overcome the perceived limitations of the setting that influence timely and comprehensive evaluation. In addition, ED physicians can inform and advocate for policy changes at local, state, and national levels that are needed to ensure comprehensive care of children with mental health illnesses. This report addresses the roles that the ED and ED health care professionals play in emergency mental health care of children and adolescents in the United States, which includes the stabilization and management of patients in mental health crisis, the discovery of mental illnesses and suicidal ideation in ED patients, and approaches to advocating for improved recognition and treatment of mental illnesses in children. The report also addresses special issues related to mental illness in the ED, such as minority populations, children with special health care needs, and children’s mental health during and after disasters and trauma. (4/11, reaffirmed 7/14)

http://pediatrics.aappublications.org/content/127/5/e1356

PEDIATRIC ANTHRAX CLINICAL MANAGEMENT (CLINICAL REPORT) John S. Bradley, MD, FAAP, FIDSA, FPIDS; Georgina Peacock, MD, MPH, FAAP; Steven E. Krug, MD, FAAP; William A. Bower, MD, FIDSA; Amanda C. Cohn, MD; Dana MeaneyDelman, MD, MPH, FACOG; Andrew T. Pavia, MD, FAAP, FIDSA; Committee on Infectious Diseases; and Disaster Preparedness Advisory Council ABSTRACT. Anthrax is a zoonotic disease caused by Bacillus anthracis, which has multiple routes of infection in humans, manifesting in different initial presentations of disease. Because

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B anthracis has the potential to be used as a biological weapon and can rapidly progress to systemic anthrax with high mortality in those who are exposed and untreated, clinical guidance that can be quickly implemented must be in place before any intentional release of the agent. This document provides clinical guidance for the prophylaxis and treatment of neonates, infants, children, adolescents, and young adults up to the age of 21 (referred to as “children”) in the event of a deliberate B anthracis release and offers guidance in areas where the unique characteristics of children dictate a different clinical recommendation from adults. (4/14)

http://pediatrics.aappublications.org/content/133/5/e1411

PEDIATRIC ANTHRAX CLINICAL MANAGEMENT: EXECUTIVE SUMMARY John S. Bradley, MD, FAAP, FIDSA, FPIDS; Georgina Peacock, MD, MPH, FAAP; Steven E. Krug, MD, FAAP; William A. Bower, MD, FIDSA; Amanda C. Cohn, MD; Dana MeaneyDelman, MD, MPH, FACOG; Andrew T. Pavia, MD, FAAP, FIDSA; Committee on Infectious Diseases; and Disaster Preparedness Advisory Council The use of Bacillus anthracis as a biological weapon is considered a potential national security threat by the US government. B anthracis has the ability to be used as a biological weapon and to cause anthrax, which can rapidly progress to systemic disease with high mortality in those who are untreated. Therefore, clear plans for managing children after a B anthracis bioterror exposure event must be in place before any intentional release of the agent. This document provides a summary of the guidance contained in the clinical report (appendices cited in this executive summary refer to those in the clinical report) for diagnosis and management of anthrax, including antimicrobial treatment and postexposure prophylaxis (PEP), use of antitoxin, and recommendations for use of anthrax vaccine in neonates, infants, children, adolescents, and young adults up to the age of 21 years (referred to as “children”). (4/14)

http://pediatrics.aappublications.org/content/133/5/940

PEDIATRIC ASPECTS OF INPATIENT HEALTH INFORMATION TECHNOLOGY SYSTEMS (TECHNICAL REPORT) Christoph U. Lehmann, MD, FAAP, FACMI, and Council on Clinical Information Technology ABSTRACT. In the past 3 years, the Health Information Technology for Economic and Clinical Health Act accelerated the adoption of electronic health records (EHRs) with providers and hospitals, who can claim incentive monies related to meaningful use. Despite the increase in adoption of commercial EHRs in pediatric settings, there has been little support for EHR tools and functionalities that promote pediatric quality improvement and patient safety, and children remain at higher risk than adults for medical errors in inpatient environments. Health information technology (HIT) tailored to the needs of pediatric health care providers can improve care by reducing the likelihood of errors through information assurance and minimizing the harm that results from errors. This technical report outlines pediatricspecific concepts, child health needs and their data elements, and required functionalities in inpatient clinical information systems that may be missing in adult-oriented HIT systems with negative consequences for pediatric inpatient care. It is imperative that inpatient (and outpatient) HIT systems be adapted to improve their ability to properly support safe health care delivery for children. (2/15)

http://pediatrics.aappublications.org/content/135/3/e756

POLICY TITLES AND ABSTRACTS

PEDIATRIC FELLOWSHIP TRAINING Federation of Pediatric Organizations (7/04)

http://pediatrics.aappublications.org/content/114/1/295 PEDIATRIC INTEGRATIVE MEDICINE (CLINICAL REPORT) Hilary McClafferty, MD, FAAP; Sunita Vohra, MD, FAAP; Michelle Bailey, MD, FAAP; Melanie Brown, MD, MSE, FAAP; Anna Esparham, MD, FAAP; Dana Gerstbacher, MD, FAAP; Brenda Golianu, MD, FAAP; Anna-Kaisa Niemi, MD, PhD, FAAP, FACMG; Erica Sibinga, MD, FAAP; Joy Weydert, MD, FAAP; Ann Ming Yeh, MD; and Section on Integrative Medicine ABSTRACT. The American Academy of Pediatrics is dedicated to optimizing the well-being of children and advancing familycentered health care. Related to this mission, the American Academy of Pediatrics recognizes the increasing use of complementary and integrative therapies for children and the subsequent need to provide reliable information and high-quality clinical resources to support pediatricians. This Clinical Report serves as an update to the original 2008 statement on complementary medicine. The range of complementary therapies is both extensive and diverse. Therefore, in-depth discussion of each therapy or product is beyond the scope of this report. Instead, our intentions are to define terms; describe epidemiology of use; outline common types of complementary therapies; review medicolegal, ethical, and research implications; review education and training for select providers of complementary therapies; provide educational resources; and suggest communication strategies for discussing complementary therapies with patients and families. (8/17) See full text on page 1027.

http://pediatrics.aappublications.org/content/140/3/e20171961

PEDIATRIC MENTAL HEALTH EMERGENCIES IN THE EMERGENCY MEDICAL SERVICES SYSTEM Committee on Pediatric Emergency Medicine (joint with American College of Emergency Physicians) ABSTRACT. Emergency departments are vital in the management of pediatric patients with mental health emergencies. Pediatric mental health emergencies are an increasing part of emergency medical practice because emergency departments have become the safety net for a fragmented mental health infrastructure that is experiencing critical shortages in services in all sectors. Emergency departments must safely, humanely, and in a culturally and developmentally appropriate manner manage pediatric patients with undiagnosed and known mental illnesses, including those with mental retardation, autistic spectrum disorders, and attention-deficit/hyperactivity disorder and those experiencing a behavioral crisis. Emergency departments also manage patients with suicidal ideation, depression, escalating aggression, substance abuse, posttraumatic stress disorder, and maltreatment and those exposed to violence and unexpected deaths. Emergency departments must address not only the physical but also the mental health needs of patients during and after mass-casualty incidents and disasters. The American Academy of Pediatrics and the American College of Emergency Physicians support advocacy for increased mental health resources, including improved pediatric mental health tools for the emergency department, increased mental health insurance coverage, and adequate reimbursement at all levels; acknowledgment of the importance of the child’s medical home; and promotion of education and research for mental health emergencies. (10/06, reaffirmed 6/09, 4/13)

http://pediatrics.aappublications.org/content/118/4/1764

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PEDIATRIC OBSERVATION UNITS (CLINICAL REPORT) Gregory P. Conners, MD, MPH, MBA; Sanford M. Melzer, MD, MBA; Committee on Hospital Care; and Committee on Pediatric Emergency Medicine ABSTRACT. Pediatric observation units (OUs) are hospital areas used to provide medical evaluation and/or management for health-related conditions in children, typically for a welldefined, brief period. Pediatric OUs represent an emerging alternative site of care for selected groups of children who historically may have received their treatment in an ambulatory setting, emergency department, or hospital-based inpatient unit. This clinical report provides an overview of pediatric OUs, including the definitions and operating characteristics of different types of OUs, quality considerations and coding for observation services, and the effect of OUs on inpatient hospital utilization. (6/12, reaffirmed 9/15)

http://pediatrics.aappublications.org/content/130/1/172

PEDIATRIC ORGAN DONATION AND TRANSPLANTATION Committee on Hospital Care, Section on Surgery, and Section on Critical Care ABSTRACT. Pediatric organ donation and organ transplantation can have a significant life-extending benefit to the young recipients of these organs and a high emotional impact on donor and recipient families. Pediatricians, pediatric medical specialists, and pediatric transplant surgeons need to be better acquainted with evolving national strategies that involve organ procurement and organ transplantation to help acquaint families with the benefits and risks of organ donation and transplantation. Efforts of pediatric professionals are needed to shape public policies to provide a system in which procurement, distribution, and cost are fair and equitable to children and adults. Major issues of concern are availability of and access to donor organs; oversight and control of the process; pediatric medical and surgical consultation and continued care throughout the organ-donation and transplantation process; ethical, social, financial, and follow-up issues; insurance-coverage issues; and public awareness of the need for organ donors of all ages. (3/10, reaffirmed 3/14)

http://pediatrics.aappublications.org/content/125/4/822

PEDIATRIC PALLIATIVE CARE AND HOSPICE CARE COMMITMENTS, GUIDELINES, AND RECOMMENDATIONS Section on Hospice and Palliative Medicine and Committee on Hospital Care ABSTRACT. Pediatric palliative care and pediatric hospice care (PPC-PHC) are often essential aspects of medical care for patients who have life-threatening conditions or need end-of-life care. PPC-PHC aims to relieve suffering, improve quality of life, facilitate informed decision-making, and assist in care coordination between clinicians and across sites of care. Core commitments of PPC-PHC include being patient centered and family engaged; respecting and partnering with patients and families; pursuing care that is high quality, readily accessible, and equitable; providing care across the age spectrum and life span, integrated into the continuum of care; ensuring that all clinicians can provide basic palliative care and consult PPC-PHC specialists in a timely manner; and improving care through research and quality improvement efforts. PPC-PHC guidelines and recommendations include ensuring that all large health care organizations serving children with life-threatening conditions have dedicated interdisciplinary PPC-PHC teams, which should develop collaborative relationships between hospital- and community-based teams; that PPC-PHC be provided as integrated multimodal care and practiced as a cornerstone of patient safety and quality for patients with life-threatening conditions; that PPC-PHC teams should facilitate clear, compassionate, and forthright discussions about medical issues and the goals of care and support

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families, siblings, and health care staff; that PPC-PHC be part of all pediatric education and training curricula, be an active area of research and quality improvement, and exemplify the highest ethical standards; and that PPC-PHC services be supported by financial and regulatory arrangements to ensure access to high-quality PPC-PHC by all patients with life-threatening and life-shortening diseases. (10/13)

http://pediatrics.aappublications.org/content/132/5/966

PEDIATRIC PRIMARY HEALTH CARE Committee on Pediatric Workforce ABSTRACT. Primary health care is described as accessible and affordable, first contact, continuous and comprehensive, and coordinated to meet the health needs of the individual and the family being served. Pediatric primary health care encompasses health supervision and anticipatory guidance; monitoring physical and psychosocial growth and development; age-appropriate screening; diagnosis and treatment of acute and chronic disorders; management of serious and life-threatening illness and, when appropriate, referral of more complex conditions; and provision of first contact care as well as coordinated management of health problems requiring multiple professional services. Pediatric primary health care for children and adolescents is family centered and incorporates community resources and strengths, needs and risk factors, and sociocultural sensitivities into strategies for care delivery and clinical practice. Pediatric primary health care is best delivered within the context of a “medical home,” where comprehensive, continuously accessible and affordable care is available and delivered or supervised by qualified child health specialists. The pediatrician, because of training (which includes 4 years of medical school education, plus an additional 3 or more years of intensive training devoted solely to all aspects of medical care for children and adolescents), coupled with the demonstrated interest in and total professional commitment to the health care of infants, children, adolescents, and young adults, is the most appropriate provider of pediatric primary health care. (1/11, reaffirmed 10/13)

http://pediatrics.aappublications.org/content/127/2/397

PEDIATRIC SUDDEN CARDIAC ARREST Section on Cardiology and Cardiac Surgery ABSTRACT. Pediatric sudden cardiac arrest (SCA), which can cause sudden cardiac death if not treated within minutes, has a profound effect on everyone: children, parents, family members, communities, and health care providers. Preventing the tragedy of pediatric SCA, defined as the abrupt and unexpected loss of heart function, remains a concern to all. The goal of this statement is to increase the knowledge of pediatricians (including primary care providers and specialists) of the incidence of pediatric SCA, the spectrum of causes of pediatric SCA, diseasespecific presentations, the role of patient and family screening, the rapidly evolving role of genetic testing, and finally, important aspects of secondary SCA prevention. This statement is not intended to address sudden infant death syndrome or sudden unexplained death syndrome, nor will specific treatment of individual cardiac conditions be discussed. This statement has been endorsed by the American College of Cardiology, the American Heart Association, and the Heart Rhythm Society. (3/12)

http://pediatrics.aappublications.org/content/129/4/e1094

THE PEDIATRICIAN AND CHILDHOOD BEREAVEMENT Committee on Psychosocial Aspects of Child and Family Health ABSTRACT. Pediatricians should understand and evaluate children’s reactions to the death of a person important to them by using age-appropriate and culturally sensitive guidance

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while being alert for normal and complicated grief responses. Pediatricians also should advise and assist families in responding to the child’s needs. Sharing, family support, and communication have been associated with positive long-term bereavement adjustment. (2/00, reaffirmed 1/04, 3/13)

http://pediatrics.aappublications.org/content/105/2/445

THE PEDIATRICIAN WORKFORCE: CURRENT STATUS AND FUTURE PROSPECTS (TECHNICAL REPORT) David C. Goodman, MD, MS, and Committee on Pediatric Workforce ABSTRACT. The effective and efficient delivery of children’s health care depends on the pediatrician workforce. The number, composition, and distribution of pediatricians necessary to deliver this care have been the subject of long-standing policy and professional debate. This technical report reviews current characteristics and recent trends in the pediatric workforce and couples the workforce to a conceptual model of improvement in children’s health and well-being. Important recent changes in the workforce include (1) the growth in the number of pediatricians in relation to the child population, (2) increased numbers of female pediatricians and their attainment of majority gender status in the specialty, (3) the persistence of a large number of international medical graduates entering training programs, (4) a lack of ethnic and racial diversity in pediatricians compared with children, and (5) the persistence of marked regional variation in pediatrician supply. Supply models projecting the pediatric workforce are reviewed and generally indicate that the number of pediatricians per child will increase by 50% over the next 20 years. The differing methods of assessing workforce requirements are presented and critiqued. The report finds that the pediatric workforce is undergoing fundamental changes that will have important effects on the professional lives of pediatricians and children’s health care delivery. (7/05)

http://pediatrics.aappublications.org/content/116/1/e156

PEDIATRICIAN WORKFORCE POLICY STATEMENT Committee on Pediatric Workforce ABSTRACT. This policy statement reviews important trends and other factors that affect the pediatrician workforce and the provision of pediatric health care, including changes in the pediatric patient population, pediatrician workforce, and nature of pediatric practice. The effect of these changes on pediatricians and the demand for pediatric care are discussed. The American Academy of Pediatrics (AAP) concludes that there is currently a shortage of pediatric medical subspecialists in many fields, as well as a shortage of pediatric surgical specialists. In addition, the AAP believes that the current distribution of primary care pediatricians is inadequate to meet the needs of children living in rural and other underserved areas, and more primary care pediatricians will be needed in the future because of the increasing number of children who have significant chronic health problems, changes in physician work hours, and implementation of current health reform efforts that seek to improve access to comprehensive patient- and family-centered care for all children in a medical home. The AAP is committed to being an active participant in physician workforce policy development with both professional organizations and governmental bodies to ensure a pediatric perspective on health care workforce issues. The overall purpose of this statement is to summarize policy recommendations and serve as a resource for the AAP and other stakeholders as they address pediatrician workforce issues that ultimately influence the quality of pediatric health care provided to children in the United States. (7/13)

http://pediatrics.aappublications.org/content/132/2/390

POLICY TITLES AND ABSTRACTS

PEDIATRICIAN-FAMILY-PATIENT RELATIONSHIPS: MANAGING THE BOUNDARIES Committee on Bioethics ABSTRACT. All professionals are concerned about maintaining the appropriate limits in their relationships with those they serve. Pediatricians should be aware that, under normal circumstances, caring for one’s own children presents significant ethical issues. Pediatricians also must strive to maintain appropriate professional boundaries in their relationships with the family members of their patients. Pediatricians should avoid behavior that patients and parents might misunderstand as having sexual or inappropriate social meaning. Romantic and sexual involvement between physicians and patients is unacceptable. The acceptance of gifts or nonmonetary compensation for medical services has the potential to affect the professional relationship adversely. (11/09, reaffirmed 1/14)

http://pediatrics.aappublications.org/content/124/6/1685

THE PEDIATRICIAN’S ROLE IN CHILD MALTREATMENT PREVENTION (CLINICAL REPORT) Emalee G. Flaherty, MD; John Stirling Jr, MD; and Committee on Child Abuse and Neglect ABSTRACT. It is the pediatrician’s role to promote the child’s well-being and to help parents raise healthy, well-adjusted children. Pediatricians, therefore, can play an important role in the prevention of child maltreatment. Previous clinical reports and policy statements from the American Academy of Pediatrics have focused on improving the identification and management of child maltreatment. This clinical report outlines how the pediatrician can help to strengthen families and promote safe, stable, nurturing relationships with the aim of preventing maltreatment. After describing some of the triggers and factors that place children at risk for maltreatment, the report describes how pediatricians can identify family strengths, recognize risk factors, provide helpful guidance, and refer families to programs and other resources with the goal of strengthening families, preventing child maltreatment, and enhancing child development. (9/10, reaffirmed 1/14)

http://pediatrics.aappublications.org/content/126/4/833

THE PEDIATRICIAN’S ROLE IN FAMILY SUPPORT AND FAMILY SUPPORT PROGRAMS Committee on Early Childhood, Adoption, and Dependent Care ABSTRACT. Children’s social, emotional, and physical health; their developmental trajectory; and the neurocircuits that are being created and reinforced in their developing brains are all directly influenced by their relationships during early childhood. The stresses associated with contemporary American life can challenge families’ abilities to promote successful developmental outcomes and emotional health for their children. Pediatricians are positioned to serve as partners with families and other community providers in supporting the well-being of children and their families. The structure and support of families involve forces that are often outside the agenda of the usual pediatric health supervision visits. Pediatricians must ensure that their medical home efforts promote a holistically healthy family environment for all children. This statement recommends opportunities for pediatricians to develop their expertise in assessing the strengths and stresses in families, in counseling families about strategies and resources, and in collaborating with others in their communities to support family relationships. (11/11, reaffirmed 12/16)

http://pediatrics.aappublications.org/content/128/6/e1680

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THE PEDIATRICIAN’S ROLE IN OPTIMIZING SCHOOL READINESS Council on Early Childhood and Council on School Health ABSTRACT. School readiness includes not only the early academic skills of children but also their physical health, language skills, social and emotional development, motivation to learn, creativity, and general knowledge. Families and communities play a critical role in ensuring children’s growth in all of these areas and thus their readiness for school. Schools must be prepared to teach all children when they reach the age of school entry, regardless of their degree of readiness. Research on early brain development emphasizes the effects of early experiences, relationships, and emotions on creating and reinforcing the neural connections that are the basis for learning. Pediatricians, by the nature of their relationships with families and children, may significantly influence school readiness. Pediatricians have a primary role in ensuring children’s physical health through the provision of preventive care, treatment of illness, screening for sensory deficits, and monitoring nutrition and growth. They can promote and monitor the social-emotional development of children by providing anticipatory guidance on development and behavior, by encouraging positive parenting practices, by modeling reciprocal and respectful communication with adults and children, by identifying and addressing psychosocial risk factors, and by providing community-based resources and referrals when warranted. Cognitive and language skills are fostered through timely identification of developmental problems and appropriate referrals for services, including early intervention and special education services; guidance regarding safe and stimulating early education and child care programs; and promotion of early literacy by encouraging language-rich activities such as reading together, telling stories, and playing games. Pediatricians are also well positioned to advocate not only for children’s access to health care but also for high-quality early childhood education and evidence-based family supports such as home visits, which help provide a foundation for optimal learning. (8/16)

http://pediatrics.aappublications.org/content/138/3/e20162293

THE PEDIATRICIAN’S ROLE IN SUPPORTING ADOPTIVE FAMILIES (CLINICAL REPORT) Veronnie F. Jones, MD, PhD; Elaine E. Schulte, MD, MPH; Committee on Early Childhood; and Council on Foster Care, Adoption, and Kinship Care ABSTRACT. Each year, more children join families through adoption. Pediatricians have an important role in assisting adoptive families in the various challenges they may face with respect to adoption. The acceptance of the differences between families formed through birth and those formed through adoption is essential in promoting positive emotional growth within the family. It is important for pediatricians to be aware of the adoptive parents’ need to be supported in their communication with their adopted children. (9/12, reaffirmed 12/16)

http://pediatrics.aappublications.org/content/130/4/e1040

THE PEDIATRICIAN’S ROLE IN THE EVALUATION AND PREPARATION OF PEDIATRIC PATIENTS UNDERGOING ANESTHESIA Section on Anesthesiology and Pain Medicine ABSTRACT. Pediatricians play a key role in helping prepare patients and families for anesthesia and surgery. The questions to be answered by the pediatrician fall into 2 categories. The first involves preparation: is the patient in optimal medical condition for surgery, and are the patient and family emotionally and cognitively ready for surgery? The second category concerns logistics: what communication and organizational needs are necessary to enable safe passage through the perioperative process?

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This revised statement updates the recommendations for the pediatrician’s role in the preoperative preparation of patients. (8/14)

http://pediatrics.aappublications.org/content/134/3/634

THE PEDIATRICIAN’S ROLE IN THE PREVENTION OF MISSING CHILDREN (CLINICAL REPORT) Committee on Psychosocial Aspects of Child and Family Health ABSTRACT. In 2002, the Second National Incidence Studies of Missing, Abducted, Runaway, and Thrownaway Children report was released by the US Department of Justice, providing new data on a problem that our nation continues to face. This clinical report describes the categories of missing children, the prevalence of each, and prevention strategies that primary care pediatricians can share with parents to increase awareness and education about the safety of their children. (10/04, reaffirmed 1/15)

http://pediatrics.aappublications.org/content/114/4/1100

PERSONAL WATERCRAFT USE BY CHILDREN AND ADOLESCENTS Committee on Injury and Poison Prevention ABSTRACT. The use of personal watercraft (PWC) has increased dramatically during the past decade as have the speed and mobility of the watercraft. A similar dramatic increase in PWCrelated injury and death has occurred simultaneously. No one younger than 16 years should operate a PWC. The operator and all passengers must wear US Coast Guard-approved personal flotation devices. Other safety recommendations are suggested for parents and pediatricians. (2/00, reaffirmed 5/04, 1/07, 6/10)

http://pediatrics.aappublications.org/content/105/2/452

PESTICIDE EXPOSURE IN CHILDREN Council on Environmental Health ABSTRACT. This statement presents the position of the American Academy of Pediatrics on pesticides. Pesticides are a collective term for chemicals intended to kill unwanted insects, plants, molds, and rodents. Children encounter pesticides daily and have unique susceptibilities to their potential toxicity. Acute poisoning risks are clear, and understanding of chronic health implications from both acute and chronic exposure are emerging. Epidemiologic evidence demonstrates associations between early life exposure to pesticides and pediatric cancers, decreased cognitive function, and behavioral problems. Related animal toxicology studies provide supportive biological plausibility for these findings. Recognizing and reducing problematic exposures will require attention to current inadequacies in medical training, public health tracking, and regulatory action on pesticides. Ongoing research describing toxicologic vulnerabilities and exposure factors across the life span are needed to inform regulatory needs and appropriate interventions. Policies that promote integrated pest management, comprehensive pesticide labeling, and marketing practices that incorporate child health considerations will enhance safe use. (11/12)

http://pediatrics.aappublications.org/content/130/6/e1757

PESTICIDE EXPOSURE IN CHILDREN (TECHNICAL REPORT) James R. Roberts, MD, MPH; Catherine J. Karr, MD, PhD; and Council on Environmental Health ABSTRACT. Pesticides are a collective term for a wide array of chemicals intended to kill unwanted insects, plants, molds, and rodents. Food, water, and treatment in the home, yard, and school are all potential sources of children’s exposure. Exposures to pesticides may be overt or subacute, and effects range from acute to chronic toxicity. In 2008, pesticides were the ninth most common substance reported to poison control centers, and approximately 45% of all reports of pesticide poisoning were for

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children. Organophosphate and carbamate poisoning are perhaps the most widely known acute poisoning syndromes, can be diagnosed by depressed red blood cell cholinesterase levels, and have available antidotal therapy. However, numerous other pesticides that may cause acute toxicity, such as pyrethroid and neonicotinoid insecticides, herbicides, fungicides, and rodenticides, also have specific toxic effects; recognition of these effects may help identify acute exposures. Evidence is increasingly emerging about chronic health implications from both acute and chronic exposure. A growing body of epidemiological evidence demonstrates associations between parental use of pesticides, particularly insecticides, with acute lymphocytic leukemia and brain tumors. Prenatal, household, and occupational exposures (maternal and paternal) appear to be the largest risks. Prospective cohort studies link early-life exposure to organophosphates and organochlorine pesticides (primarily DDT) with adverse effects on neurodevelopment and behavior. Among the findings associated with increased pesticide levels are poorer mental development by using the Bayley index and increased scores on measures assessing pervasive developmental disorder, inattention, and attention-deficit/hyperactivity disorder. Related animal toxicology studies provide supportive biological plausibility for these findings. Additional data suggest that there may also be an association between parental pesticide use and adverse birth outcomes including physical birth defects, low birth weight, and fetal death, although the data are less robust than for cancer and neurodevelopmental effects. Children’s exposures to pesticides should be limited as much as possible. (11/12)

http://pediatrics.aappublications.org/content/130/6/e1765

PHOTOTHERAPY TO PREVENT SEVERE NEONATAL HYPERBILIRUBINEMIA IN THE NEWBORN INFANT 35 OR MORE WEEKS OF GESTATION (TECHNICAL REPORT) Vinod K. Bhutani, MD, and Committee on Fetus and Newborn ABSTRACT. Objective. To standardize the use of phototherapy consistent with the American Academy of Pediatrics clinical practice guideline for the management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Methods. Relevant literature was reviewed. Phototherapy devices currently marketed in the United States that incorporate fluorescent, halogen, fiber-optic, or blue light-emitting diode light sources were assessed in the laboratory. Results. The efficacy of phototherapy units varies widely because of differences in light source and configuration. The following characteristics of a device contribute to its effectiveness: (1) emission of light in the blue-to-green range that overlaps the in vivo plasma bilirubin absorption spectrum (~460–490 nm); (2) irradiance of at least 30  µW·cm–2·nm–1 (confirmed with an appropriate irradiance meter calibrated over the appropriate wavelength range); (3) illumination of maximal body surface; and (4) demonstration of a decrease in total bilirubin concentrations during the first 4 to 6 hours of exposure. Recommendations. The intensity and spectral output of phototherapy devices is useful in predicting potential effectiveness in treating hyperbilirubinemia (group B recommendation). Clinical effectiveness should be evaluated before and monitored during use (group B recommendation). Blocking the light source or reducing exposed body surface should be avoided (group B recommendation). Standardization of irradiance meters, improvements in device design, and lower-upper limits of light intensity for phototherapy units merit further study. Comparing the in vivo performance of devices is not practical, in general, and alternative procedures need to be explored. (9/11, reaffirmed 7/14)

http://pediatrics.aappublications.org/content/128/4/e1046

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PHYSICIAN HEALTH AND WELLNESS (CLINICAL REPORT) Hilary McClafferty, MD, FAAP; Oscar W. Brown, MD, FAAP; Section on Integrative Medicine; and Committee on Practice and Ambulatory Medicine ABSTRACT. Physician health and wellness is a critical issue gaining national attention because of the high prevalence of physician burnout. Pediatricians and pediatric trainees experience burnout at levels equivalent to other medical specialties, highlighting a need for more effective efforts to promote health and well-being in the pediatric community. This report will provide an overview of physician burnout, an update on work in the field of preventive physician health and wellness, and a discussion of emerging initiatives that have potential to promote health at all levels of pediatric training. Pediatricians are uniquely positioned to lead this movement nationally, in part because of the emphasis placed on wellness in the Pediatric Milestone Project, a joint collaboration between the Accreditation Council for Graduate Medical Education and the American Board of Pediatrics. Updated core competencies calling for a balanced approach to health, including focus on nutrition, exercise, mindfulness, and effective stress management, signal a paradigm shift and send the message that it is time for pediatricians to cultivate a culture of wellness better aligned with their responsibilities as role models and congruent with advances in pediatric training. Rather than reviewing programs in place to address substance abuse and other serious conditions in distressed physicians, this article focuses on forward progress in the field, with an emphasis on the need for prevention and anticipation of predictable stressors related to burnout in medical training and practice. Examples of positive progress and several programs designed to promote physician health and wellness are reviewed. Areas where more research is needed are highlighted. (9/14)

http://pediatrics.aappublications.org/content/134/4/830

PHYSICIAN REFUSAL TO PROVIDE INFORMATION OR TREATMENT ON THE BASIS OF CLAIMS OF CONSCIENCE Committee on Bioethics ABSTRACT. Health care professionals may have moral objections to particular medical interventions. They may refuse to provide or cooperate in the provision of these interventions. Such objections are referred to as conscientious objections. Although it may be difficult to characterize or validate claims of conscience, respecting the individual physician’s moral integrity is important. Conflicts arise when claims of conscience impede a patient’s access to medical information or care. A physician’s conscientious objection to certain interventions or treatments may be constrained in some situations. Physicians have a duty to disclose to prospective patients treatments they refuse to perform. As part of informed consent, physicians also have a duty to inform their patients of all relevant and legally available treatment options, including options to which they object. They have a moral obligation to refer patients to other health care professionals who are willing to provide those services when failing to do so would cause harm to the patient, and they have a duty to treat patients in emergencies when referral would significantly increase the probability of mortality or serious morbidity. Conversely, the health care system should make reasonable accommodations for physicians with conscientious objections. (11/09, reaffirmed 1/14)

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PHYSICIANS’ ROLES IN COORDINATING CARE OF HOSPITALIZED CHILDREN (CLINICAL REPORT) Patricia S. Lye, MD; Committee on Hospital Care; and Section on Hospital Medicine ABSTRACT. The care of hospitalized children and adolescents has become increasingly complex and often involves multiple physicians beyond the traditional primary care pediatrician. Hospitalists, medical subspecialists, surgical specialists, and hospital attending physicians may all participate in the care of hospitalized children and youth. This report summarizes the responsibilities of the pediatrician and other involved physicians in ensuring that children receive coordinated and comprehensive medical care delivered within the context of their medical homes as inpatients, and that care is appropriately continued on an outpatient basis. (9/10, reaffirmed 7/14)

http://pediatrics.aappublications.org/content/126/4/829

PLANNED HOME BIRTH Committee on Fetus and Newborn ABSTRACT. The American Academy of Pediatrics concurs with the recent statement of the American College of Obstetricians and Gynecologists affirming that hospitals and birthing centers are the safest settings for birth in the United States while respecting the right of women to make a medically informed decision about delivery. This statement is intended to help pediatricians provide supportive, informed counsel to women considering home birth while retaining their role as child advocates and to summarize the standards of care for newborn infants born at home, which are consistent with standards for infants born in a medical care facility. Regardless of the circumstances of his or her birth, including location, every newborn infant deserves health care that adheres to the standards highlighted in this statement, more completely described in other publications from the American Academy of Pediatrics, including Guidelines for Perinatal Care. The goal of providing high-quality care to all newborn infants can best be achieved through continuing efforts by all participating health care providers and institutions to develop and sustain communications and understanding on the basis of professional interaction and mutual respect throughout the health care system. (4/13, reaffirmed 12/16)

http://pediatrics.aappublications.org/content/131/5/1016

POINT-OF-CARE ULTRASONOGRAPHY BY PEDIATRIC EMERGENCY MEDICINE PHYSICIANS Committee on Pediatric Emergency Medicine (joint with Society for Academic Emergency Medicine Academy of Emergency Ultrasound, American College of Emergency Physicians Pediatric Emergency Medicine Committee, and World Interactive Network Focused on Critical Ultrasound) ABSTRACT. Point-of-care ultrasonography is increasingly being used to facilitate accurate and timely diagnoses and to guide procedures. It is important for pediatric emergency medicine (PEM) physicians caring for patients in the emergency department to receive adequate and continued point-of-care ultrasonography training for those indications used in their practice setting. Emergency departments should have credentialing and quality assurance programs. PEM fellowships should provide appropriate training to physician trainees. Hospitals should provide privileges to physicians who demonstrate competency in point-of-care ultrasonography. Ongoing research will provide the necessary measures to define the optimal training and competency assessment standards. Requirements for credentialing and hospital privileges will vary and will be specific to individual departments and hospitals. As more physicians are trained and more research is completed, there should be one national standard for credentialing and privileging in point-of-care ultrasonography for PEM physicians. (3/15)

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POINT-OF-CARE ULTRASONOGRAPHY BY PEDIATRIC EMERGENCY MEDICINE PHYSICIANS (TECHNICAL REPORT) Jennifer R. Marin, MD, MSc; Resa E. Lewiss, MD; and Committee on Pediatric Emergency Medicine (joint with Society for Academic Emergency Medicine Academy of Emergency Ultrasound, American College of Emergency Physicians Pediatric Emergency Medicine Committee, and World Interactive Network Focused on Critical Ultrasound) ABSTRACT. Emergency physicians have used point-of-care ultrasonography since the 1990s. Pediatric emergency medicine physicians have more recently adopted this technology. Point-of-care ultrasonography is used for various scenarios, particularly the evaluation of soft tissue infections or blunt abdominal trauma and procedural guidance. To date, there are no published statements from national organizations specifically for pediatric emergency physicians describing the incorporation of point-of-care ultrasonography into their practice. This document outlines how pediatric emergency departments may establish a formal point-of-care ultrasonography program. This task includes appointing leaders with expertise in point-of-care ultrasonography, effectively training and credentialing physicians in the department, and providing ongoing quality assurance reviews. Point-of-care ultrasonography (US) is a bedside technology that enables clinicians to integrate clinical examination findings with real-time sonographic imaging. General emergency physicians and other specialists have used point-of-care US for many years, and more recently, pediatric emergency medicine (PEM) physicians have adopted point-of-care US as a diagnostic and procedural adjunct. This technical report and accompanying policy statement provide a framework for point-of-care US training and point-of-care US integration into pediatric care by PEM physicians. (3/15)

http://pediatrics.aappublications.org/content/135/4/e1113

POSTDISCHARGE FOLLOW-UP OF INFANTS WITH CONGENITAL DIAPHRAGMATIC HERNIA (CLINICAL REPORT) Section on Surgery and Committee on Fetus and Newborn ABSTRACT. Infants with congenital diaphragmatic hernia often require intensive treatment after birth, have prolonged hospitalizations, and have other congenital anomalies. After discharge from the hospital, they may have long-term sequelae such as respiratory insufficiency, gastroesophageal reflux, poor growth, neurodevelopmental delay, behavior problems, hearing loss, hernia recurrence, and orthopedic deformities. Structured follow-up for these patients facilitates early recognition and treatment of these complications. In this report, follow-up of infants with congenital diaphragmatic hernia is outlined. (3/08, reaffirmed 5/11)

http://pediatrics.aappublications.org/content/121/3/627

POSTNATAL CORTICOSTEROIDS TO PREVENT OR TREAT BRONCHOPULMONARY DYSPLASIA Kristi L. Watterberg, MD, and Committee on Fetus and Newborn ABSTRACT. The purpose of this revised statement is to review current information on the use of postnatal glucocorticoids to prevent or treat bronchopulmonary dysplasia in the preterm infant and to make updated recommendations regarding their use. High-dose dexamethasone (0.5 mg/kg per day) does not seem to confer additional therapeutic benefit over lower doses and is not recommended. Evidence is insufficient to make a recommendation regarding other glucocorticoid doses and preparations. The clinician must use clinical judgment when attempting to balance the potential adverse effects of g ­ lucocorticoid

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treatment with those of bronchopulmonary dysplasia. (9/10, reaffirmed 1/14)

http://pediatrics.aappublications.org/content/126/4/800

POSTNATAL GLUCOSE HOMEOSTASIS IN LATE-PRETERM AND TERM INFANTS (CLINICAL REPORT) David H. Adamkin, MD, and Committee on Fetus and Newborn ABSTRACT. This report provides a practical guide and algorithm for the screening and subsequent management of neonatal hypoglycemia. Current evidence does not support a specific concentration of glucose that can discriminate normal from abnormal or can potentially result in acute or chronic irreversible neurologic damage. Early identification of the at-risk infant and institution of prophylactic measures to prevent neonatal hypoglycemia are recommended as a pragmatic approach despite the absence of a consistent definition of hypoglycemia in the literature. (3/11, reaffirmed 6/15)

http://pediatrics.aappublications.org/content/127/3/575

POVERTY AND CHILD HEALTH IN THE UNITED STATES Council on Community Pediatrics ABSTRACT. Almost half of young children in the United States live in poverty or near poverty. The American Academy of Pediatrics is committed to reducing and ultimately eliminating child poverty in the United States. Poverty and related social determinants of health can lead to adverse health outcomes in childhood and across the life course, negatively affecting physical health, socioemotional development, and educational achievement. The American Academy of Pediatrics advocates for programs and policies that have been shown to improve the quality of life and health outcomes for children and families living in poverty. With an awareness and understanding of the effects of poverty on children, pediatricians and other pediatric health practitioners in a family-centered medical home can assess the financial stability of families, link families to resources, and coordinate care with community partners. Further research, advocacy, and continuing education will improve the ability of pediatricians to address the social determinants of health when caring for children who live in poverty. Accompanying this policy statement is a technical report that describes current knowledge on child poverty and the mechanisms by which poverty influences the health and well-being of children. (3/16)

http://pediatrics.aappublications.org/content/137/4/e20160339

PRACTICAL APPROACHES TO OPTIMIZE ADOLESCENT IMMUNIZATION (CLINICAL REPORT) Henry H. Bernstein, DO, MHCM, FAAP; Joseph A. Bocchini Jr, MD, FAAP; and Committee on Infectious Diseases ABSTRACT. With the expansion of the adolescent immunization schedule during the past decade, immunization rates notably vary by vaccine and by state. Addressing barriers to improving adolescent vaccination rates is a priority. Every visit can be viewed as an opportunity to update and complete an adolescent’s immunizations. It is essential to continue to focus and refine the appropriate techniques in approaching the adolescent patient and parent in the office setting. Health care providers must continuously strive to educate their patients and develop skills that can help parents and adolescents overcome vaccine hesitancy. Research on strategies to achieve higher vaccination rates is ongoing, and it is important to increase the knowledge and implementation of these strategies. This clinical report focuses on increasing adherence to the universally recommended vaccines in the annual adolescent immunization schedule of the American Academy of Pediatrics, the American Academy of Family Physicians, the Centers for Disease Control and Prevention, and the American Congress of Obstetricians and Gynecologists. This will be accomplished by

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(1) ­examining ­strategies that heighten confidence in immunizations and address patient and parental concerns to promote adolescent immunization and (2) exploring how best to approach the adolescent and family to improve immunization rates. (2/17) See full text on page 1051.

http://pediatrics.aappublications.org/content/139/3/e20164187 PREMEDICATION FOR NONEMERGENCY ENDOTRACHEAL INTUBATION IN THE NEONATE (CLINICAL REPORT) Praveen Kumar, MD; Susan E. Denson, MD; Thomas J. Mancuso, MD; Committee on Fetus and Newborn; and Section on Anesthesiology and Pain Medicine ABSTRACT. Endotracheal intubation is a common procedure in newborn care. The purpose of this clinical report is to review currently available evidence on use of premedication for intubation, identify gaps in knowledge, and provide guidance for making decisions about the use of premedication. (2/10, reaffirmed 8/13)

http://pediatrics.aappublications.org/content/125/3/608

PRENATAL SUBSTANCE ABUSE: SHORT- AND LONG-TERM EFFECTS ON THE EXPOSED FETUS (TECHNICAL REPORT) Marylou Behnke, MD; Vincent C. Smith, MD; Committee on Substance Abuse; and Committee on Fetus and Newborn ABSTRACT. Prenatal substance abuse continues to be a significant problem in this country and poses important health risks for the developing fetus. The primary care pediatrician’s role in addressing prenatal substance exposure includes prevention, identification of exposure, recognition of medical issues for the exposed newborn infant, protection of the infant, and follow-up of the exposed infant. This report will provide information for the most common drugs involved in prenatal exposure: nicotine, alcohol, marijuana, opiates, cocaine, and methamphetamine. (2/13)

http://pediatrics.aappublications.org/content/131/3/e1009

THE PRENATAL VISIT (CLINICAL REPORT) George J. Cohen, MD, and Committee on Psychosocial Aspects of Child and Family Health ABSTRACT. As advocates for children and their families, pediatricians can support and guide expectant parents in the prenatal period. Prenatal visits allow the pediatrician to gather basic information from expectant parents, offer them information and advice, and identify high-risk conditions that may require special care. In addition, a prenatal visit is the first step in establishing a relationship between the family and the pediatrician (the infant’s medical home) and in helping the parents develop parenting skills and confidence. There are several possible formats for this first visit. The one used depends on the experience and preference of the parents, the style of the pediatrician’s practice, and pragmatic issues of reimbursement. (9/09, reaffirmed 5/14)

http://pediatrics.aappublications.org/content/124/4/1227

PREPARATION FOR EMERGENCIES IN THE OFFICES OF PEDIATRICIANS AND PEDIATRIC PRIMARY CARE PROVIDERS Committee on Pediatric Emergency Medicine ABSTRACT. High-quality pediatric emergency care can be provided only through the collaborative efforts of many health care professionals and child advocates working together throughout a continuum of care that extends from prevention and the medical home to prehospital care, to emergency department stabilization, to critical care and rehabilitation, and finally to a return to care in the medical home. At times, the office of the pediatric primary care provider will serve as the entry site into the emergency care system, which comprises out-of-hospital emergency medical services personnel, emergency department nurses and

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physicians, and other emergency and critical care providers. Recognizing the important role of pediatric primary care providers in the emergency care system for children and understanding the capabilities and limitations of that system are essential if pediatric primary care providers are to offer the best chance at intact survival for every child who is brought to the office with an emergency. Optimizing pediatric primary care provider office readiness for emergencies requires consideration of the unique aspects of each office practice, the types of patients and emergencies that might be seen, the resources on site, and the resources of the larger emergency care system of which the pediatric primary care provider’s office is a part. Parent education regarding prevention, recognition, and response to emergencies, patient triage, early recognition and stabilization of pediatric emergencies in the office, and timely transfer to an appropriate facility for definitive care are important responsibilities of every pediatric primary care provider. In addition, pediatric primary care providers can collaborate with out-of-hospital and hospital-based providers and advocate for the best-quality emergency care for their patients. (7/07, reaffirmed 6/11)

http://pediatrics.aappublications.org/content/120/1/200

PREPARING FOR PEDIATRIC EMERGENCIES: DRUGS TO CONSIDER (CLINICAL REPORT) Mary A. Hegenbarth, MD, and Committee on Drugs ABSTRACT. This clinical report provides current recommendations regarding the selection and use of drugs in preparation for pediatric emergencies. It is not intended to be a comprehensive list of all medications that may be used in all emergencies. When possible, dosage recommendations are consistent with those used in current emergency references such as the Advanced Pediatric Life Support and Pediatric Advanced Life Support textbooks and the recently revised American Heart Association resuscitation guidelines. (2/08, reaffirmed 10/11, 2/16)

http://pediatrics.aappublications.org/content/121/2/433

PRESCRIBING ASSISTIVE-TECHNOLOGY SYSTEMS: FOCUS ON CHILDREN WITH IMPAIRED COMMUNICATION (CLINICAL REPORT) Larry W. Desch, MD; Deborah Gaebler-Spira, MD; and Council on Children With Disabilities ABSTRACT. This clinical report defines common terms of use and provides information on current practice, research, and limitations of assistive technology that can be used in systems for communication. The assessment process to determine the best devices for use with a particular child (ie, the best fit of a device) is also reviewed. The primary care pediatrician, as part of the medical home, plays an important role in the interdisciplinary effort to provide appropriate assistive technology and may be asked to make a referral for assessment or prescribe a particular device. This report provides resources to assist pediatricians in this role and reviews the interdisciplinary team functional evaluation using standardized assessments; the multiple funding opportunities available for obtaining devices and ways in which pediatricians can assist families with obtaining them; the training necessary to use these systems once the devices are procured; the follow-up evaluation to ensure that the systems are meeting their goals; and the leadership skills needed to advocate for this technology. The American Academy of Pediatrics acknowledges the need for key resources to be identified in the community and recognizes that these resources are a shared medical, educational, therapeutic, and family responsibility. Although this report primarily deals with assistive technology specific for communication impairments, many of the details in this report also can aid in the acquisition and use of other types of assistive technology. (6/08, reaffirmed 1/12)

http://pediatrics.aappublications.org/content/121/6/1271

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PRESCRIBING THERAPY SERVICES FOR CHILDREN WITH MOTOR DISABILITIES (CLINICAL REPORT) Committee on Children With Disabilities ABSTRACT. Pediatricians often are called on to prescribe physical, occupational, and speech-language therapy services for children with motor disabilities. This report defines the context in which rehabilitation therapies should be prescribed, emphasizing the evaluation and enhancement of the child’s function and abilities and participation in age-appropriate life roles. The report encourages pediatricians to work with teams including the parents, child, teachers, therapists, and other physicians to ensure that their patients receive appropriate therapy services. (6/04, reaffirmed 12/16)

http://pediatrics.aappublications.org/content/113/6/1836

PRESERVATION OF FERTILITY IN PEDIATRIC AND ADOLESCENT PATIENTS WITH CANCER (TECHNICAL REPORT) Mary E. Fallat, MD; John Hutter, MD; Committee on Bioethics; Section on Hematology/Oncology; and Section on Surgery ABSTRACT. Many cancers that present in children and adolescents are curable with surgery, chemotherapy, and/or radiation therapy. Potential adverse consequences of treatment include sterility, infertility, or subfertility as a result of either gonad removal or damage to germ cells from adjuvant therapy. In recent years, treatment of solid tumors and hematologic malignancies has been modified in an attempt to reduce damage to the gonads. Simultaneously, advances in assisted reproductive techniques have led to new possibilities for the prevention and treatment of infertility. This technical report reviews the topic of fertility preservation in pediatric and adolescent patients with cancer, including ethical considerations. (5/08, reaffirmed 2/12)

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lifestyle rather than on weight. Evidence suggests that obesity prevention and treatment, if conducted correctly, do not predispose to EDs. (8/16)

http://pediatrics.aappublications.org/content/138/3/e20161649 PREVENTION AND MANAGEMENT OF PROCEDURAL PAIN IN THE NEONATE: AN UPDATE Committee on Fetus and Newborn and Section on Anesthesiology and Pain Medicine ABSTRACT. The prevention of pain in neonates should be the goal of all pediatricians and health care professionals who work with neonates, not only because it is ethical but also because repeated painful exposures have the potential for deleterious consequences. Neonates at greatest risk of neurodevelopmental impairment as a result of preterm birth (ie, the smallest and sickest) are also those most likely to be exposed to the greatest number of painful stimuli in the NICU. Although there are major gaps in knowledge regarding the most effective way to prevent and relieve pain in neonates, proven and safe therapies are currently underused for routine minor, yet painful procedures. Therefore, every health care facility caring for neonates should implement (1) a pain-prevention program that includes strategies for minimizing the number of painful procedures performed and (2) a pain assessment and management plan that includes routine assessment of pain, pharmacologic and nonpharmacologic therapies for the prevention of pain associated with routine minor procedures, and measures for minimizing pain associated with surgery and other major procedures. (1/16)

http://pediatrics.aappublications.org/content/137/2/e20154271

PREVENTING AND TREATING HOMESICKNESS (CLINICAL REPORT) Christopher A. Thurber, PhD; Edward Walton, MD; and Council on School Health ABSTRACT. Homesickness is the distress and functional impairment caused by an actual or anticipated separation from home and attachment objects such as parents. It is characterized by acute longing and preoccupying thoughts of home. Almost all children, adolescents, and adults experience some degree of homesickness when they are apart from familiar people and environments. Pediatricians and other health care professionals are in a unique position to assist families in understanding the etiology, prevention, and treatment of homesickness. In the case of planned separations, such as summer camp, techniques are provided that may aid in prevention. In the case of unanticipated or traumatic separations, such as hospitalization, effective treatment strategies are available. (1/07, reaffirmed 5/12)

PREVENTION OF AGRICULTURAL INJURIES AMONG CHILDREN AND ADOLESCENTS Committee on Injury and Poison Prevention and Committee on Community Health Services ABSTRACT. Although the annual number of farm deaths to children and adolescents has decreased since publication of the 1988 American Academy of Pediatrics statement, “Rural Injuries,” the rate of nonfatal farm injuries has increased. Approximately 100 unintentional injury deaths occur annually to children and adolescents on US farms, and an additional 22 000 injuries to children younger than 20 years occur on farms. Relatively few adolescents are employed on farms compared with other types of industry, yet the proportion of fatalities in agriculture is higher than that for any other type of adolescent employment. The high mortality and severe morbidity associated with farm injuries require continuing and improved injury-control strategies. This statement provides recommendations for pediatricians regarding patient and community education as well as public advocacy related to agricultural injury prevention in childhood and adolescence. (10/01, reaffirmed 1/07, 11/11)

PREVENTING OBESITY AND EATING DISORDERS IN ADOLESCENTS (CLINICAL REPORT) Neville H. Golden, MD, FAAP; Marcie Schneider, MD, FAAP; Christine Wood, MD, FAAP; Committee on Nutrition; Committee on Adolescence; and Section on Obesity ABSTRACT. Obesity and eating disorders (EDs) are both prevalent in adolescents. There are concerns that obesity prevention efforts may lead to the development of an ED. Most adolescents who develop an ED did not have obesity previously, but some teenagers, in an attempt to lose weight, may develop an ED. This clinical report addresses the interaction between obesity prevention and EDs in teenagers, provides the pediatrician with evidence-informed tools to identify behaviors that predispose to both obesity and EDs, and provides guidance about obesity and ED prevention messages. The focus should be on a healthy

PREVENTION OF CHILDHOOD LEAD TOXICITY Council on Environmental Health ABSTRACT. Blood lead concentrations have decreased dramatically in US children over the past 4 decades, but too many children still live in housing with deteriorated lead-based paint and are at risk for lead exposure with resulting lead-associated cognitive impairment and behavioral problems. Evidence continues to accrue that commonly encountered blood lead concentrations, even those below 5 μg/dL (50 ppb), impair cognition; there is no identified threshold or safe level of lead in blood. From 2007 to 2010, approximately 2.6% of preschool children in the United States had a blood lead concentration ≥5 μg/dL (≥50 ppb), which represents about 535 000 US children 1 to 5 years of age. Evidence-based guidance is available for managing increased lead exposure in children, and reducing sources of

http://pediatrics.aappublications.org/content/121/5/e1461

http://pediatrics.aappublications.org/content/119/1/192

http://pediatrics.aappublications.org/content/108/4/1016

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lead in the environment, including lead in housing, soil, water, and consumer products, has been shown to be cost-beneficial. Primary prevention should be the focus of policy on childhood lead toxicity. (6/16)

http://pediatrics.aappublications.org/content/138/1/e20161493

PREVENTION OF CHOKING AMONG CHILDREN Committee on Injury, Violence, and Poison Prevention ABSTRACT. Choking is a leading cause of morbidity and mortality among children, especially those aged 3 years or younger. Food, coins, and toys are the primary causes of choking-related injury and death. Certain characteristics, including shape, size, and consistency, of certain toys and foods increase their potential to cause choking among children. Childhood choking hazards should be addressed through comprehensive and coordinated prevention activities. The US Consumer Product Safety Commission (CPSC) should increase efforts to ensure that toys that are sold in retail store bins, vending machines, or on the Internet have appropriate choking-hazard warnings; work with manufacturers to improve the effectiveness of recalls of products that pose a choking risk to children; and increase efforts to prevent the resale of these recalled products via online auction sites. Current gaps in choking-prevention standards for children’s toys should be reevaluated and addressed, as appropriate, via revisions to the standards established under the Child Safety Protection Act, the Consumer Product Safety Improvement Act, or regulation by the CPSC. Prevention of food-related choking among children in the United States has been inadequately addressed at the federal level. The US Food and Drug Administration should establish a systematic, i­nstitutionalized process for examining and addressing the hazards of foodrelated choking. This process should include the establishment of the necessary surveillance, hazard evaluation, enforcement, and public education activities to prevent food-related choking among children. While maintaining its highly cooperative arrangements with the CPSC and the US Department of Agriculture, the Food and Drug Administration should have the authority to address choking-related risks of all food products, including meat products that fall under the jurisdiction of the US Department of Agriculture. The existing National Electronic Injury Surveillance System–All Injury Program of the CPSC should be modified to conduct more-detailed surveillance of choking on food among children. Food manufacturers should design new foods and redesign existing foods to avoid shapes, sizes, textures, and other characteristics that increase choking risk to children, to the extent possible. Pediatricians, dentists, and other infant and child health care providers should provide choking-prevention counseling to parents as an integral part of anticipatory guidance activities. (2/10)

http://pediatrics.aappublications.org/content/125/3/601

PREVENTION OF DROWNING Committee on Injury, Violence, and Poison Prevention ABSTRACT. Drowning is a leading cause of injury-related death in children. In 2006, fatal drowning claimed the lives of approximately 1100 US children younger than 20 years. A number of strategies are available to prevent these tragedies. As educators and advocates, pediatricians can play an important role in the prevention of drowning. (5/10)

http://pediatrics.aappublications.org/content/126/1/178

PREVENTION OF DROWNING (TECHNICAL REPORT) Jeffrey Weiss, MD, and Committee on Injury, Violence, and Poison Prevention ABSTRACT. Drowning is a leading cause of injury-related death in children. In 2006, approximately 1100 US children younger than 20 years died from drowning. A number of strategies are available to prevent these tragedies. As educators and advocates,

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pediatricians can play an important role in the prevention of drowning. (5/10)

http://pediatrics.aappublications.org/content/126/1/e253

PREVENTION OF SEXUAL HARASSMENT IN THE WORKPLACE AND EDUCATIONAL SETTINGS Committee on Pediatric Workforce ABSTRACT. The American Academy of Pediatrics is committed to working to ensure that workplaces and educational settings in which pediatricians spend time are free of sexual harassment. The purpose of this statement is to heighten awareness and sensitivity to this important issue, recognizing that institutions, clinics, and office-based practices may have existing policies. (10/06, reaffirmed 5/09, 1/12, 10/14)

http://pediatrics.aappublications.org/content/118/4/1752

THE PREVENTION OF UNINTENTIONAL INJURY AMONG AMERICAN INDIAN AND ALASKA NATIVE CHILDREN: A SUBJECT REVIEW (CLINICAL REPORT) Committee on Native American Child Health and Committee on Injury and Poison Prevention ABSTRACT. Among ethnic groups in the United States, American Indian and Alaska Native (AI/AN) children experience the highest rates of injury mortality and morbidity. Injury mortality rates for AI/AN children have decreased during the past quarter century, but remain almost double the rate for all children in the United States. The Indian Health Service (IHS), the federal agency with the primary responsibility for the health care of AI/ AN people, has sponsored an internationally recognized injury prevention program designed to reduce the risk of injury death by addressing community-specific risk factors. Model programs developed by the IHS and tribal governments have led to successful outcomes in motor vehicle occupant safety, drowning prevention, and fire safety. Injury prevention programs in tribal communities require special attention to the sovereignty of tribal governments and the unique cultural aspects of health care and communication. Pediatricians working with AI/AN children on reservations or in urban environments are strongly urged to collaborate with tribes and the IHS to create community-based coalitions and develop programs to address highly preventable injury-related mortality and morbidity. Strong advocacy also is needed to promote childhood injury prevention as an important priority for federal agencies and tribes. (12/99, reaffirmed 12/02 COIVPP, 5/03 CONACH, 1/06, 9/08)

http://pediatrics.aappublications.org/content/104/6/1397

THE PRIMARY CARE PEDIATRICIAN AND THE CARE OF CHILDREN WITH CLEFT LIP AND/OR CLEFT PALATE (CLINICAL REPORT) Charlotte W. Lewis, MD, MPH, FAAP; Lisa S. Jacob, DDS, MS; Christoph U. Lehmann, MD, FAAP, FACMI; and Section on Oral Health ABSTRACT. Orofacial clefts, specifically cleft lip and/or cleft palate (CL/P), are among the most common congenital anomalies. CL/P vary in their location and severity and comprise 3 overarching groups: cleft lip (CL), cleft lip with cleft palate (CLP), and cleft palate alone (CP). CL/P may be associated with one of many syndromes that could further complicate a child’s needs. Care of patients with CL/P spans prenatal diagnosis into adulthood. The appropriate timing and order of specific cleftrelated care are important factors for optimizing outcomes; however, care should be individualized to meet the specific needs of each patient and family. Children with CL/P should receive their specialty cleft-related care from a multidisciplinary cleft or craniofacial team with sufficient patient and surgical volume to promote successful outcomes. The primary care pediatrician at the child’s medical home has an essential role in making a timely

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diagnosis and referral; providing ongoing health care maintenance, anticipatory guidance, and acute care; and functioning as an advocate for the patient and a liaison between the family and the craniofacial/cleft team. This document provides background on CL/P and multidisciplinary team care, information about typical timing and order of cleft-related care, and recommendations for cleft/craniofacial teams and primary care pediatricians in the care of children with CL/P. (4/17) See full text on page 1067.

http://pediatrics.aappublications.org/content/139/5/e20170628

PRINCIPLES OF CHILD HEALTH CARE FINANCING Mark L. Hudak, MD, FAAP; Mark E. Helm, MD, MBA, FAAP; Patience H. White, MD, MA, FAAP, FACP; and Committee on Child Health Financing ABSTRACT. After passage of the Patient Protection and Affordable Care Act, more children and young adults have become insured and have benefited from health care coverage than at any time since the creation of the Medicaid program in 1965. From 2009 to 2015, the uninsurance rate for children younger than 19 years fell from 9.7% to 5.3%, whereas the uninsurance rate for young adults 19 to 25 years of age declined from 31.7% to 14.5%. Nonetheless, much work remains to be done. The American Academy of Pediatrics (AAP) believes that the United States can and should ensure that all children, adolescents, and young adults from birth through the age of 26 years who reside within its borders have affordable access to high-quality and comprehensive health care, regardless of their or their families’ incomes. Public and private health insurance should safeguard existing benefits for children and take further steps to cover the full array of essential health care services recommended by the AAP. Each family should be able to afford the premiums, deductibles, and other cost-sharing provisions of the plan. Health plans providing these benefits should ensure, insofar as possible, that families have a choice of professionals and facilities with expertise in the care of children within a reasonable distance of their residence. Traditional and innovative payment methodologies by public and private payers should be structured to guarantee the economic viability of the pediatric medical home and of other pediatric specialty and subspecialty practices to address developing shortages in the pediatric specialty and subspecialty workforce, to promote the use of health information technology, to improve population health and the experience of care, and to encourage the delivery of evidencebased and quality health care in the medical home, as well as in other outpatient, inpatient, and home settings. All current and future health care insurance plans should incorporate the principles for child health financing outlined in this statement. Espousing the core principle to do no harm, the AAP believes that the United States must not sacrifice any of the hard-won gains for our children. Medicaid, as the largest single payer of health care for children and young adults, should remain true to its origins as an entitlement program; in other words, future fiscal or regulatory reforms of Medicaid should not reduce the eligibility and scope of benefits for children and young adults below current levels nor jeopardize children’s access to care. Proposed Medicaid funding “reforms” (eg, institution of block grant, capped allotment, or per-capita capitation payments to states) will achieve their goal of securing cost savings but will inevitably compel states to reduce enrollee eligibility, trim existing benefits (such as Early and Periodic Screening, Diagnostic, and Treatment), and/or compromise children’s access to necessary and timely care through cuts in payments to providers and delivery systems. In fact, the AAP advocates for increased Medicaid funding to improve access to essential care for existing enrollees, fund care for eligible but uninsured children once they enroll, and accommodate enrollment growth that will occur in

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states that choose to expand Medicaid eligibility. The AAP also calls for Congress to extend funding for the Children’s Health Insurance Program, a plan vital to the 8.9 million children it covered in fiscal year 2016, for a minimum of 5 years. (8/17) See full text on page 1083.

http://pediatrics.aappublications.org/content/140/3/e20172098

PRINCIPLES OF PEDIATRIC PATIENT SAFETY: REDUCING HARM DUE TO MEDICAL CARE Steering Committee on Quality Improvement and Management and Committee on Hospital Care ABSTRACT. Pediatricians are rendering care in an environment that is increasingly complex, which results in multiple opportunities to cause unintended harm. National awareness of patient safety risks has grown in the 10 years since the Institute of Medicine published its report To Err Is Human, and patients and society as a whole continue to challenge health care providers to examine their practices and implement safety solutions. The depth and breadth of harm incurred by the practice of medicine is still being defined as reports continue to uncover a variety of avoidable errors, from those that involve specific high-risk medications to those that are more generalizable, such as patient misidentification. Pediatricians in all venues must have a working knowledge of patient-safety language, advocate for best practices that attend to risks that are unique to children, identify and support a culture of safety, and lead efforts to eliminate avoidable harm in any setting in which medical care is rendered to children. (5/11)

http://pediatrics.aappublications.org/content/127/6/1199

PROBIOTICS AND PREBIOTICS IN PEDIATRICS (CLINICAL REPORT) Dan W. Thomas, MD; Frank R. Greer, MD; Committee on Nutrition; and Section on Gastroenterology, Hepatology, and Nutrition ABSTRACT. This clinical report reviews the currently known health benefits of probiotic and prebiotic products, including those added to commercially available infant formula and other food products for use in children. Probiotics are supplements or foods that contain viable microorganisms that cause alterations of the microflora of the host. Use of probiotics has been shown to be modestly effective in randomized clinical trials (RCTs) in (1) treating acute viral gastroenteritis in healthy children; and (2) preventing antibiotic-associated diarrhea in healthy children. There is some evidence that probiotics prevent necrotizing enterocolitis in very low birth weight infants (birth weight between 1000 and 1500 g), but more studies are needed. The results of RCTs in which probiotics were used to treat childhood Helicobacter pylori gastritis, irritable bowel syndrome, chronic ulcerative colitis, and infantile colic, as well as in preventing childhood atopy, although encouraging, are preliminary and require further confirmation. Probiotics have not been proven to be beneficial in treating or preventing human cancers or in treating children with Crohn disease. There are also safety concerns with the use of probiotics in infants and children who are immunocompromised, chronically debilitated, or seriously ill with indwelling medical devices. Prebiotics are supplements or foods that contain a nondigestible food ingredient that selectively stimulates the favorable growth and/or activity of indigenous probiotic bacteria. Human milk contains substantial quantities of prebiotics. There is a paucity of RCTs examining prebiotics in children, although there may be some long-term benefit of prebiotics for the prevention of atopic eczema and common infections in healthy infants. Confirmatory well-designed clinical research studies are necessary. (11/10)

http://pediatrics.aappublications.org/content/126/6/1217

POLICY TITLES AND ABSTRACTS

PROCEDURES FOR THE EVALUATION OF THE VISUAL SYSTEM BY PEDIATRICIANS (CLINICAL REPORT) Sean P. Donahue, MD, PhD, FAAP; Cynthia N. Baker, MD, FAAP; Committee on Practice and Ambulatory Medicine; and Section on Ophthalmology (joint with American Association of Certified Orthoptists, American Association for Pediatric Ophthalmology and Strabismus, and American Academy of Ophthalmology) ABSTRACT. Vision screening is crucial for the detection of visual and systemic disorders. It should begin in the newborn nursery and continue throughout childhood. This clinical report provides details regarding methods for pediatricians to use for screening. (12/15)

http://pediatrics.aappublications.org/content/137/1/e20153597

PROFESSIONAL LIABILITY INSURANCE AND MEDICOLEGAL EDUCATION FOR PEDIATRIC RESIDENTS AND FELLOWS Committee on Medical Liability and Risk Management ABSTRACT. The American Academy of Pediatrics believes that pediatric residents and fellows should be fully informed of the scope and limitations of their professional liability insurance coverage while in training. The academy states that residents and fellows should be educated by their training institutions on matters relating to medical liability and the importance of maintaining adequate and continuous professional liability insurance coverage throughout their careers in medicine. (8/11)

http://pediatrics.aappublications.org/content/128/3/624

PROFESSIONALISM IN PEDIATRICS (TECHNICAL REPORT) Mary E. Fallat, MD; Jacqueline Glover, PhD; and Committee on Bioethics ABSTRACT. The purpose of this report is to provide a concrete overview of the ideal standards of behavior and professional practice to which pediatricians should aspire and by which students and residents can be evaluated. Recognizing that the ideal is not always achievable in the practical sense, this document details the key components of professionalism in pediatric practice with an emphasis on core professional values for which pediatricians should strive and that will serve as a moral compass needed to provide quality care for children and their families. (10/07, reaffirmed 5/11)

http://pediatrics.aappublications.org/content/120/4/e1123

PROFESSIONALISM IN PEDIATRICS: STATEMENT OF PRINCIPLES Committee on Bioethics ABSTRACT. The purpose of this statement is to delineate the concept of professionalism within the context of pediatrics and to provide a brief statement of principles to guide the behavior and professional practice of pediatricians. (10/07, reaffirmed 5/11)

http://pediatrics.aappublications.org/content/120/4/895

PROMOTING EDUCATION, MENTORSHIP, AND SUPPORT FOR PEDIATRIC RESEARCH Committee on Pediatric Research ABSTRACT. Pediatricians play a key role in advancing child health research to best attain and improve the physical, mental, and social health and well-being of all infants, children, adolescents, and young adults. Child health presents unique issues that require investigators who specialize in pediatric research. In addition, the scope of the pediatric research enterprise is transdisciplinary and includes the full spectrum of basic science, translational, community-based, health services, and child health policy research. Although most pediatricians do not directly engage in research, knowledge of research m ­ ethodologies and

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approaches promotes critical evaluation of scientific literature, the practice of evidence-based medicine, and advocacy for evidence-based child health policy. This statement includes specific recommendations to promote further research education and support at all levels of pediatric training, from premedical to continuing medical education, as well as recommendations to increase support and mentorship for research activities. Pediatric research is crucial to the American Academy of Pediatrics’ goal of improving the health of all children. The American Academy of Pediatrics continues to promote and encourage efforts to facilitate the creation of new knowledge and ways to reduce barriers experienced by trainees, practitioners, and academic faculty pursuing research. (4/14)

http://pediatrics.aappublications.org/content/133/5/943

PROMOTING FOOD SECURITY FOR ALL CHILDREN Council on Community Pediatrics and Committee on Nutrition ABSTRACT. Sixteen million US children (21%) live in households without consistent access to adequate food. After multiple risk factors are considered, children who live in households that are food insecure, even at the lowest levels, are likely to be sick more often, recover from illness more slowly, and be hospitalized more frequently. Lack of adequate healthy food can impair a child’s ability to concentrate and perform well in school and is linked to higher levels of behavioral and emotional problems from preschool through adolescence. Food insecurity can affect children in any community, not only traditionally underserved ones. Pediatricians can play a central role in screening and identifying children at risk for food insecurity and in connecting families with needed community resources. Pediatricians should also advocate for federal and local policies that support access to adequate healthy food for an active and healthy life for all children and their families. (10/15)

http://pediatrics.aappublications.org/content/136/5/e1431

PROMOTING OPTIMAL DEVELOPMENT: SCREENING FOR BEHAVIORAL AND EMOTIONAL PROBLEMS (CLINICAL REPORT) Carol Weitzman, MD, FAAP; Lynn Wegner, MD, FAAP; Section on Developmental and Behavioral Pediatrics; Committee on Psychosocial Aspects of Child and Family Health; and Council on Early Childhood (joint with Society for Developmental and Behavioral Pediatrics) ABSTRACT. By current estimates, at any given time, approximately 11% to 20% of children in the United States have a behavioral or emotional disorder, as defined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Between 37% and 39% of children will have a behavioral or emotional disorder diagnosed by 16 years of age, regardless of geographic location in the United States. Behavioral and emotional problems and concerns in children and adolescents are not being reliably identified or treated in the US health system. This clinical report focuses on the need to increase behavioral screening and offers potential changes in practice and the health system, as well as the research needed to accomplish this. This report also (1) reviews the prevalence of behavioral and emotional disorders, (2) describes factors affecting the emergence of behavioral and emotional problems, (3) articulates the current state of detection of these problems in pediatric primary care, (4) describes barriers to screening and means to overcome those barriers, and (5) discusses potential changes at a practice and systems level that are needed to facilitate successful behavioral and emotional screening. Highlighted and discussed are the many factors at the level of the pediatric practice, health system, and society contributing to these behavioral and emotional problems. (1/15)

http://pediatrics.aappublications.org/content/135/2/384

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PROMOTING THE PARTICIPATION OF CHILDREN WITH DISABILITIES IN SPORTS, RECREATION, AND PHYSICAL ACTIVITIES (CLINICAL REPORT) Nancy A. Murphy, MD; Paul S. Carbone, MD; and Council on Children With Disabilities ABSTRACT. The benefits of physical activity are universal for all children, including those with disabilities. The participation of children with disabilities in sports and recreational activities promotes inclusion, minimizes deconditioning, optimizes physical functioning, and enhances overall well-being. Despite these benefits, children with disabilities are more restricted in their participation, have lower levels of fitness, and have higher levels of obesity than their peers without disabilities. Pediatricians and parents may overestimate the risks or overlook the benefits of physical activity in children with disabilities. Well-informed decisions regarding each child’s participation must consider overall health status, individual activity preferences, safety precautions, and availability of appropriate programs and equipment. Health supervision visits afford pediatricians, children with disabilities, and parents opportunities to collaboratively generate goal-directed activity “prescriptions.” Child, family, financial, and societal barriers to participation need to be directly identified and addressed in the context of local, state, and federal laws. The goal is inclusion for all children with disabilities in appropriate activities. This clinical report discusses the importance of physical activity, recreation, and sports participation for children with disabilities and offers practical suggestions to pediatric health care professionals for the promotion of participation. (5/08, reaffirmed 1/12)

http://pediatrics.aappublications.org/content/121/5/1057

PROMOTING THE WELL-BEING OF CHILDREN WHOSE PARENTS ARE GAY OR LESBIAN Committee on Psychosocial Aspects of Child and Family Health ABSTRACT. To promote optimal health and well-being of all children, the American Academy of Pediatrics (AAP) supports access for all children to (1) civil marriage rights for their parents and (2) willing and capable foster and adoptive parents, regardless of the parents’ sexual orientation. The AAP has always been an advocate for, and has developed policies to support, the optimal physical, mental, and social health and well-being of all infants, children, adolescents, and young adults. In so doing, the AAP has supported families in all their diversity, because the family has always been the basic social unit in which children develop the supporting and nurturing relationships with adults that they need to thrive. Children may be born to, adopted by, or cared for temporarily by married couples, nonmarried couples, single parents, grandparents, or legal guardians, and any of these may be heterosexual, gay or lesbian, or of another orientation. Children need secure and enduring relationships with committed and nurturing adults to enhance their life experiences for optimal social-emotional and cognitive development. Scientific evidence affirms that children have similar developmental and emotional needs and receive similar parenting whether they are raised by parents of the same or different genders. If a child has 2 living and capable parents who choose to create a permanent bond by way of civil marriage, it is in the best interests of their child(ren) that legal and social institutions allow and support them to do so, irrespective of their sexual orientation. If 2 parents are not available to the child, adoption or foster parenting remain acceptable options to provide a loving home for a child and should be available without regard to the sexual orientation of the parent(s). (3/13)

http://pediatrics.aappublications.org/content/131/4/827

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PROMOTING THE WELL-BEING OF CHILDREN WHOSE PARENTS ARE GAY OR LESBIAN (TECHNICAL REPORT) Ellen C. Perrin, MD, MA; Benjamin S. Siegel, MD; and Committee on Psychosocial Aspects of Child and Family Health ABSTRACT. Extensive data available from more than 30 years of research reveal that children raised by gay and lesbian parents have demonstrated resilience with regard to social, psychological, and sexual health despite economic and legal disparities and social stigma. Many studies have demonstrated that children’s well-being is affected much more by their relationships with their parents, their parents’ sense of competence and security, and the presence of social and economic support for the family than by the gender or the sexual orientation of their parents. Lack of opportunity for same-gender couples to marry adds to families’ stress, which affects the health and welfare of all household members. Because marriage strengthens families and, in so doing, benefits children’s development, children should not be deprived of the opportunity for their parents to be married. Paths to parenthood that include assisted reproductive techniques, adoption, and foster parenting should focus on competency of the parents rather than their sexual orientation. (3/13)

http://pediatrics.aappublications.org/content/131/4/e1374

PROMOTION OF HEALTHY WEIGHT-CONTROL PRACTICES IN YOUNG ATHLETES (CLINICAL REPORT) Rebecca L. Carl, MD, MS, FAAP; Miriam D. Johnson, MD, FAAP; Thomas J. Martin, MD, FAAP; and Council on Sports Medicine and Fitness ABSTRACT. Children and adolescents may participate in sports that favor a particular body type. Some sports, such as gymnastics, dance, and distance running, emphasize a slim or lean physique for aesthetic or performance reasons. Participants in weight-class sports, such as wrestling and martial arts, may attempt weight loss so they can compete at a lower weight class. Other sports, such as football and bodybuilding, highlight a muscular physique; young athletes engaged in these sports may desire to gain weight and muscle mass. This clinical report describes unhealthy methods of weight loss and gain as well as policies and approaches used to curb these practices. The report also reviews healthy strategies for weight loss and weight gain and provides recommendations for pediatricians on how to promote healthy weight control in young athletes. (8/17) See full text on page 1093.

http://pediatrics.aappublications.org/content/140/3/e20171871

PROTECTING CHILDREN FROM SEXUAL ABUSE BY HEALTH CARE PROVIDERS Committee on Child Abuse and Neglect ABSTRACT. Sexual abuse or exploitation of children is never acceptable. Such behavior by health care providers is particularly concerning because of the trust that children and their families place on adults in the health care profession. The American Academy of Pediatrics strongly endorses the social and moral prohibition against sexual abuse or exploitation of children by health care providers. The academy opposes any such sexual abuse or exploitation by providers, particularly by the academy’s members. Health care providers should be trained to recognize and abide by appropriate provider-patient boundaries. Medical institutions should screen staff members for a history of child abuse issues, train them to respect and maintain appropriate boundaries, and establish policies and procedures to receive and investigate concerns about patient abuse. Each person has a responsibility to ensure the safety of children in health care settings and to scrupulously follow appropriate legal and ethical reporting and investigation procedures. (6/11, reaffirmed 10/14)

http://pediatrics.aappublications.org/content/128/2/407

POLICY TITLES AND ABSTRACTS

PROTECTING CHILDREN FROM TOBACCO, NICOTINE, AND TOBACCO SMOKE (TECHNICAL REPORT) Harold J. Farber, MD, MSPH, FAAP; Judith Groner, MD, FAAP; Susan Walley, MD, FAAP; Kevin Nelson, MD, PhD, FAAP; and Section on Tobacco Control ABSTRACT. This technical report serves to provide the evidence base for the American Academy of Pediatrics’ policy statements “Clinical Practice Policy to Protect Children From Tobacco, Nicotine, and Tobacco Smoke” and “Public Policy to Protect Children From Tobacco, Nicotine, and Tobacco Smoke.” Tobacco use and involuntary exposure are major preventable causes of morbidity and premature mortality in adults and children. Tobacco dependence almost always starts in childhood or adolescence. Electronic nicotine delivery systems are rapidly gaining popularity among youth, and their significant harms are being documented. In utero tobacco smoke exposure, in addition to increasing the risk of preterm birth, low birth weight, stillbirth, placental abruption, and sudden infant death, has been found to increase the risk of obesity and neurodevelopmental disorders. Actions by pediatricians can help to reduce children’s risk of developing tobacco dependence and reduce children’s involuntary tobacco smoke exposure. Public policy actions to protect children from tobacco are essential to reduce the toll that the tobacco epidemic takes on our children. (10/15)

http://pediatrics.aappublications.org/content/136/5/e1439

PROTECTIVE EYEWEAR FOR YOUNG ATHLETES Committee on Sports Medicine and Fitness (joint with American Academy of Ophthalmology) ABSTRACT. The American Academy of Pediatrics and American Academy of Ophthalmology strongly recommend protective eyewear for all participants in sports in which there is risk of eye injury. Protective eyewear should be mandatory for athletes who are functionally 1-eyed and for athletes whose ophthalmologists recommend eye protection after eye surgery or trauma. (3/04, reaffirmed 2/08, 6/11, 2/15)

http://pediatrics.aappublications.org/content/113/3/619

PROVIDING A PRIMARY CARE MEDICAL HOME FOR CHILDREN AND YOUTH WITH CEREBRAL PALSY (CLINICAL REPORT) Gregory S. Liptak, MD, MPH; Nancy A. Murphy, MD; and Council on Children With Disabilities ABSTRACT. All primary care providers will care for children with cerebral palsy in their practice. In addition to well-child and acute illness care, the role of the medical home in the management of these children includes diagnosis, planning for interventions, authorizing treatments, and follow-up. Optimizing health and well-being for children with cerebral palsy and their families entails family-centered care provided in the medical home; comanagement is the most common model. This report reviews the aspects of care specific to cerebral palsy that a medical home should provide beyond the routine health care needed by all children. (10/11, reaffirmed 11/14)

http://pediatrics.aappublications.org/content/128/5/e1321

PROVIDING A PRIMARY CARE MEDICAL HOME FOR CHILDREN AND YOUTH WITH SPINA BIFIDA (CLINICAL REPORT) Robert Burke, MD, MPH; Gregory S. Liptak, MD, MPH; and Council on Children With Disabilities ABSTRACT. The pediatric primary care provider in the medical home has a central and unique role in the care of children with spina bifida. The primary care provider addresses not only the typical issues of preventive and acute health care but also the needs specific to these children. Optimal care requires communication and comanagement with pediatric medical and developmental subspecialists, surgical specialists, therapists,

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and community providers. The medical home provider is essential in supporting the family and advocating for the child from the time of entry into the practice through adolescence, which includes transition and transfer to adult health care. This report reviews aspects of care specific to the infant with spina bifida (particularly myelomeningocele) that will facilitate optimal medical, functional, and developmental outcomes. (11/11, reaffirmed 2/15)

http://pediatrics.aappublications.org/content/128/6/e1645

PROVIDING CARE FOR CHILDREN AND ADOLESCENTS FACING HOMELESSNESS AND HOUSING INSECURITY Council on Community Pediatrics ABSTRACT. Child health and housing security are closely intertwined, and children without homes are more likely to suffer from chronic disease, hunger, and malnutrition than are children with homes. Homeless children and youth often have significant psychosocial development issues, and their education is frequently interrupted. Given the overall effects that homelessness can have on a child’s health and potential, it is important for pediatricians to recognize the factors that lead to homelessness, understand the ways that homelessness and its causes can lead to poor health outcomes, and when possible, help children and families mitigate some of the effects of homelessness. Through practice change, partnership with community resources, awareness, and advocacy, pediatricians can help optimize the health and well-being of children affected by homelessness. (5/13, reaffirmed 10/16)

http://pediatrics.aappublications.org/content/131/6/1206

PROVIDING CARE FOR IMMIGRANT, MIGRANT, AND BORDER CHILDREN Council on Community Pediatrics ABSTRACT. This policy statement, which recognizes the large changes in immigrant status since publication of the 2005 statement “Providing Care for Immigrant, Homeless, and Migrant Children,” focuses on strategies to support the health of immigrant children, infants, adolescents, and young adults. Homeless children will be addressed in a forthcoming separate statement (“Providing Care for Children and Adolescents Facing Homelessness and Housing Insecurity”). While recognizing the diversity across and within immigrant, migrant, and border populations, this statement provides a basic framework for serving and advocating for all immigrant children, with a particular focus on low-income and vulnerable populations. Recommendations include actions needed within and outside the health care system, including expansion of access to high-quality medical homes with culturally and linguistically effective care as well as education and literacy programs. The statement recognizes the unique and special role that pediatricians can play in the lives of immigrant children and families. Recommendations for policies that support immigrant child health are included. (5/13)

http://pediatrics.aappublications.org/content/131/6/e2028

PROVIDING PSYCHOSOCIAL SUPPORT TO CHILDREN AND FAMILIES IN THE AFTERMATH OF DISASTERS AND CRISES (CLINICAL REPORT) David J. Schonfeld, MD, FAAP; Thomas Demaria, PhD; Disaster Preparedness Advisory Council; and Committee on Psychosocial Aspects of Child and Family Health ABSTRACT. Disasters have the potential to cause short- and long-term effects on the psychological functioning, emotional adjustment, health, and developmental trajectory of children. This clinical report provides practical suggestions on how to identify common adjustment difficulties in children in the ­aftermath of a disaster and to promote effective coping strategies to mitigate the impact of the disaster as well as any associated

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bereavement and secondary stressors. This information can serve as a guide to pediatricians as they offer anticipatory guidance to families or consultation to schools, child care centers, and other child congregate care sites. Knowledge of risk factors for adjustment difficulties can serve as the basis for mental health triage. The importance of basic supportive services, psychological first aid, and professional self-care are discussed. Stress is intrinsic to many major life events that children and families face, including the experience of significant illness and its treatment. The information provided in this clinical report may, therefore, be relevant for a broad range of patient encounters, even outside the context of a disaster. Most pediatricians enter the profession because of a heartfelt desire to help children and families most in need. If adequately prepared and supported, pediatricians who are able to draw on their skills to assist children, families, and communities to recover after a disaster will find the work to be particularly rewarding. (9/15)

http://pediatrics.aappublications.org/content/136/4/e1120

PROVISION OF EDUCATIONALLY RELATED SERVICES FOR CHILDREN AND ADOLESCENTS WITH CHRONIC DISEASES AND DISABLING CONDITIONS Council on Children With Disabilities ABSTRACT. Children and adolescents with chronic diseases and disabling conditions often need educationally related services. As medical home providers, physicians and other health care professionals can assist children, adolescents, and their families with the complex federal, state, and local laws, regulations, and systems associated with these services. Expanded roles for physicians and other health care professionals in individualized family service plan, individualized education plan, and Section 504 plan development and implementation are recommended. Recent updates to the Individuals With Disabilities Education Act will also affect these services. Funding for these services by private and nonprivate sources also continue to affect the availability of these educationally related services. The complex range of federal, state, and local laws, regulations, and systems for special education and related services for children and adolescents in public schools is beyond the scope of this statement. Readers are referred to the American Academy of Pediatrics policy statement “The Pediatrician’s Role in Development and Implementation of an Individual Education Plan (IEP) and/or an Individual Family Service Plan (IFSP)” for additional background materials. The focus of this statement is the role that health care professionals have in determining and managing educationally related services in the school setting. This policy statement is a revision of a previous statement, “Provision of Educationally Related Services for Children and Adolescents With Chronic Diseases and Disabling Conditions,” published in February 2000 by the Committee on Children With Disabilities (http://aappolicy.aappublications.org/cgi/ content/full/pediatrics;105/2/448). (6/07, reaffirmed 11/14)

http://pediatrics.aappublications.org/content/119/6/1218

PSYCHOLOGICAL MALTREATMENT (CLINICAL REPORT) Roberta Hibbard, MD; Jane Barlow, DPhil; Harriet MacMillan, MD; Committee on Child Abuse and Neglect (joint with American Academy of Child and Adolescent Psychiatry Child Maltreatment and Violence Committee) ABSTRACT. Psychological or emotional maltreatment of children may be the most challenging and prevalent form of child abuse and neglect. Caregiver behaviors include acts of omission (ignoring need for social interactions) or commission (spurning, terrorizing); may be verbal or nonverbal, active or passive, and with or without intent to harm; and negatively affect the child’s cognitive, social, emotional, and/or physical development. Psychological maltreatment has been linked with disorders of attachment, developmental and educational problems,

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s­ocialization problems, disruptive behavior, and later psychopathology. Although no evidence-based interventions that can prevent psychological maltreatment have been identified to date, it is possible that interventions shown to be effective in reducing overall types of child maltreatment, such as the Nurse Family Partnership, may have a role to play. Furthermore, prevention before occurrence will require both the use of universal interventions aimed at promoting the type of parenting that is now recognized to be necessary for optimal child development, alongside the use of targeted interventions directed at improving parental sensitivity to a child’s cues during infancy and later parent-child interactions. Intervention should, first and foremost, focus on a thorough assessment and ensuring the child’s safety. Potentially effective treatments include cognitive behavioral parenting programs and other psychotherapeutic interventions. The high prevalence of psychological abuse in advanced Western societies, along with the serious consequences, point to the importance of effective management. Pediatricians should be alert to the occurrence of psychological maltreatment and identify ways to support families who have risk indicators for, or evidence of, this problem. (7/12, reaffirmed 4/16)

http://pediatrics.aappublications.org/content/130/2/372

PSYCHOSOCIAL IMPLICATIONS OF DISASTER OR TERRORISM ON CHILDREN: A GUIDE FOR THE PEDIATRICIAN (CLINICAL REPORT) Joseph F. Hagan Jr, MD; Committee on Psychosocial Aspects of Child and Family Health; and Task Force on Terrorism ABSTRACT. During and after disasters, pediatricians can assist parents and community leaders not only by accommodating the unique needs of children but also by being cognizant of the psychological responses of children to reduce the possibility of long-term psychological morbidity. The effects of disaster on children are mediated by many factors including personal experience, parental reaction, developmental competency, gender, and the stage of disaster response. Pediatricians can be effective advocates for the child and family and at the community level and can affect national policy in support of families. In this report, specific children’s responses are delineated, risk factors for adverse reactions are discussed, and advice is given for pediatricians to ameliorate the effects of disaster on children. (9/05, reaffirmed 11/14)

http://pediatrics.aappublications.org/content/116/3/787

PSYCHOSOCIAL SUPPORT FOR YOUTH LIVING WITH HIV (CLINICAL REPORT) Jaime Martinez, MD, FAAP; Rana Chakraborty, MD, FAAP; and Committee on Pediatric AIDS ABSTRACT. This clinical report provides guidance for the pediatrician in addressing the psychosocial needs of adolescents and young adults living with HIV, which can improve linkage to care and adherence to life-saving antiretroviral (ARV) therapy. Recent national case surveillance data for youth (defined here as adolescents and young adults 13 to 24 years of age) revealed that the burden of HIV/AIDS fell most heavily and disproportionately on African American youth, particularly males having sex with males. To effectively increase linkage to care and sustain adherence to therapy, interventions should address the immediate drivers of ARV compliance and also address factors that provide broader social and structural support for HIV-infected adolescents and young adults. Interventions should address psychosocial development, including lack of future orientation, inadequate educational attainment and limited health literacy, failure to focus on the long-term consequences of near-term risk behaviors, and coping ability. Associated challenges are closely linked to the structural environment. Individual case management is essential to linkage to and retention in care, ­ ARV adherence, and management of associated c­ omorbidities.

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Integrating these skills into pediatric and adolescent HIV practice in a medical home setting is critical, given the alarming increase in new HIV infections in youth in the United States. (2/14)

http://pediatrics.aappublications.org/content/133/3/558

A PUBLIC HEALTH RESPONSE TO OPIOID USE IN PREGNANCY Stephen W. Patrick, MD, MPH, MS, FAAP; Davida M. Schiff, MD, FAAP; and Committee on Substance Use and Prevention ABSTRACT. The use of opioids during pregnancy has grown rapidly in the past decade. As opioid use during pregnancy increased, so did complications from their use, including neonatal abstinence syndrome. Several state governments responded to this increase by prosecuting and incarcerating pregnant women with substance use disorders; however, this approach has no proven benefits for maternal or infant health and may lead to avoidance of prenatal care and a decreased willingness to engage in substance use disorder treatment programs. A public health response, rather than a punitive approach to the opioid epidemic and substance use during pregnancy, is critical, including the following: a focus on preventing unintended pregnancies and improving access to contraception; universal screening for alcohol and other drug use in women of childbearing age; knowledge and informed consent of maternal drug testing and reporting practices; improved access to comprehensive obstetric care, including opioid-replacement therapy; gender-specific substance use treatment programs; and improved funding for social services and child welfare systems. The American College of Obstetricians and Gynecologists supports the value of this clinical document as an educational tool (December 2016). (2/17) See full text on page 1109.

http://pediatrics.aappublications.org/content/139/3/e20164070

PUBLIC POLICY TO PROTECT CHILDREN FROM TOBACCO, NICOTINE, AND TOBACCO SMOKE Section on Tobacco Control ABSTRACT. Tobacco use and tobacco smoke exposure are among the most important health threats to children, adolescents, and adults. There is no safe level of tobacco smoke exposure. The developing brains of children and adolescents are particularly vulnerable to the development of tobacco and nicotine dependence. Tobacco is unique among consumer products in that it causes disease and death when used exactly as intended. Tobacco continues to be heavily promoted to children and young adults. Flavored and alternative tobacco products, including little cigars, chewing tobacco, and electronic nicotine delivery systems, are gaining popularity among youth. This statement describes important evidence-based public policy actions that, when implemented, will reduce tobacco product use and tobacco smoke exposure among youth and, by doing so, improve the health of children and young adults. (10/15)

http://pediatrics.aappublications.org/content/136/5/998

QUALITY EARLY EDUCATION AND CHILD CARE FROM BIRTH TO KINDERGARTEN Elaine A. Donoghue, MD, FAAP, and Council on Early Childhood ABSTRACT. High-quality early education and child care for young children improves physical and cognitive outcomes for the children and can result in enhanced school readiness. Preschool education can be viewed as an investment (especially for at-risk children), and studies show a positive return on that investment. Barriers to high-quality early childhood education include inadequate funding and staff education as well as variable regulation and enforcement. Steps that have been taken to improve the quality of early education and child care include creating multidisciplinary, evidence-based child care practice standards; establishing state quality rating and improvement

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systems; improving federal and state regulations; providing child care health consultation; and initiating other innovative partnerships. Pediatricians have a role in promoting quality early education and child care for all children not only in the medical home but also at the community, state, and national levels. (7/17) See full text on page 1119.

http://pediatrics.aappublications.org/content/140/2/e20171488

RACE, ETHNICITY, AND SOCIOECONOMIC STATUS IN RESEARCH ON CHILD HEALTH Tina L. Cheng, MD, MPH, FAAP; Elizabeth Goodman, MD, FAAP; and Committee on Pediatric Research ABSTRACT. An extensive literature documents the existence of pervasive and persistent child health, development, and health care disparities by race, ethnicity, and socioeconomic status (SES). Disparities experienced during childhood can result in a wide variety of health and health care outcomes, including adult morbidity and mortality, indicating that it is crucial to examine the influence of disparities across the life course. Studies often collect data on the race, ethnicity, and SES of research participants to be used as covariates or explanatory factors. In the past, these variables have often been assumed to exert their effects through individual or genetically determined biologic mechanisms. However, it is now widely accepted that these variables have important social dimensions that influence health. SES, a multidimensional construct, interacts with and confounds analyses of race and ethnicity. Because SES, race, and ethnicity are often difficult to measure accurately, leading to the potential for misattribution of causality, thoughtful consideration should be given to appropriate measurement, analysis, and interpretation of such factors. Scientists who study child and adolescent health and development should understand the multiple measures used to assess race, ethnicity, and SES, including their validity and shortcomings and potential confounding of race and ethnicity with SES. The American Academy of Pediatrics (AAP) recommends that research on eliminating health and health care disparities related to race, ethnicity, and SES be a priority. Data on race, ethnicity, and SES should be collected in research on child health to improve their definitions and increase understanding of how these factors and their complex interrelationships affect child health. Furthermore, the AAP believes that researchers should consider both biological and social mechanisms of action of race, ethnicity, and SES as they relate to the aims and hypothesis of the specific area of investigation. It is important to measure these variables, but it is not sufficient to use these variables alone as explanatory for differences in disease, morbidity, and outcomes without attention to the social and biologic influences they have on health throughout the life course. The AAP recommends more research, both in the United States and internationally, on measures of race, ethnicity, and SES and how these complex constructs affect health care and health outcomes throughout the life course. (12/14)

http://pediatrics.aappublications.org/content/135/1/e225

RACIAL AND ETHNIC DISPARITIES IN THE HEALTH AND HEALTH CARE OF CHILDREN (TECHNICAL REPORT) Glenn Flores, MD, and Committee on Pediatric Research ABSTRACT. Objective. This technical report reviews and synthesizes the published literature on racial/ethnic disparities in children’s health and health care. Methods. A systematic review of the literature was conducted for articles published between 1950 and March 2007. Inclusion criteria were peer-reviewed, original research articles in English on racial/ethnic disparities in the health and health care of US children. Search terms used included “child,” “disparities,” and the Index Medicus terms for each racial/ethnic minority group.

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Results. Of 781 articles initially reviewed, 111 met inclusion criteria and constituted the final database. Review of the literature revealed that racial/ethnic disparities in children’s health and health care are quite extensive, pervasive, and persistent. Disparities were noted across the spectrum of health and health care, including in mortality rates, access to care and use of services, prevention and population health, health status, adolescent health, chronic diseases, special health care needs, quality of care, and organ transplantation. Mortality-rate disparities were noted for children in all 4 major US racial/ethnic minority groups, including substantially greater risks than white children of all-cause mortality; death from drowning, from acute lymphoblastic leukemia, and after congenital heart defect surgery; and an earlier median age at death for those with Down syndrome and congenital heart defects. Certain methodologic flaws were commonly observed among excluded studies, including failure to evaluate children separately from adults (22%), combining all nonwhite children into 1 group (9%), and failure to provide a white comparison group (8%). Among studies in the final database, 22% did not perform multivariable or stratified analyses to ensure that disparities persisted after adjustment for potential confounders. Conclusions. Racial/ethnic disparities in children’s health and health care are extensive, pervasive, and persistent, and occur across the spectrum of health and health care. Methodologic flaws were identified in how such disparities are sometimes documented and analyzed. Optimal health and health care for all children will require recognition of disparities as pervasive problems, methodologically sound disparities studies, and rigorous evaluation of disparities interventions. (3/10, reaffirmed 5/13)

http://pediatrics.aappublications.org/content/125/4/e979

RADIATION DISASTERS AND CHILDREN Committee on Environmental Health ABSTRACT. The special medical needs of children make it essential that pediatricians be prepared for radiation disasters, including (1) the detonation of a nuclear weapon; (2) a nuclear power plant event that unleashes a radioactive cloud; and (3) the dispersal of radionuclides by conventional explosive or the crash of a transport vehicle. Any of these events could occur unintentionally or as an act of terrorism. Nuclear facilities (eg, power plants, fuel processing centers, and food irradiation facilities) are often located in highly populated areas, and as they age, the risk of mechanical failure increases. The short- and long-term consequences of a radiation disaster are significantly greater in children for several reasons. First, children have a disproportionately higher minute ventilation, leading to greater internal exposure to radioactive gases. Children have a significantly greater risk of developing cancer even when they are exposed to radiation in utero. Finally, children and the parents of young children are more likely than are adults to develop enduring psychologic injury after a radiation disaster. The pediatrician has a critical role in planning for radiation disasters. For example, potassium iodide is of proven value for thyroid protection but must be given before or soon after exposure to radioiodines, requiring its placement in homes, schools, and child care centers. Pediatricians should work with public health authorities to ensure that children receive full consideration in local planning for a radiation disaster. (6/03, reaffirmed 1/07)

http://pediatrics.aappublications.org/content/111/6/1455

SECTION 5/CURRENT POLICIES

RADIATION RISK TO CHILDREN FROM COMPUTED TOMOGRAPHY (CLINICAL REPORT) Alan S. Brody, MD; Donald P. Frush, MD; Walter Huda, PhD; Robert L. Brent, MD, PhD; and Section on Radiology ABSTRACT. Imaging studies that use ionizing radiation are an essential tool for the evaluation of many disorders of childhood. Ionizing radiation is used in radiography, fluoroscopy, angiography, and computed tomography scanning. Computed tomography is of particular interest because of its relatively high radiation dose and wide use. Consensus statements on radiation risk suggest that it is reasonable to act on the assumption that low-level radiation may have a small risk of causing cancer. The medical community should seek ways to decrease radiation exposure by using radiation doses as low as reasonably achievable and by performing these studies only when necessary. There is wide agreement that the benefits of an indicated computed tomography scan far outweigh the risks. Pediatric health care professionals’ roles in the use of computed tomography on children include deciding when a computed tomography scan is necessary and discussing the risk with patients and families. Radiologists should be a source of consultation when forming imaging strategies and should create specific protocols with scanning techniques optimized for pediatric patients. Families and patients should be encouraged to ask questions about the risks and benefits of computed tomography scanning. The information in this report is provided to aid in decision-making and discussions with the health care team, patients, and families. (9/07)

http://pediatrics.aappublications.org/content/120/3/677

RECOGNITION AND MANAGEMENT OF IATROGENICALLY INDUCED OPIOID DEPENDENCE AND WITHDRAWAL IN CHILDREN (CLINICAL REPORT) Jeffrey Galinkin, MD, FAAP; Jeffrey Lee Koh, MD, FAAP; Committee on Drugs; and Section on Anesthesiology and Pain Medicine ABSTRACT. Opioids are often prescribed to children for pain relief related to procedures, acute injuries, and chronic conditions. Round-the-clock dosing of opioids can produce opioid dependence within 5 days. According to a 2001 consensus paper from the American Academy of Pain Medicine, American Pain Society, and American Society of Addiction Medicine, dependence is defined as “a state of adaptation that is manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist.” Although the experience of many children undergoing iatrogenically induced withdrawal may be mild or goes unreported, there is currently no guidance for recognition or management of withdrawal for this population. Guidance on this subject is available only for adults and primarily for adults with substance use disorders. The guideline will summarize existing literature and provide readers with information currently not available in any single source specific for this vulnerable pediatric population. (12/13)

http://pediatrics.aappublications.org/content/133/1/152

RECOGNITION AND MANAGEMENT OF MEDICAL COMPLEXITY (CLINICAL REPORT) Dennis Z. Kuo, MD, MHS, FAAP; Amy J. Houtrow, MD, PhD, MPH, FAAP; and Council on Children With Disabilities ABSTRACT. Children with medical complexity have extensive needs for health services, experience functional limitations, and are high resource utilizers. Addressing the needs of this population to achieve high-value health care requires optimizing care within the medical home and medical neighborhood. Opportunities exist for health care providers, payers, and

POLICY TITLES AND ABSTRACTS

policy makers to develop strategies to enhance care delivery and to decrease costs. Important outcomes include decreasing unplanned hospital admissions, decreasing emergency department use, ensuring access to health services, limiting out-ofpocket expenses for families, and improving patient and family experiences, quality of life, and satisfaction with care. This report describes the population of children with medical complexity and provides strategies to optimize medical and health outcomes. (11/16)

http://pediatrics.aappublications.org/content/138/6/e20163021

RECOGNIZING AND RESPONDING TO MEDICAL NEGLECT (CLINICAL REPORT) Carole Jenny, MD, MBA, and Committee on Child Abuse and Neglect ABSTRACT. A caregiver may fail to recognize or respond to a child’s medical needs for a variety of reasons. An effective response by a health care professional to medical neglect requires a comprehensive assessment of the child’s needs, the parents’ resources, the parents’ efforts to provide for the needs of the child, and options for ensuring optimal health for the child. Such an assessment requires clear, 2-way communication between the family and the health care professional. Physicians should consider the least intrusive options for managing cases of medical neglect that ensure the health and safety of the child. (12/07, reaffirmed 1/11, 2/16)

http://pediatrics.aappublications.org/content/120/6/1385

RECOMMENDATIONS FOR PREVENTION AND CONTROL OF INFLUENZA IN CHILDREN, 2017–2018 Committee on Infectious Diseases ABSTRACT. This statement updates the recommendations for routine use of the seasonal influenza vaccine and antiviral medications for the prevention and treatment of influenza in children. The American Academy of Pediatrics recommends annual seasonal influenza immunization for everyone 6 months and older, including children and adolescents. Highlights for the upcoming 2017–2018 season include the following: 1. Annual universal influenza immunization is indicated with either a trivalent or quadrivalent (no preference) inactivated vaccine; 2. The 2017–2018 influenza A (H1N1) vaccine strain differs from that contained in the 2016–2017 seasonal vaccines. The 2017–2018 influenza A (H3N2) vaccine strain and influenza B vaccine strains included in the trivalent and quadrivalent vaccines are the same as those contained in the 2016–2017 seasonal vaccines: a. trivalent vaccine contains an A/Michigan/45/2015 (H1N1)pdm09-like virus, an A/Hong Kong/4801/2014 (H3N2)-like virus, and a B/Brisbane/60/2008-like virus (B/Victoria lineage); and b. quadrivalent vaccine contains an additional B virus (B/ Phuket/3073/2013-like virus [B/Yamagata lineage]); 3. Quadrivalent live attenuated influenza vaccine (LAIV4) is not recommended for use in any setting in the United States during the 2017–2018 influenza season. This interim recommendation, originally made in 2016, followed observational data from the US Influenza Vaccine Effectiveness Network revealing that LAIV4 performed poorly against influenza A (H1N1)pdm09 viruses in recent influenza seasons; 4. All children with an egg allergy of any severity can receive an influenza vaccine without any additional precautions beyond those recommended for any vaccine;

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5. All health care personnel should receive an annual seasonal influenza vaccine, a crucial step in preventing influenza and reducing health care–associated influenza infections, because health care personnel often care for individuals at high risk for influenza-related complications; and 6. Pediatricians should attempt to promptly identify children suspected of having influenza infection for timely initiation of antiviral treatment, when indicated, to reduce morbidity and mortality. Best results are seen when treated within 48 hours of symptom onset. (9/17) See full text on page 1127.

http://pediatrics.aappublications.org/content/140/4/e20172550

RECOMMENDATIONS FOR SEROGROUP B MENINGOCOCCAL VACCINE FOR PERSONS 10 YEARS AND OLDER Committee on Infectious Diseases ABSTRACT. This policy statement provides recommendations for the prevention of serogroup B meningococcal disease through the use of 2 newly licensed serogroup B meningococcal vaccines: MenB-FHbp (Trumenba; Wyeth Pharmaceuticals, a subsidiary of Pfizer, Philadelphia, PA) and MenB-4C (Bexsero; Novartis Vaccines, Siena, Italy). Both vaccines are approved for use in persons 10 through 25 years of age. MenB-FHbp is licensed as a 2- or 3-dose series, and MenB-4C is licensed as a 2-dose series for all groups. Either vaccine is recommended for routine use in persons 10 years and older who are at increased risk of serogroup B meningococcal disease (category A recommendation). Persons at increased risk of meningococcal serogroup B disease include the following: (1) persons with persistent complement component diseases, including inherited or chronic deficiencies in C3, C5–C9, properdin, factor D, or factor H, or persons receiving eculizumab (Soliris; Alexion Pharmaceuticals, Cheshire, CT), a monoclonal antibody that acts as a terminal complement inhibitor by binding C5 and inhibiting cleavage of C5 to C5A; (2) persons with anatomic or functional asplenia, including sickle cell disease; and (3) healthy persons at increased risk because of a serogroup B meningococcal disease outbreak. Both serogroup B meningococcal vaccines have been shown to be safe and immunogenic and are licensed by the US Food and Drug Administration for individuals between the ages of 10 and 25 years. On the basis of epidemiologic and antibody persistence data, the American Academy of Pediatrics agrees with the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention that either vaccine may be administered to healthy adolescents and young adults 16 through 23 years of age (preferred ages are 16 through 18 years) to provide short-term protection against most strains of serogroup B meningococcal disease (category B recommendation). (8/16)

http://pediatrics.aappublications.org/content/138/3/e20161890 RECOMMENDED CHILDHOOD AND ADOLESCENT IMMUNIZATION SCHEDULE—UNITED STATES, 2018 Committee on Infectious Diseases (1/18) See full text on page 1149.

http://pediatrics.aappublications.org/content/early/2018/02/ 02/peds.2018-0083 REDUCING INJURY RISK FROM BODY CHECKING IN BOYS’ YOUTH ICE HOCKEY Council on Sports Medicine and Fitness ABSTRACT. Ice hockey is an increasingly popular sport that allows intentional collision in the form of body checking for males but not for females. There is a two- to threefold increased risk of all injury, severe injury, and concussion related to body checking at all levels of boys’ youth ice hockey. The American Academy of Pediatrics reinforces the importance of stringent

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enforcement of rules to protect player safety as well as educational interventions to decrease unsafe tactics. To promote ice hockey as a lifelong recreational pursuit for boys, the American Academy of Pediatrics recommends the expansion of nonchecking programs and the restriction of body checking to elite levels of boys’ youth ice hockey, starting no earlier than 15 years of age. (5/14)

http://pediatrics.aappublications.org/content/133/6/1151

REDUCING THE NUMBER OF DEATHS AND INJURIES FROM RESIDENTIAL FIRES Committee on Injury and Poison Prevention ABSTRACT. Smoke inhalation, severe burns, and death from residential fires are devastating events, most of which are preventable. In 1998, approximately 381 500 residential structure fires resulted in 3250 non-firefighter deaths, 17 175 injuries, and approximately $4.4 billion in property loss. This statement reviews important prevention messages and intervention strategies related to residential fires. It also includes recommendations for pediatricians regarding office anticipatory guidance, work in the community, and support of regulation and legislation that could result in a decrease in the number of fire-related injuries and deaths to children. (6/00)

http://pediatrics.aappublications.org/content/105/6/1355

REFERRAL TO PEDIATRIC SURGICAL SPECIALISTS Surgical Advisory Panel ABSTRACT. The American Academy of Pediatrics, with the collaboration of the Surgical Sections of the American Academy of Pediatrics, has created referral recommendations intended to serve as voluntary practice parameters to assist general pediatricians in determining when and to whom to refer their patients for pediatric surgical specialty care. It is recognized that these recommendations may be difficult to implement, because communities vary in terms of access to major pediatric medical centers. Limited access does not negate the value of the recommendations, however, because the child who needs specialized surgical and anesthetic care is best served by the skills of the appropriate pediatric surgical team. Major congenital anomalies, malignancies, major trauma, and chronic illnesses (including those associated with preterm birth) in infants and children should be managed by pediatric medical subspecialists and pediatric surgical specialists at pediatric referral centers that can provide expertise in many areas, including the pediatric medical subspecialties and surgical specialties of pediatric radiology, pediatric anesthesiology, pediatric pathology, and pediatric intensive care. The optimal management of the child with complex problems, chronic illness, or disabilities requires coordination, communication, and cooperation of the pediatric surgical specialist with the child’s primary care pediatrician or physician. (1/14)

http://pediatrics.aappublications.org/content/133/2/350

REIMBURSEMENT FOR FOODS FOR SPECIAL DIETARY USE Committee on Nutrition ABSTRACT. Foods for special dietary use are recommended by physicians for chronic diseases or conditions of childhood, including inherited metabolic diseases. Although many states have created legislation requiring reimbursement for foods for special dietary use, legislation is now needed to mandate consistent coverage and reimbursement for foods for special dietary use and related support services with accepted medical benefit for children with designated medical conditions. (5/03, reaffirmed 1/06)

http://pediatrics.aappublications.org/content/111/5/1117

SECTION 5/CURRENT POLICIES

RELIEF OF PAIN AND ANXIETY IN PEDIATRIC PATIENTS IN EMERGENCY MEDICAL SYSTEMS (CLINICAL REPORT) Joel A. Fein, MD, MPH; William T. Zempsky, MD, MPH; Joseph P. Cravero, MD; Committee on Pediatric Emergency Medicine; and Section on Anesthesiology and Pain Medicine ABSTRACT. Control of pain and stress for children is a vital component of emergency medical care. Timely administration of analgesia affects the entire emergency medical experience and can have a lasting effect on a child’s and family’s reaction to current and future medical care. A systematic approach to pain management and anxiolysis, including staff education and protocol development, can provide comfort to children in the emergency setting and improve staff and family satisfaction. (10/12, reaffirmed 9/15)

http://pediatrics.aappublications.org/content/130/5/e1391

RESCUE MEDICINE FOR EPILEPSY IN EDUCATION SETTINGS (CLINICAL REPORT) Adam L. Hartman, MD, FAAP; Cynthia Di Laura Devore, MD; Section on Neurology; and Council on School Health ABSTRACT. Children and adolescents with epilepsy may experience prolonged seizures in school-associated settings (eg, during transportation, in the classroom, or during sports activities). Prolonged seizures may evolve into status epilepticus. Administering a seizure rescue medication can abort the seizure and may obviate the need for emergency medical services and subsequent care in an emergency department. In turn, this may save patients from the morbidity of more invasive interventions and the cost of escalated care. There are significant variations in prescribing practices for seizure rescue medications, partly because of inconsistencies between jurisdictions in legislation and professional practice guidelines among potential first responders (including school staff). There also are potential liability issues for prescribers, school districts, and unlicensed assistive personnel who might administer the seizure rescue medications. This clinical report highlights issues that providers may consider when prescribing seizure rescue medications and creating school medical orders and/or action plans for students with epilepsy. Collaboration among prescribing providers, families, and schools may be useful in developing plans for the use of seizure rescue medications. (12/15)

http://pediatrics.aappublications.org/content/137/1/e20153876

RESPIRATORY SUPPORT IN PRETERM INFANTS AT BIRTH Committee on Fetus and Newborn ABSTRACT. Current practice guidelines recommend administration of surfactant at or soon after birth in preterm infants with respiratory distress syndrome. However, recent multicenter randomized controlled trials indicate that early use of continuous positive airway pressure with subsequent selective surfactant administration in extremely preterm infants results in lower rates of bronchopulmonary dysplasia/death when compared with treatment with prophylactic or early surfactant therapy. Continuous positive airway pressure started at or soon after birth with subsequent selective surfactant administration may be considered as an alternative to routine intubation with prophylactic or early surfactant administration in preterm infants. (12/13)

http://pediatrics.aappublications.org/content/133/1/171

RESPONDING TO PARENTAL REFUSALS OF IMMUNIZATION OF CHILDREN (CLINICAL REPORT) Douglas S. Diekema, MD, MPH, and Committee on Bioethics ABSTRACT. The American Academy of Pediatrics strongly endorses universal immunization. However, for childhood immunization programs to be successful, parents must comply with immunization recommendations. The problem of parental

POLICY TITLES AND ABSTRACTS

refusal of immunization for children is an important one for pediatricians. The goal of this report is to assist pediatricians in understanding the reasons parents may have for refusing to immunize their children, review the limited circumstances under which parental refusals should be referred to child protective services agencies or public health authorities, and provide practical guidance to assist the pediatrician faced with a parent who is reluctant to allow immunization of his or her child. (5/05, reaffirmed 1/09, 11/12)

http://pediatrics.aappublications.org/content/115/5/1428

RESPONSIBLE INNOVATION IN CHILDREN’S SURGICAL CARE Section on Surgery and Committee on Bioethics (joint with American Pediatric Surgical Association New Technology Committee) ABSTRACT. Advances in medical care may occur when a change in practice incorporates a new treatment or methodology. In surgery, this may involve the translation of a completely novel concept into a new procedure or device or the adaptation of existing treatment approaches or technology to a new clinical application. Regardless of the specifics, innovation should have, as its primary goal, the enhancement of care leading to improved outcomes from the patient’s perspective. This policy statement examines innovation as it pertains to surgical care, focusing on some of the definitions that help differentiate applied innovation or innovative therapy from research. The ethical challenges and the potential for conflict of interest for surgeons or institutions seeking to offer innovative surgical therapy are examined. The importance of engaging patients and families as “innovation partners” to ensure complete transparency of expectations from the patient’s and provider’s perspectives is also examined, with specific emphasis on cultural competence and mutually respectful approaches. A framework for identifying, evaluating, and safely implementing innovative surgical therapy in children is provided. (12/16) See full text on page 1153.

http://pediatrics.aappublications.org/content/139/1/e20163437

RETURNING TO LEARNING FOLLOWING A CONCUSSION (CLINICAL REPORT) Mark E. Halstead, MD, FAAP; Karen McAvoy, PsyD; Cynthia D. Devore, MD, FAAP; Rebecca Carl, MD, FAAP; Michael Lee, MD, FAAP; Kelsey Logan, MD, FAAP; Council on Sports Medicine and Fitness; and Council on School Health ABSTRACT. Following a concussion, it is common for children and adolescents to experience difficulties in the school setting. Cognitive difficulties, such as learning new tasks or remembering previously learned material, may pose challenges in the classroom. The school environment may also increase symptoms with exposure to bright lights and screens or noisy cafeterias and hallways. Unfortunately, because most children and adolescents look physically normal after a concussion, school officials often fail to recognize the need for academic or environmental adjustments. Appropriate guidance and recommendations from the pediatrician may ease the transition back to the school environment and facilitate the recovery of the child or adolescent. This report serves to provide a better understanding of possible factors that may contribute to difficulties in a school environment after a concussion and serves as a framework for the medical home, the educational home, and the family home to guide the student to a successful and safe return to learning. (10/13)

http://pediatrics.aappublications.org/content/132/5/948 RITUAL GENITAL CUTTING OF FEMALE MINORS Board of Directors (6/10)

http://pediatrics.aappublications.org/content/126/1/191

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ROLE OF PEDIATRICIANS IN ADVOCATING LIFE SUPPORT TRAINING COURSES FOR PARENTS AND THE PUBLIC Committee on Pediatric Emergency Medicine ABSTRACT. Available literature suggests a need for both initial cardiopulmonary resuscitation basic life support training and refresher courses for parents and the public as well as health care professionals. The promotion of basic life support training courses that establish a pediatric chain of survival spanning from prevention of cardiac arrest and trauma to rehabilitative and follow-up care for victims of cardiopulmonary arrest is advocated in this policy statement and is the focus of an accompanying technical report. Immediate bystander cardiopulmonary resuscitation for victims of cardiac arrest improves survival for outof-hospital cardiac arrest. Pediatricians will improve the chance of survival of children and adults who experience cardiac arrest by advocating for cardiopulmonary resuscitation training and participating in basic life support training courses as participants and instructors. (12/04, reaffirmed 5/07, 8/10, 8/13, 7/16)

http://pediatrics.aappublications.org/content/114/6/1676

ROLE OF PEDIATRICIANS IN ADVOCATING LIFE SUPPORT TRAINING COURSES FOR PARENTS AND THE PUBLIC (TECHNICAL REPORT) Lee A. Pyles, MD; Jane Knapp, MD; and Committee on Pediatric Emergency Medicine ABSTRACT. Available literature suggests a need for both initial cardiopulmonary resuscitation training and refresher courses. The establishment of a pediatric chain of survival for victims of cardiopulmonary arrest is the focus of this technical report and is advocated in the accompanying policy statement. Immediate bystander cardiopulmonary resuscitation for victims of cardiac arrest improves survival for out-of-hospital cardiac arrest. Pediatricians will improve the chance of survival of children and adults who experience cardiac arrest by advocating for basic life support training and participating in basic life support courses as participants and teachers. (12/04, reaffirmed 5/07, 8/10, 1/14)

http://pediatrics.aappublications.org/content/114/6/e761

ROLE OF PULSE OXIMETRY IN EXAMINING NEWBORNS FOR CONGENITAL HEART DISEASE: A SCIENTIFIC STATEMENT FROM THE AHA AND AAP William T. Mahle, MD; Jane W. Newburger, MD, MPH; G. Paul Matherne, MD; Frank C. Smith, MD; Tracey R. Hoke, MD; Robert Koppel, MD; Samuel S. Gidding, MD; Robert H. Beekman III, MD; Scott D. Grosse, PhD; on behalf of Section on Cardiology and Cardiac Surgery and Committee of Fetus and Newborn (joint with American Heart Association Congenital Heart Defects Committee of the Council on Cardiovascular Disease in the Young, Council on Cardiovascular Nursing, and Interdisciplinary Council on Quality of Care and Outcomes Research) ABSTRACT. Background. The purpose of this statement is to address the state of evidence on the routine use of pulse oximetry in newborns to detect critical congenital heart disease (CCHD). Methods and Results. A writing group appointed by the American Heart Association and the American Academy of Pediatrics reviewed the available literature addressing current detection methods for CCHD, burden of missed and/or delayed diagnosis of CCHD, rationale of oximetry screening, and clinical studies of oximetry in otherwise asymptomatic newborns. MEDLINE database searches from 1966 to 2008 were done for English-language papers using the following search terms: congenital heart disease, pulse oximetry, physical examination, murmur, echocardiography, fetal echocardiography, and newborn screening. The reference lists of identified papers were also searched. Published abstracts from major pediatric scientific meetings in 2006 to 2008 were also reviewed. The American Heart Association classification of recommendations and levels of evidence for practice guidelines were used. In an analysis

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of pooled studies of oximetry assessment performed after 24 hours of life, the estimated sensitivity for detecting CCHD was 69.6%, and the positive predictive value was 47.0%; however, sensitivity varied dramatically among studies from 0% to 100%. False-positive screens that required further evaluation occurred in only 0.035% of infants screened after 24 hours. Conclusions. Currently, CCHD is not detected in some newborns until after their hospital discharge, which results in significant morbidity and occasional mortality. Furthermore, routine pulse oximetry performed on asymptomatic newborns after 24 hours of life, but before hospital discharge, may detect CCHD. Routine pulse oximetry performed after 24 hours in hospitals that have on-site pediatric cardiovascular services incurs very low cost and risk of harm. Future studies in larger populations and across a broad range of newborn delivery systems are needed to determine whether this practice should become standard of care in the routine assessment of the neonate. (8/09)

http://pediatrics.aappublications.org/content/124/2/823

THE ROLE OF THE PEDIATRICIAN IN PRIMARY PREVENTION OF OBESITY (CLINICAL REPORT) Stephen R. Daniels, MD, PhD, FAAP; Sandra G. Hassink, MD, FAAP; and Committee on Nutrition ABSTRACT. The adoption of healthful lifestyles by individuals and families can result in a reduction in many chronic diseases and conditions of which obesity is the most prevalent. Obesity prevention, in addition to treatment, is an important public health priority. This clinical report describes the rationale for pediatricians to be an integral part of the obesity-­ prevention effort. In addition, the 2012 Institute of Medicine report “Accelerating Progress in Obesity Prevention” includes health care providers as a crucial component of successful weight control. Research on obesity prevention in the pediatric care setting as well as evidence-informed practical approaches and targets for prevention are reviewed. Pediatricians should use a longitudinal, developmentally appropriate life-course approach to help identify children early on the path to obesity and base prevention efforts on family dynamics and reduction in high-risk dietary and activity behaviors. They should promote a diet free of sugar-sweetened beverages, of fewer foods with high caloric density, and of increased intake of fruits and vegetables. It is also important to promote a lifestyle with reduced sedentary behavior and with 60 minutes of daily moderate to vigorous physical activity. This report also identifies important gaps in evidence that need to be filled by future research. (6/15)

http://pediatrics.aappublications.org/content/136/1/e275

THE ROLE OF THE PEDIATRICIAN IN RURAL EMERGENCY MEDICAL SERVICES FOR CHILDREN Committee on Pediatric Emergency Medicine ABSTRACT. In rural America, pediatricians can play a key role in the development, implementation, and ongoing supervision of emergency medical services for children (EMSC). Pediatricians may represent the only source of pediatric expertise for a large region and are a vital resource for rural physicians (eg, general and family practice, emergency medicine) and other rural health care professionals (physician assistants, nurse practitioners, and emergency medical technicians), providing education about management and prevention of pediatric illness and injury; appropriate equipment for the acutely ill or injured child; and acute, chronic, and rehabilitative care. In addition to providing clinical expertise, the pediatrician may be involved in quality assurance, clinical protocol development, and advocacy, and may serve as a liaison between emergency medical services and other entities working with children (eg, school nurses, child care centers, athletic programs, and programs for children with special health care needs). (10/12, reaffirmed 9/15)

http://pediatrics.aappublications.org/content/130/5/978

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ROLE OF THE PEDIATRICIAN IN YOUTH VIOLENCE PREVENTION Committee on Injury, Violence, and Poison Prevention ABSTRACT. Youth violence continues to be a serious threat to the health of children and adolescents in the United States. It is crucial that pediatricians clearly define their role and develop the appropriate skills to address this threat effectively. From a clinical perspective, pediatricians should become familiar with Connected Kids: Safe, Strong, Secure, the American Academy of Pediatrics’ primary care violence prevention protocol. Using this material, practices can incorporate preventive education, screening for risk, and linkages to community-based counseling and treatment resources. As advocates, pediatricians may bring newly developed information regarding key risk factors such as exposure to firearms, teen dating violence, and bullying to the attention of local and national policy makers. This policy statement refines the developing role of pediatricians in youth violence prevention and emphasizes the importance of this issue in the strategic agenda of the American Academy of Pediatrics. (6/09)

http://pediatrics.aappublications.org/content/124/1/393

ROLE OF THE SCHOOL NURSE IN PROVIDING SCHOOL HEALTH SERVICES Council on School Health ABSTRACT. The American Academy of Pediatrics recognizes the important role school nurses play in promoting the optimal biopsychosocial health and well-being of school-aged children in the school setting. Although the concept of a school nurse has existed for more than a century, uniformity among states and school districts regarding the role of a registered professional nurse in schools and the laws governing it are lacking. By understanding the benefits, roles, and responsibilities of school nurses working as a team with the school physician, as well as their contributions to school-aged children, pediatricians can collaborate with, support, and promote school nurses in their own communities, thus improving the health, wellness, and safety of children and adolescents. (5/16)

http://pediatrics.aappublications.org/content/137/6/e20160852

ROLE OF THE SCHOOL PHYSICIAN Council on School Health ABSTRACT. The American Academy of Pediatrics recognizes the important role physicians play in promoting the optimal biopsychosocial well-being of children in the school setting. Although the concept of a school physician has existed for more than a century, uniformity among states and school districts regarding physicians in schools and the laws governing it are lacking. By understanding the roles and contributions physicians can make to schools, pediatricians can support and promote school physicians in their communities and improve health and safety for children. (12/12)

http://pediatrics.aappublications.org/content/131/1/178

SAFE SLEEP AND SKIN-TO-SKIN CARE IN THE NEONATAL PERIOD FOR HEALTHY TERM NEWBORNS (CLINICAL REPORT) Lori Feldman-Winter, MD, MPH, FAAP; Jay P. Goldsmith, MD, FAAP; Committee on Fetus and Newborn; and Task Force on Sudden Infant Death Syndrome ABSTRACT. Skin-to-skin care (SSC) and rooming-in have become common practice in the newborn period for healthy newborns with the implementation of maternity care practices that support breastfeeding as delineated in the World Health Organization’s “Ten Steps to Successful Breastfeeding.” SSC and rooming-in are supported by evidence that indicates that the implementation of these practices increases overall and exclusive breastfeeding, safer and healthier transitions, and improved

POLICY TITLES AND ABSTRACTS

maternal-infant bonding. In some cases, however, the practice of SSC and rooming-in may pose safety concerns, particularly with regard to sleep. There have been several recent case reports and case series of severe and sudden unexpected postnatal collapse in the neonatal period among otherwise healthy newborns and near fatal or fatal events related to sleep, suffocation, and falls from adult hospital beds. Although these are largely case reports, there are potential dangers of unobserved SSC immediately after birth and throughout the postpartum hospital period as well as with unobserved rooming-in for at-risk situations. Moreover, behaviors that are modeled in the hospital after birth, such as sleep position, are likely to influence sleeping practices after discharge. Hospitals and birthing centers have found it difficult to develop policies that will allow SSC and rooming-in to continue in a safe manner. This clinical report is intended for birthing centers and delivery hospitals caring for healthy newborns to assist in the establishment of appropriate SSC and safe sleep policies. (8/16)

http://pediatrics.aappublications.org/content/138/3/e20161889

SAFE TRANSPORTATION OF NEWBORNS AT HOSPITAL DISCHARGE Committee on Injury and Poison Prevention ABSTRACT. All hospitals should set policies that require the discharge of every newborn in a car safety seat that is appropriate for the infant’s maturity and medical condition. Discharge policies for newborns should include a parent education component, regular review of educational materials, and periodic in-service education for responsible staff. Appropriate child restraint systems should become a benefit of coverage by Medicaid, managed care organizations, and other third-party insurers. (10/99, reaffirmed 1/03, 1/06, 10/08)

http://pediatrics.aappublications.org/content/104/4/986

SAFE TRANSPORTATION OF PRETERM AND LOW BIRTH WEIGHT INFANTS AT HOSPITAL DISCHARGE (CLINICAL REPORT) Marilyn J. Bull, MD; William A. Engle, MD; Committee on Injury, Violence, and Poison Prevention; and Committee on Fetus and Newborn ABSTRACT. Safe transportation of preterm and low birth weight infants requires special considerations. Both physiologic immaturity and low birth weight must be taken into account to properly position such infants. This clinical report provides guidelines for pediatricians and other caregivers who counsel parents of preterm and low birth weight infants about car safety seats. (4/09, reaffirmed 8/13)

http://pediatrics.aappublications.org/content/123/5/1424

SCHOOL BUS TRANSPORTATION OF CHILDREN WITH SPECIAL HEALTH CARE NEEDS Committee on Injury and Poison Prevention (8/01, reaffirmed 1/05, 2/08, 5/13)

http://pediatrics.aappublications.org/content/108/2/516

SCHOOL HEALTH ASSESSMENTS Committee on School Health ABSTRACT. Comprehensive health assessments often are performed in school-based clinics or public health clinics by health professionals other than pediatricians. Pediatricians or other physicians skilled in child health care should participate in such evaluations. This statement provides guidance on the scope of in-school health assessments and the roles of the pediatrician, school nurse, school, and community. (4/00, reaffirmed 6/03, 5/06, 10/11)

http://pediatrics.aappublications.org/content/105/4/875

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SCHOOL READINESS (TECHNICAL REPORT) Pamela C. High, MD; Committee on Early Childhood, Adoption, and Dependent Care; and Council on School Health ABSTRACT. School readiness includes the readiness of the individual child, the school’s readiness for children, and the ability of the family and community to support optimal early child development. It is the responsibility of schools to be ready for all children at all levels of readiness. Children’s readiness for kindergarten should become an outcome measure for community-based programs, rather than an exclusion criterion at the beginning of the formal educational experience. Our new knowledge of early brain and child development has revealed that modifiable factors in a child’s early experience can greatly affect that child’s learning trajectory. Many US children enter kindergarten with limitations in their social, emotional, cognitive, and physical development that might have been significantly diminished or eliminated through early identification of and attention to child and family needs. Pediatricians have a role in promoting school readiness for all children, beginning at birth, through their practices and advocacy. The American Academy of Pediatrics affords pediatricians many opportunities to promote the physical, social-emotional, and educational health of young children, with other advocacy groups. This technical report supports American Academy of Pediatrics policy statements “Quality Early Education and Child Care From Birth to Kindergarten” and “The Inappropriate Use of School ‘Readiness’ Tests.” (4/08, reaffirmed 9/13)

http://pediatrics.aappublications.org/content/121/4/e1008

SCHOOL START TIMES FOR ADOLESCENTS Adolescent Sleep Working Group, Committee on Adolescence, and Council on School Health ABSTRACT. The American Academy of Pediatrics recognizes insufficient sleep in adolescents as an important public health issue that significantly affects the health and safety, as well as the academic success, of our nation’s middle and high school students. Although a number of factors, including biological changes in sleep associated with puberty, lifestyle choices, and academic demands, negatively affect middle and high school students’ ability to obtain sufficient sleep, the evidence strongly implicates earlier school start times (ie, before 8:30 AM) as a key modifiable contributor to insufficient sleep, as well as circadian rhythm disruption, in this population. Furthermore, a substantial body of research has now demonstrated that delaying school start times is an effective countermeasure to chronic sleep loss and has a wide range of potential benefits to students with regard to physical and mental health, safety, and academic achievement. The American Academy of Pediatrics strongly supports the efforts of school districts to optimize sleep in students and urges high schools and middle schools to aim for start times that allow students the opportunity to achieve optimal levels of sleep (8.5–9.5 hours) and to improve physical (eg, reduced obesity risk) and mental (eg, lower rates of depression) health, safety (eg, drowsy driving crashes), academic performance, and quality of life. (8/14)

http://pediatrics.aappublications.org/content/134/3/642

SCHOOL TRANSPORTATION SAFETY Committee on Injury, Violence, and Poison Prevention and Council on School Health ABSTRACT. This policy statement replaces the previous version published in 1996. It provides new information, studies, regulations, and recommendations related to the safe transportation of children to and from school and school-related activities. Pediatricians can play an important role at the patient/family, community, state, and national levels as child advocates and

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consultants to schools and early education programs about transportation safety. (7/07, reaffirmed 10/11)

http://pediatrics.aappublications.org/content/120/1/213

SCHOOL-BASED HEALTH CENTERS AND PEDIATRIC PRACTICE Council on School Health ABSTRACT. School-based health centers (SBHCs) have become an important method of health care delivery for the youth of our nation. Although they only represent 1 aspect of a coordinated school health program approach, SBHCs have provided access to health care services for youth confronted with age, financial, cultural, and geographic barriers. A fundamental principle of SBHCs is to create an environment of service coordination and collaboration that addresses the health needs and well-being of youth with health disparities or poor access to health care services. Some pediatricians have concerns that these centers are in conflict with the primary care provider’s medical home. This policy provides an overview of SBHCs and some of their documented benefits, addresses the issue of potential conflict with the medical home, and provides recommendations that support the integration and coordination of SBHCs and the pediatric medical home practice. (1/12)

http://pediatrics.aappublications.org/content/129/2/387

SCOPE OF HEALTH CARE BENEFITS FOR CHILDREN FROM BIRTH THROUGH AGE 26 Committee on Child Health Financing ABSTRACT. The optimal health of all children is best achieved with access to appropriate and comprehensive health care benefits. This policy statement outlines and defines the recommended set of health insurance benefits for children through age 26. The American Academy of Pediatrics developed a set of recommendations concerning preventive care services for children, adolescents, and young adults. These recommendations are compiled in the publication Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, third edition. The Bright Futures recommendations were referenced as a standard for access and design of age-appropriate health insurance benefits for infants, children, adolescents, and young adults in the Patient Protection and Affordable Care Act of 2010 (Pub L No. 114–148). (11/11)

http://pediatrics.aappublications.org/content/129/1/185

SCOPE OF PRACTICE ISSUES IN THE DELIVERY OF PEDIATRIC HEALTH CARE Committee on Pediatric Workforce ABSTRACT. The American Academy of Pediatrics (AAP) believes that optimal pediatric health care depends on a teambased approach with supervision by a physician leader, preferably a pediatrician. The pediatrician, here defined to include not only pediatric generalists but all pediatric medical subspecialists, all surgical specialists, and internal medicine/pediatric physicians, is uniquely qualified to manage, coordinate, and supervise the entire spectrum of pediatric care, from diagnosis through all stages of treatment, in all practice settings. The AAP recognizes the valuable contributions of nonphysician clinicians, including nurse practitioners and physician assistants, in delivering optimal pediatric care. However, the expansion of the scope of practice of nonphysician pediatric clinicians raises critical public policy and child health advocacy concerns. Pediatricians should serve as advocates for optimal pediatric care in state legislatures, public policy forums, and the media and should pursue opportunities to resolve scope of practice conflicts outside state legislatures. The AAP affirms the importance of appropriate

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­ ocumentation and standards in pediatric education, training, d skills, clinical competencies, examination, regulation, and patient care to ensure safety and quality health care for all infants, children, adolescents, and young adults. (5/13, reaffirmed 10/15)

http://pediatrics.aappublications.org/content/131/6/1211

SCREENING EXAMINATION OF PREMATURE INFANTS FOR RETINOPATHY OF PREMATURITY Section on Ophthalmology (joint with American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, and American Association of Certified Orthoptists) ABSTRACT. This statement revises a previous statement on screening of preterm infants for retinopathy of prematurity (ROP) that was published in 2006. ROP is a pathologic process that occurs only in immature retinal tissue and can progress to a tractional retinal detachment, which can result in functional or complete blindness. Use of peripheral retinal ablative therapy by using laser photocoagulation for nearly 2 decades has resulted in a high probability of markedly decreasing the incidence of this poor visual outcome, but the sequential nature of ROP creates a requirement that at-risk preterm infants be examined at proper times and intervals to detect the changes of ROP before they become permanently destructive. This statement presents the attributes on which an effective program for detecting and treating ROP could be based, including the timing of initial examination and subsequent reexamination intervals. (12/12, reaffirmed 2/16)

http://pediatrics.aappublications.org/content/131/1/189

SCREENING FOR NONVIRAL SEXUALLY TRANSMITTED INFECTIONS IN ADOLESCENTS AND YOUNG ADULTS Committee on Adolescence (joint with Society for Adolescent Health and Medicine) ABSTRACT. Prevalence rates of many sexually transmitted infections (STIs) are highest among adolescents. If nonviral STIs are detected early, they can be treated, transmission to others can be eliminated, and sequelae can be averted. The US Preventive Services Task Force and the Centers for Disease Control and Prevention have published chlamydia, gonorrhea, and syphilis screening guidelines that recommend screening those at risk on the basis of epidemiologic and clinical outcomes data. This policy statement specifically focuses on these curable, nonviral STIs and reviews the evidence for nonviral STI screening in adolescents, communicates the value of screening, and outlines recommendations for routine nonviral STI screening of adolescents. (6/14)

http://pediatrics.aappublications.org/content/134/1/e302

SCREENING FOR RETINOPATHY IN THE PEDIATRIC PATIENT WITH TYPE 1 DIABETES MELLITUS (CLINICAL REPORT) Gregg T. Lueder, MD; Janet Silverstein, MD; Section on Ophthalmology; and Section on Endocrinology (joint with American Association for Pediatric Ophthalmology and Strabismus) ABSTRACT. Diabetic retinopathy (DR) is the leading cause of blindness in young adults in the United States. Early identification and treatment of DR can decrease the risk of vision loss in affected patients. This clinical report reviews the risk factors for the development of DR and screening guidance for pediatric patients with type 1 diabetes mellitus. (7/05, reaffirmed 1/09, 7/14)

http://pediatrics.aappublications.org/content/116/1/270

POLICY TITLES AND ABSTRACTS

SECONDHAND AND PRENATAL TOBACCO SMOKE EXPOSURE (TECHNICAL REPORT) Dana Best, MD, MPH; Committee on Environmental Health; Committee on Native American Child Health; and Committee on Adolescence ABSTRACT. Secondhand tobacco smoke (SHS) exposure of children and their families causes significant morbidity and mortality. In their personal and professional roles, pediatricians have many opportunities to advocate for elimination of SHS exposure of children, to counsel tobacco users to quit, and to counsel children never to start. This report discusses the harms of tobacco use and SHS exposure, the extent and costs of tobacco use and SHS exposure, and the evidence that supports counseling and other clinical interventions in the cycle of tobacco use. Recommendations for future research, policy, and clinical practice change are discussed. To improve understanding and provide support for these activities, the harms of SHS exposure are discussed, effective ways to eliminate or reduce SHS exposure are presented, and policies that support a smoke-free environment are outlined. (10/09, reaffirmed 5/14)

http://pediatrics.aappublications.org/content/124/5/e1017

SELECTING APPROPRIATE TOYS FOR YOUNG CHILDREN: THE PEDIATRICIAN’S ROLE (CLINICAL REPORT) Committee on Early Childhood, Adoption, and Dependent Care ABSTRACT. Play is essential for learning in children. Toys are the tools of play. Which play materials are provided and how they are used are equally important. Adults caring for children can be reminded that toys facilitate but do not substitute for the most important aspect of nurture—warm, loving, dependable relationships. Toys should be safe, affordable, and developmentally appropriate. Children do not need expensive toys. Toys should be appealing to engage the child over a period of time. Information and resources are provided in this report so pediatricians can give parents advice about selecting toys. (4/03, reaffirmed 10/06, 5/11)

http://pediatrics.aappublications.org/content/111/4/911

SENSORY INTEGRATION THERAPIES FOR CHILDREN WITH DEVELOPMENTAL AND BEHAVIORAL DISORDERS Section on Complementary and Integrative Medicine and Council on Children With Disabilities ABSTRACT. Sensory-based therapies are increasingly used by occupational therapists and sometimes by other types of therapists in treatment of children with developmental and behavioral disorders. Sensory-based therapies involve activities that are believed to organize the sensory system by providing vestibular, proprioceptive, auditory, and tactile inputs. Brushes, swings, balls, and other specially designed therapeutic or recreational equipment are used to provide these inputs. However, it is unclear whether children who present with sensory-based problems have an actual “disorder” of the sensory pathways of the brain or whether these deficits are characteristics associated with other developmental and behavioral disorders. Because there is no universally accepted framework for diagnosis, sensory processing disorder generally should not be diagnosed. Other developmental and behavioral disorders must always be considered, and a thorough evaluation should be completed. Difficulty tolerating or processing sensory information is a characteristic that may be seen in many developmental behavioral disorders, including autism spectrum disorders, attention-­ deficit/hyperactivity disorder, developmental coordination disorders, and childhood anxiety disorders. Occupational therapy with the use of sensory-based therapies may be acceptable as one of the components of a comprehensive treatment plan. However, parents should be informed that

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the amount of research regarding the effectiveness of sensory integration therapy is limited and inconclusive. Important roles for pediatricians and other clinicians may include discussing these limitations with parents, talking with families about a trial period of sensory integration therapy, and teaching families how to evaluate the effectiveness of a therapy. (5/12)

http://pediatrics.aappublications.org/content/129/6/1186

SEXUAL AND REPRODUCTIVE HEALTH CARE SERVICES IN THE PEDIATRIC SETTING (CLINICAL REPORT) Arik V. Marcell, MD, MPH; Gale R. Burstein, MD, MPH; and Committee on Adolescence ABSTRACT. Pediatricians are an important source of health care for adolescents and young adults and can play a significant role in addressing their patients’ sexual and reproductive health needs, including preventing unintended pregnancies and sexually transmitted infections (STIs), including HIV, and promoting healthy relationships. STIs, HIV, and unintended pregnancy are all preventable health outcomes with potentially serious permanent sequelae; the highest rates of STIs, HIV, and unintended pregnancy are reported among adolescents and young adults. Office visits present opportunities to provide comprehensive education and health care services to adolescents and young adults to prevent STIs, HIV, and unintended pregnancies. The American Academy of Pediatrics, other professional medical organizations, and the government have guidelines and recommendations regarding the provision of sexual and reproductive health information and services. However, despite these recommendations, recent studies have revealed that there is substantial room for improvement in actually delivering the recommended services. The purpose of this clinical report is to assist pediatricians to operationalize the provision of various aspects of sexual and reproductive health care into their practices and to provide guidance on overcoming barriers to providing this care routinely while maximizing opportunities for confidential health services delivery in their offices. (10/17) See full text on page 1165.

http://pediatrics.aappublications.org/content/140/5/e20172858

SEXUALITY EDUCATION FOR CHILDREN AND ADOLESCENTS (CLINICAL REPORT) Cora C. Breuner, MD, MPH; Gerri Mattson, MD, MSPH; Committee on Adolescence; and Committee on Psychosocial Aspects of Child and Family Health ABSTRACT. The purpose of this clinical report is to provide pediatricians updated research on evidence-based sexual and reproductive health education conducted since the original clinical report on the subject was published by the American Academy of Pediatrics in 2001. Sexuality education is defined as teaching about human sexuality, including intimate relationships, human sexual anatomy, sexual reproduction, sexually transmitted infections, sexual activity, sexual orientation, gender identity, abstinence, contraception, and reproductive rights and responsibilities. Developmentally appropriate and evidence-based education about human sexuality and sexual reproduction over time provided by pediatricians, schools, other professionals, and parents is important to help children and adolescents make informed, positive, and safe choices about healthy relationships, responsible sexual activity, and their reproductive health. Sexuality education has been shown to help to prevent and reduce the risks of adolescent pregnancy, HIV, and sexually transmitted infections for children and adolescents with and without chronic health conditions and disabilities in the United States. (7/16)

http://pediatrics.aappublications.org/content/138/2/e20161348

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SEXUALITY OF CHILDREN AND ADOLESCENTS WITH DEVELOPMENTAL DISABILITIES (CLINICAL REPORT) Nancy A. Murphy, MD; Ellen Roy Elias, MD; for Council on Children With Disabilities ABSTRACT. Children and adolescents with developmental disabilities, like all children, are sexual persons. However, attention to their complex medical and functional issues often consumes time that might otherwise be invested in addressing the anatomic, physiologic, emotional, and social aspects of their developing sexuality. This report discusses issues of puberty, contraception, psychosexual development, sexual abuse, and sexuality education specific to children and adolescents with disabilities and their families. Pediatricians, in the context of the medical home, are encouraged to discuss issues of sexuality on a regular basis, ensure the privacy of each child and adolescent, promote self-care and social independence among persons with disabilities, advocate for appropriate sexuality education, and provide ongoing education for children and adolescents with developmental disabilities and their families. (7/06, reaffirmed 12/09, 7/13)

http://pediatrics.aappublications.org/content/118/1/398

SHARED DECISION-MAKING AND CHILDREN WITH DISABILITIES: PATHWAYS TO CONSENSUS (CLINICAL REPORT) Richard C. Adams, MD, FAAP; Susan E. Levy, MD, MPH, FAAP; and Council on Children With Disabilities ABSTRACT. Shared decision-making (SDM) promotes family and clinician collaboration, with ultimate goals of improved health and satisfaction. This clinical report provides a basis for a systematic approach to the implementation of SDM by clinicians for children with disabilities. Often in the discussion of treatment plans, there are gaps between the child’s/family’s values, priorities, and understanding of perceived “best choices” and those of the clinician. When conducted well, SDM affords an appropriate balance incorporating voices of all stakeholders, ultimately supporting both the child/family and clinician. With increasing knowledge of and functional use of SDM skills, the clinician will become an effective partner in the decision-making process with families, providing family-centered care. The outcome of the process will support the beneficence of the physician, the authority of the family, and the autonomy and well-being of the child. (5/17) See full text on page 1181.

http://pediatrics.aappublications.org/content/139/6/e20170956

SHOPPING CART–RELATED INJURIES TO CHILDREN Committee on Injury, Violence, and Poison Prevention ABSTRACT. Shopping cart–related injuries to children are common and can result in severe injury or even death. Most injuries result from falls from carts or cart tip-overs, and injuries to the head and neck represent three fourths of cases. The current US standard for shopping carts should be revised to include clear and effective performance criteria to prevent falls from carts and cart tip-overs. Pediatricians have an important role as educators, researchers, and advocates to promote the prevention of these injuries. (8/06, reaffirmed 4/09, 8/13)

http://pediatrics.aappublications.org/content/118/2/825

SHOPPING CART–RELATED INJURIES TO CHILDREN (TECHNICAL REPORT) Gary A. Smith, MD, DrPH, for Committee on Injury, Violence, and Poison Prevention ABSTRACT. An estimated 24 200 children younger than 15 years, 20 700 (85%) of whom were younger than 5  years, were treated in US hospital emergency departments in 2005 for

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shopping cart–related injuries. Approximately 4% of shopping cart–related injuries to children younger than 15 years require admission to the hospital. Injuries to the head and neck represent three fourths of all injuries. Fractures account for 45% of all hospitalizations. Deaths have occurred from falls from shopping carts and cart tip-overs. Falls are the most common mechanism of injury and account for more than half of injuries associated with shopping carts. Cart tip-overs are the second most common mechanism, responsible for up to one fourth of injuries and almost 40% of shopping cart–related injuries among children younger than 2 years. Public-awareness initiatives, education programs, and parental supervision, although important, are not enough to prevent these injuries effectively. European Standard EN 1929-1:1998 and joint Australian/New Zealand Standard AS/NZS 3847.1:1999 specify requirements for the construction, performance, testing, and safety of shopping carts and have been implemented as national standards in 21 countries. A US performance standard for shopping carts (ASTM [American Society for Testing and Materials] F2372-04) was established in July 2004; however, it does not adequately address falls and cart tip-overs, which are the leading mechanisms of shopping cart–related injuries to children. The current US standard for shopping carts should be revised to include clear and effective performance criteria for shopping cart child-restraint systems and cart stability to prevent falls from carts and cart tip-overs. This is imperative to decrease the number and severity of shopping cart–related injuries to children. Recommendations from the American Academy of Pediatrics regarding prevention of shopping cart–related injuries are included in the accompanying policy statement. (8/06, reaffirmed 4/09, 8/13)

http://pediatrics.aappublications.org/content/118/2/e540

SIDS AND OTHER SLEEP-RELATED INFANT DEATHS: UPDATED 2016 RECOMMENDATIONS FOR A SAFE INFANT SLEEPING ENVIRONMENT Task Force on Sudden Infant Death Syndrome ABSTRACT. Approximately 3500 infants die annually in the United States from sleep-related infant deaths, including sudden infant death syndrome (SIDS; International Classification of Diseases, 10th Revision [ICD-10], R95), ill-defined deaths (ICD-10 R99), and accidental suffocation and strangulation in bed (ICD10 W75). After an initial decrease in the 1990s, the overall death rate attributable to sleep-related infant deaths has not declined in more recent years. Many of the modifiable and nonmodifiable risk factors for SIDS and other sleep-related infant deaths are strikingly similar. The American Academy of Pediatrics recommends a safe sleep environment that can reduce the risk of all sleep-related infant deaths. Recommendations for a safe sleep environment include supine positioning, the use of a firm sleep surface, room-sharing without bed-sharing, and the avoidance of soft bedding and overheating. Additional recommendations for SIDS reduction include the avoidance of exposure to smoke, alcohol, and illicit drugs; breastfeeding; routine immunization; and use of a pacifier. New evidence is presented for skin-to-skin care for newborn infants, use of bedside and in-bed sleepers, sleeping on couches/armchairs and in sitting devices, and use of soft bedding after 4 months of age. The recommendations and strength of evidence for each recommendation are included in this policy statement. The rationale for these recommendations is discussed in detail in the accompanying technical report (www. pediatrics.org/cgi/doi/10.1542/peds.2016-2940). (10/16)

http://pediatrics.aappublications.org/content/138/5/e20162938

POLICY TITLES AND ABSTRACTS

SIDS AND OTHER SLEEP-RELATED INFANT DEATHS: EVIDENCE BASE FOR 2016 UPDATED RECOMMENDATIONS FOR A SAFE INFANT SLEEPING ENVIRONMENT (TECHNICAL REPORT) Rachel Y. Moon, MD, FAAP, and Task Force on Sudden Infant Death Syndrome ABSTRACT. Approximately 3500 infants die annually in the United States from sleep-related infant deaths, including sudden infant death syndrome (SIDS), ill-defined deaths, and accidental suffocation and strangulation in bed. After an initial decrease in the 1990s, the overall sleep-related infant death rate has not declined in more recent years. Many of the modifiable and nonmodifiable risk factors for SIDS and other sleep-related infant deaths are strikingly similar. The American Academy of Pediatrics recommends a safe sleep environment that can reduce the risk of all sleep-related infant deaths. Recommendations for a safe sleep environment include supine positioning, use of a firm sleep surface, room-sharing without bed-sharing, and avoidance of soft bedding and overheating. Additional recommendations for SIDS risk reduction include avoidance of exposure to smoke, alcohol, and illicit drugs; breastfeeding; routine immunization; and use of a pacifier. New evidence and rationale for recommendations are presented for skin-to-skin care for newborn infants, bedside and in-bed sleepers, sleeping on couches/armchairs and in sitting devices, and use of soft bedding after 4 months of age. In addition, expanded recommendations for infant sleep location are included. The recommendations and strength of evidence for each recommendation are published in the accompanying policy statement, “SIDS and Other Sleep-Related Infant Deaths: Updated 2016 Recommendations for a Safe Infant Sleeping Environment,” which is included in this issue. (10/16)

http://pediatrics.aappublications.org/content/138/5/e20162940

SKATEBOARD AND SCOOTER INJURIES Committee on Injury, Violence, and Poison Prevention ABSTRACT. Skateboard-related injuries account for an estimated 50 000 emergency department visits and 1500 hospitalizations among children and adolescents in the United States each year. Nonpowered scooter-related injuries accounted for an estimated 9400 emergency department visits between January and August 2000, and 90% of these patients were children younger than 15 years. Many such injuries can be avoided if children and youth do not ride in traffic, if proper protective gear is worn, and if, in the absence of close adult supervision, skateboards and scooters are not used by children younger than 10 and 8 years, respectively. (3/02, reaffirmed 5/05, 10/08, 10/13)

http://pediatrics.aappublications.org/content/109/3/542

SKIN-TO-SKIN CARE FOR TERM AND PRETERM INFANTS IN THE NEONATAL ICU (CLINICAL REPORT) Jill Baley, MD, and Committee on Fetus and Newborn ABSTRACT. “Kangaroo mother care” was first described as an alternative method of caring for low birth weight infants in resource-limited countries, where neonatal mortality and infection rates are high because of overcrowded nurseries, inadequate staffing, and lack of equipment. Intermittent skin-to-skin care (SSC), a modified version of kangaroo mother care, is now being offered in resource-rich countries to infants needing neonatal intensive care, including those who require ventilator support or are extremely premature. SSC significantly improves milk production by the mother and is associated with a longer duration of breastfeeding. Increased parent satisfaction, better sleep organization, a longer duration of quiet sleep, and decreased pain perception during procedures have also been reported in association with SSC. Despite apparent physiologic stability during SSC, it is prudent that infants in the NICU have continuous cardiovascular monitoring and that care be taken to verify correct head positioning for airway patency as well as the stability

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of the endotracheal tube, arterial and venous access devices, and other life support equipment. (8/15)

http://pediatrics.aappublications.org/content/136/3/596

SNACKS, SWEETENED BEVERAGES, ADDED SUGARS, AND SCHOOLS Council on School Health and Committee on Nutrition ABSTRACT. Concern over childhood obesity has generated a decade-long reformation of school nutrition policies. Food is available in school in 3 venues: federally sponsored school meal programs; items sold in competition to school meals, such as a la carte, vending machines, and school stores; and foods available in myriad informal settings, including packed meals and snacks, bake sales, fundraisers, sports booster sales, in-class parties, or other school celebrations. High-energy, low-nutrient beverages, in particular, contribute substantial calories, but little nutrient content, to a student’s diet. In 2004, the American Academy of Pediatrics recommended that sweetened drinks be replaced in school by water, white and flavored milks, or 100% fruit and vegetable beverages. Since then, school nutrition has undergone a significant transformation. Federal, state, and local regulations and policies, along with alternative products developed by industry, have helped decrease the availability of nutrient-poor foods and beverages in school. However, regular access to foods of high energy and low quality remains a school issue, much of it attributable to students, parents, and staff. Pediatricians, aligning with experts on child nutrition, are in a position to offer a perspective promoting nutrient-rich foods within calorie guidelines to improve those foods brought into or sold in schools. A positive emphasis on nutritional value, variety, appropriate portion, and encouragement for a steady improvement in quality will be a more effective approach for improving nutrition and health than simply advocating for the elimination of added sugars. (2/15)

http://pediatrics.aappublications.org/content/135/3/575

SNOWMOBILING HAZARDS Committee on Injury and Poison Prevention ABSTRACT. Snowmobiles continue to pose a significant risk to children younger than 15 years and adolescents and young adults 15 through 24 years of age. Head injuries remain the leading cause of mortality and serious morbidity, arising largely from snowmobilers colliding, falling, or overturning during operation. Children also were injured while being towed in a variety of conveyances by snowmobiles. No uniform code of state laws governs the use of snowmobiles by children and youth. Because evidence is lacking to support the effectiveness of operator safety certification and because many children and adolescents do not have the required strength and skills to operate a snowmobile safely, the recreational operation of snowmobiles by persons younger than 16 years is not recommended. Snowmobiles should not be used to tow persons on a tube, tire, sled, or saucer. Furthermore, a graduated licensing program is advised for snowmobilers 16 years and older. Both active and passive snowmobile injury prevention strategies are suggested, as well as recommendations for manufacturers to make safer equipment for snowmobilers of all ages. (11/00, reaffirmed 5/04, 1/07, 6/10)

http://pediatrics.aappublications.org/content/106/5/1142

SPECIAL REQUIREMENTS OF ELECTRONIC HEALTH RECORD SYSTEMS IN PEDIATRICS (CLINICAL REPORT) S. Andrew Spooner, MD, MS, and Council on Clinical Information Technology ABSTRACT. Some functions of an electronic health record system are much more important in providing pediatric care than in adult care. Pediatricians commonly complain about the absence of these “pediatric functions” when they are not available in

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electronic health record systems. To stimulate electronic health record system vendors to recognize and incorporate pediatric functionality into pediatric electronic health record systems, this clinical report reviews the major functions of importance to child health care providers. Also reviewed are important but less critical functions, any of which might be of major importance in a particular clinical context. The major areas described here are immunization management, growth tracking, medication dosing, data norms, and privacy in special pediatric populations. The American Academy of Pediatrics believes that if the functions described in this document are supported in all electronic health record systems, these systems will be more useful for patients of all ages. (3/07, reaffirmed 5/12, 5/16)

http://pediatrics.aappublications.org/content/119/3/631

SPECTRUM OF NONINFECTIOUS HEALTH EFFECTS FROM MOLDS Committee on Environmental Health ABSTRACT. Molds are eukaryotic (possessing a true nucleus) nonphotosynthetic organisms that flourish both indoors and outdoors. For humans, the link between mold exposure and asthma exacerbations, allergic rhinitis, infections, and toxicities from ingestion of mycotoxin-contaminated foods are well known. However, the cause-and-effect relationship between inhalational exposure to mold and other untoward health effects (eg, acute idiopathic pulmonary hemorrhage in infants and other illnesses and health complaints) requires additional investigation. Pediatricians play an important role in the education of families about mold, its adverse health effects, exposure prevention, and remediation procedures. (12/06, reaffirmed 9/16)

http://pediatrics.aappublications.org/content/118/6/2582

SPECTRUM OF NONINFECTIOUS HEALTH EFFECTS FROM MOLDS (TECHNICAL REPORT) Lynnette J. Mazur, MD, MPH; Janice Kim, MD, PhD, MPH; and Committee on Environmental Health ABSTRACT. Molds are multicellular fungi that are ubiquitous in outdoor and indoor environments. For humans, they are both beneficial (for the production of antimicrobial agents, chemotherapeutic agents, and vitamins) and detrimental. Exposure to mold can occur through inhalation, ingestion, and touching moldy surfaces. Adverse health effects may occur through allergic, infectious, irritant, or toxic processes. The cause-and-effect relationship between mold exposure and allergic and infectious illnesses is well known. Exposures to toxins via the gastrointestinal tract also are well described. However, the cause-and-effect relationship between inhalational exposure to mold toxins and other untoward health effects (eg, acute idiopathic pulmonary hemorrhage in infants and other illnesses and health complaints) is controversial and requires additional investigation. In this report we examine evidence of fungal-related illnesses and the unique aspects of mold exposure to children. Mold-remediation procedures are also discussed. (12/06, reaffirmed 9/16)

http://pediatrics.aappublications.org/content/118/6/e1909

SPORT-RELATED CONCUSSION IN CHILDREN AND ADOLESCENTS (CLINICAL REPORT) Mark E. Halstead, MD; Kevin D. Walter, MD; and Council on Sports Medicine and Fitness ABSTRACT. Sport-related concussion is a “hot topic” in the media and in medicine. It is a common injury that is likely underreported by pediatric and adolescent athletes. Football has the highest incidence of concussion, but girls have higher concussion rates than boys do in similar sports. A clear understanding

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of the definition, signs, and symptoms of concussion is ­necessary to recognize it and rule out more severe intracranial injury. Concussion can cause symptoms that interfere with school, social and family relationships, and participation in sports. Recognition and education are paramount, because although proper equipment, sport technique, and adherence to rules of the sport may decrease the incidence or severity of concussions, nothing has been shown to prevent them. Appropriate management is essential for reducing the risk of long-term symptoms and complications. Cognitive and physical rest is the mainstay of management after diagnosis, and neuropsychological testing is a helpful tool in the management of concussion. Return to sport should be accomplished by using a progressive exercise program while evaluating for any return of signs or symptoms. This report serves as a basis for understanding the diagnosis and management of concussion in children and adolescent athletes. (8/10, reaffirmed 8/14)

http://pediatrics.aappublications.org/content/126/3/597

SPORTS DRINKS AND ENERGY DRINKS FOR CHILDREN AND ADOLESCENTS: ARE THEY APPROPRIATE? (CLINICAL REPORT) Committee on Nutrition and Council on Sports Medicine and Fitness ABSTRACT. Sports and energy drinks are being marketed to children and adolescents for a wide variety of inappropriate uses. Sports drinks and energy drinks are significantly different products, and the terms should not be used interchangeably. The primary objectives of this clinical report are to define the ingredients of sports and energy drinks, categorize the similarities and differences between the products, and discuss misuses and abuses. Secondary objectives are to encourage screening during annual physical examinations for sports and energy drink use, to understand the reasons why youth consumption is widespread, and to improve education aimed at decreasing or eliminating the inappropriate use of these beverages by children and adolescents. Rigorous review and analysis of the literature reveal that caffeine and other stimulant substances contained in energy drinks have no place in the diet of children and adolescents. Furthermore, frequent or excessive intake of caloric sports drinks can substantially increase the risk for overweight or obesity in children and adolescents. Discussion regarding the appropriate use of sports drinks in the youth athlete who participates regularly in endurance or high-intensity sports and vigorous physical activity is beyond the scope of this report. (5/11)

http://pediatrics.aappublications.org/content/127/6/1182

SPORTS SPECIALIZATION AND INTENSIVE TRAINING IN YOUNG ATHLETES (CLINICAL REPORT) Joel S. Brenner, MD, MPH, FAAP, and Council on Sports Medicine and Fitness ABSTRACT. Sports specialization is becoming the norm in youth sports for a variety of reasons. When sports specialization occurs too early, detrimental effects may occur, both physically and psychologically. If the timing is correct and sports specialization is performed under the correct conditions, the athlete may be successful in reaching specific goals. Young athletes who train intensively, whether specialized or not, can also be at risk of adverse effects on the mind and body. The purpose of this clinical report is to assist pediatricians in counseling their young athlete patients and their parents regarding sports specialization and intensive training. This report supports the American Academy of Pediatrics clinical report “Overuse Injuries, Overtraining, and Burnout in Child and Adolescent Athletes.” (8/16)

http://pediatrics.aappublications.org/content/138/3/e20162148

POLICY TITLES AND ABSTRACTS

STANDARD TERMINOLOGY FOR FETAL, INFANT, AND PERINATAL DEATHS (CLINICAL REPORT) Wanda D. Barfield, MD, MPH, and Committee on Fetus and Newborn ABSTRACT. Accurately defining and reporting perinatal deaths (ie, fetal and infant deaths) is a critical first step in understanding the magnitude and causes of these important events. In addition to obstetric health care providers, neonatologists and pediatricians should have easy access to current and updated resources that clearly provide US definitions and reporting requirements for live births, fetal deaths, and infant deaths. Correct identification of these vital events will improve local, state, and national data so that these deaths can be better addressed and prevented. (4/16)

http://pediatrics.aappublications.org/content/137/5/e20160551

STANDARDIZATION OF INPATIENT HANDOFF COMMUNICATION (CLINICAL REPORT) Jennifer A. Jewell, MD, FAAP, and Committee on Hospital Care ABSTRACT. Handoff communication is identified as an integral part of hospital care. Throughout medical communities, inadequate handoff communication is being highlighted as a significant risk to patients. The complexity of hospitals and the number of providers involved in the care of hospitalized patients place inpatients at high risk of communication lapses. This miscommunication and the potential resulting harm make effective handoffs more critical than ever. Although hospitalized patients are being exposed to many handoffs each day, this report is limited to describing the best handoff practices between providers at the time of shift change. (10/16)

http://pediatrics.aappublications.org/content/138/5/e20162681

STANDARDS FOR HEALTH INFORMATION TECHNOLOGY TO ENSURE ADOLESCENT PRIVACY Committee on Adolescence and Council on Clinical Information Technology ABSTRACT. Privacy and security of health information is a basic expectation of patients. Despite the existence of federal and state laws safeguarding the privacy of health information, health information systems currently lack the capability to allow for protection of this information for minors. This policy statement reviews the challenges to privacy for adolescents posed by commercial health information technology systems and recommends basic principles for ideal electronic health record systems. This policy statement has been endorsed by the Society for Adolescent Health and Medicine. (10/12)

http://pediatrics.aappublications.org/content/130/5/987

STANDARDS FOR PEDIATRIC CANCER CENTERS Section on Hematology/Oncology ABSTRACT. Since the American Academy of Pediatrics–published guidelines for pediatric cancer centers in 1986, 1997, and 2004, significant changes in the delivery of health care have prompted a review of the role of medical centers in the care of pediatric patients. The potential effect of these changes on the treatment and survival rates of children with cancer led to this revision. The intent of this statement is to delineate personnel, capabilities, and facilities that are essential to provide state-ofthe-art care for children, adolescents, and young adults with cancer. This statement emphasizes the importance of boardcertified pediatric hematologists/oncologists and appropriately qualified pediatric medical subspecialists and pediatric surgical specialists overseeing patient care and the need for specialized facilities as essential for the initial management and much of the follow-up for pediatric, adolescent, and young adult patients with cancer. For patients without practical access to a pediatric cancer center, care may be provided locally by a primary care

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physician or adult oncologist but at the direction of a pediatric oncologist. (7/14)

http://pediatrics.aappublications.org/content/134/2/410

STIGMA EXPERIENCED BY CHILDREN AND ADOLESCENTS WITH OBESITY Stephen J. Pont, MD, MPH, FAAP; Rebecca Puhl, PhD, FTOS; Stephen R. Cook, MD, MPH, FAAP, FTOS; Wendelin Slusser, MD, MS, FAAP; Section on Obesity; and The Obesity Society ABSTRACT. The stigmatization of people with obesity is widespread and causes harm. Weight stigma is often propagated and tolerated in society because of beliefs that stigma and shame will motivate people to lose weight. However, rather than motivating positive change, this stigma contributes to behaviors such as binge eating, social isolation, avoidance of health care services, decreased physical activity, and increased weight gain, which worsen obesity and create additional barriers to healthy behavior change. Furthermore, experiences of weight stigma also dramatically impair quality of life, especially for youth. Health care professionals continue to seek effective strategies and resources to address the obesity epidemic; however, they also frequently exhibit weight bias and stigmatizing behaviors. This policy statement seeks to raise awareness regarding the prevalence and negative effects of weight stigma on pediatric patients and their families and provides 6 clinical practice and 4 advocacy recommendations regarding the role of pediatricians in addressing weight stigma. In summary, these recommendations include improving the clinical setting by modeling best practices for nonbiased behaviors and language; using empathetic and empowering counseling techniques, such as motivational interviewing, and addressing weight stigma and bullying in the clinic visit; advocating for inclusion of training and education about weight stigma in medical schools, residency programs, and continuing medical education programs; and empowering families to be advocates to address weight stigma in the home environment and school setting. (11/17) See full text on page 1193.

http://pediatrics.aappublications.org/content/140/6/e20173034

STRATEGIES FOR PREVENTION OF HEALTH CARE–ASSOCIATED INFECTIONS IN THE NICU (CLINICAL REPORT) Richard A. Polin, MD; Susan Denson, MD; Michael T. Brady, MD; Committee on Fetus and Newborn; and Committee on Infectious Diseases ABSTRACT. Health care–associated infections in the NICU result in increased morbidity and mortality, prolonged lengths of stay, and increased medical costs. Neonates are at high risk of acquiring health care–associated infections because of impaired host-defense mechanisms, limited amounts of protective endogenous flora on skin and mucosal surfaces at time of birth, reduced barrier function of their skin, use of invasive procedures and devices, and frequent exposure to broad-spectrum antibiotic agents. This clinical report reviews management and prevention of health care–associated infections in newborn infants. (3/12, reaffirmed 2/16)

http://pediatrics.aappublications.org/content/129/4/e1085

STRENGTH TRAINING BY CHILDREN AND ADOLESCENTS Council on Sports Medicine and Fitness ABSTRACT. Pediatricians are often asked to give advice on the safety and efficacy of strength-training programs for children and adolescents. This statement, which is a revision of a previous American Academy of Pediatrics policy statement, defines relevant terminology and provides current information on risks and benefits of strength training for children and adolescents. (4/08, reaffirmed 6/11, 12/16)

http://pediatrics.aappublications.org/content/121/4/835

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SUBSTANCE USE SCREENING, BRIEF INTERVENTION, AND REFERRAL TO TREATMENT Committee on Substance Use and Prevention ABSTRACT. The enormous public health impact of adolescent substance use and its preventable morbidity and mortality show the need for the health care sector, including pediatricians and the medical home, to increase its capacity related to substance use prevention, detection, assessment, and intervention. The American Academy of Pediatrics published its policy statement “Substance Use Screening, Brief Intervention, and Referral to Treatment for Pediatricians” in 2011 to introduce the concepts and terminology of screening, brief intervention, and referral to treatment (SBIRT) and to offer clinical guidance about available substance use screening tools and intervention procedures. This policy statement is a revision of the 2011 SBIRT statement. An accompanying clinical report updates clinical guidance for adolescent SBIRT. (6/16)

in marked and severe functional limitations. The impairment(s) must be expected to result in death or have lasted or be expected to last for a continuous period of at least 12 months. The income and assets of families of children with disabilities are also considered when determining financial eligibility. When an individual with a disability becomes an adult at 18 years of age, the SSA considers only the individual’s income and assets. The SSA considers an adult to be disabled if there is a medically determinable impairment (or combination of impairments) that prevents substantial gainful activity for at least 12 continuous months. SSI benefits are important for youth with chronic conditions who are transitioning to adulthood. The purpose of this statement is to provide updated information about the SSI medical and financial eligibility criteria and the disability-determination process. This statement also discusses how pediatricians can help children and youth when they apply for SSI benefits. (11/09, reaffirmed 2/15)

SUBSTANCE USE SCREENING, BRIEF INTERVENTION, AND REFERRAL TO TREATMENT (CLINICAL REPORT) Sharon J. L. Levy, MD, MPH, FAAP; Janet F. Williams, MD, FAAP; and Committee on Substance Use and Prevention ABSTRACT. The enormous public health impact of adolescent substance use and its preventable morbidity and mortality highlight the need for the health care sector, including pediatricians and the medical home, to increase its capacity regarding adolescent substance use screening, brief intervention, and referral to treatment (SBIRT). The American Academy of Pediatrics first published a policy statement on SBIRT and adolescents in 2011 to introduce SBIRT concepts and terminology and to offer clinical guidance about available substance use screening tools and intervention procedures. This clinical report provides a ­simplified adolescent SBIRT clinical approach that, in combination with the accompanying updated policy statement, guides pediatricians in implementing substance use prevention, detection, assessment, and intervention practices across the varied clinical settings in which adolescents receive health care. (6/16)

SUPPORTING THE FAMILY AFTER THE DEATH OF A CHILD (CLINICAL REPORT) Esther Wender, MD, and Committee on Psychosocial Aspects of Child and Family Health ABSTRACT. The death of a child can have a devastating effect on the family. The pediatrician has an important role to play in supporting the parents and any siblings still in his or her practice after such a death. Pediatricians may be poorly prepared to provide this support. Also, because of the pain of confronting the grief of family members, they may be reluctant to become involved. This statement gives guidelines to help the pediatrician provide such support. It describes the grief reactions that can be expected in family members after the death of a child. Ways of supporting family members are suggested, and other helpful resources in the community are described. The goal of this guidance is to prevent outcomes that may impair the health and development of affected parents and children. (11/12, reaffirmed 12/16)

http://pediatrics.aappublications.org/content/138/1/e20161210

http://pediatrics.aappublications.org/content/138/1/e20161211

SUICIDE AND SUICIDE ATTEMPTS IN ADOLESCENTS (CLINICAL REPORT) Benjamin Shain, MD, PhD, and Committee on Adolescence ABSTRACT. Suicide is the second leading cause of death for adolescents 15 to 19 years old. This report updates the previous statement of the American Academy of Pediatrics and is intended to assist pediatricians, in collaboration with other child and adolescent health care professionals, in the identification and management of the adolescent at risk for suicide. Suicide risk can only be reduced, not eliminated, and risk factors provide no more than guidance. Nonetheless, care for suicidal adolescents may be improved with the pediatrician’s knowledge, skill, and comfort with the topic, as well as ready access to appropriate community resources and mental health professionals. (6/16)

http://pediatrics.aappublications.org/content/138/1/e20161420

SUPPLEMENTAL SECURITY INCOME (SSI) FOR CHILDREN AND YOUTH WITH DISABILITIES Council on Children With Disabilities ABSTRACT. The Supplemental Security Income (SSI) program remains an important source of financial support for lowincome families of children with special health care needs and disabling conditions. In most states, SSI eligibility also qualifies children for the state Medicaid program, providing access to health care services. The Social Security Administration (SSA), which administers the SSI program, considers a child disabled under SSI if there is a medically determinable physical or ­mental impairment or combination of impairments that results

http://pediatrics.aappublications.org/content/124/6/1702

http://pediatrics.aappublications.org/content/130/6/1164

SUPPORTING THE GRIEVING CHILD AND FAMILY (CLINICAL REPORT) David J. Schonfeld, MD, FAAP; Thomas Demaria, PhD; Committee on Psychosocial Aspects of Child and Family Health; and Disaster Preparedness Advisory Council ABSTRACT. The death of someone close to a child often has a profound and lifelong effect on the child and results in a range of both short- and long-term reactions. Pediatricians, within a patient-centered medical home, are in an excellent position to provide anticipatory guidance to caregivers and to offer assistance and support to children and families who are grieving. This clinical report offers practical suggestions on how to talk with grieving children to help them better understand what has happened and its implications and to address any misinformation, misinterpretations, or misconceptions. An understanding of guilt, shame, and other common reactions, as well an appreciation of the role of secondary losses and the unique challenges facing children in communities characterized by chronic trauma and cumulative loss, will help the pediatrician to address factors that may impair grieving and children’s adjustment and to identify complicated mourning and situations when professional counseling is indicated. Advice on how to support children’s participation in funerals and other memorial services and to anticipate and address grief triggers and anniversary reactions is provided so that pediatricians are in a better position to advise caregivers and to offer consultation to schools, early education and child care facilities, and other child congregate care sites. Pediatricians often enter their profession out of a profound desire to minimize the suffering of children and may find it

POLICY TITLES AND ABSTRACTS

­ ersonally challenging when they find themselves in situations p in which they are asked to bear witness to the distress of children who are acutely grieving. The importance of professional preparation and self-care is therefore emphasized, and resources are recommended. (8/16)

http://pediatrics.aappublications.org/content/138/3/e20162147

SUPPORTING THE HEALTH CARE TRANSITION FROM ADOLESCENCE TO ADULTHOOD IN THE MEDICAL HOME (CLINICAL REPORT) American Academy of Pediatrics, American Academy of Family Physicians, and American College of Physicians Transitions Clinical Report Authoring Group ABSTRACT. Optimal health care is achieved when each person, at every age, receives medically and developmentally appropriate care. The goal of a planned health care transition is to maximize lifelong functioning and well-being for all youth, including those who have special health care needs and those who do not. This process includes ensuring that high-quality, developmentally appropriate health care services are available in an uninterrupted manner as the person moves from adolescence to adulthood. A well-timed transition from child- to adult-oriented health care is specific to each person and ideally occurs between the ages of 18 and 21 years. Coordination of patient, family, and provider responsibilities enables youth to optimize their ability to assume adult roles and activities. This clinical report represents expert opinion and consensus on the practice-based implementation of transition for all youth beginning in early adolescence. It provides a structure for training and continuing education to further understanding of the nature of adolescent transition and how best to support it. Primary care physicians, nurse practitioners, and physician assistants, as well as medical subspecialists, are encouraged to adopt these materials and make this process specific to their settings and populations. (7/11, reaffirmed 8/15)

http://pediatrics.aappublications.org/content/128/1/182

SURFACTANT REPLACEMENT THERAPY FOR PRETERM AND TERM NEONATES WITH RESPIRATORY DISTRESS (CLINICAL REPORT) Richard A. Polin, MD, FAAP; Waldemar A. Carlo, MD, FAAP; and Committee on Fetus and Newborn ABSTRACT. Respiratory failure secondary to surfactant deficiency is a major cause of morbidity and mortality in preterm infants. Surfactant therapy substantially reduces mortality and respiratory morbidity for this population. Secondary surfactant deficiency also contributes to acute respiratory morbidity in late-preterm and term neonates with meconium aspiration syndrome, pneumonia/sepsis, and perhaps pulmonary hemorrhage; surfactant replacement may be beneficial for these infants. This statement summarizes the evidence regarding indications, administration, formulations, and outcomes for surfactant-replacement therapy. The clinical strategy of intubation, surfactant administration, and extubation to continuous positive airway pressure and the effect of continuous positive airway pressure on outcomes and surfactant use in preterm infants are also reviewed. (12/13)

http://pediatrics.aappublications.org/content/133/1/156

TACKLING IN YOUTH FOOTBALL Council on Sports Medicine and Fitness ABSTRACT. American football remains one of the most popular sports for young athletes. The injuries sustained during football, especially those to the head and neck, have been a topic of intense interest recently in both the public media and medical literature. The recognition of these injuries and the potential for long-term sequelae have led some physicians to call for a

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reduction in the number of contact practices, a postponement of tackling until a certain age, and even a ban on high school football. This statement reviews the literature regarding injuries in football, particularly those of the head and neck, the relationship between tackling and football-related injuries, and the potential effects of limiting or delaying tackling on injury risk. (10/15)

http://pediatrics.aappublications.org/content/136/5/e1419

THE TEEN DRIVER Committee on Injury, Violence, and Poison Prevention and Committee on Adolescence ABSTRACT. Motor vehicle–related injuries to adolescents continue to be of paramount importance to society. Since the original policy statement on the teenaged driver was published in 1996, there have been substantial changes in many state laws and much new research on this topic. There is a need to provide pediatricians with up-to-date information and materials to facilitate appropriate counseling and anticipatory guidance. This statement describes why teenagers are at greater risk of motor vehicle–related injuries, suggests topics suitable for office-based counseling, describes innovative programs, and proposes preventive interventions for pediatricians, parents, legislators, educators, and other child advocates. (12/06, reaffirmed 6/10, 7/16)

http://pediatrics.aappublications.org/content/118/6/2570

TELEMEDICINE FOR EVALUATION OF RETINOPATHY OF PREMATURITY (TECHNICAL REPORT) Walter M. Fierson, MD, FAAP; Antonio Capone Jr, MD; and Section on Ophthalmology (joint with American Academy of Ophthalmology and American Association of Certified Orthoptists) ABSTRACT. Retinopathy of prematurity (ROP) remains a significant threat to vision for extremely premature infants despite the availability of therapeutic modalities capable, in most cases, of managing this disorder. It has been shown in many controlled trials that application of therapies at the appropriate time is essential to successful outcomes in premature infants affected by ROP. Bedside binocular indirect ophthalmoscopy has been the standard technique for diagnosis and monitoring of ROP in these patients. However, implementation of routine use of this screening method for at-risk premature infants has presented challenges within our existing care systems, including relative local scarcity of qualified ophthalmologist examiners in some locations and the remote location of some NICUs. Modern technology, including the development of wide-angle ocular digital fundus photography, coupled with the ability to send digital images electronically to remote locations, has led to the development of telemedicine-based remote digital fundus imaging (RDFI-TM) evaluation techniques. These techniques have the potential to allow the diagnosis and monitoring of ROP to occur in lieu of the necessity for some repeated on-site examinations in NICUs. This report reviews the currently available literature on RDFI-TM evaluations for ROP and outlines pertinent practical and risk management considerations that should be used when including RDFI-TM in any new or existing ROP care structure. (12/14)

http://pediatrics.aappublications.org/content/135/1/e238

TELEMEDICINE: PEDIATRIC APPLICATIONS (TECHNICAL REPORT) Bryan L. Burke Jr, MD, FAAP; R. W. Hall, MD, FAAP; and Section on Telehealth Care ABSTRACT. Telemedicine is a technological tool that is improving the health of children around the world. This report chronicles the use of telemedicine by pediatricians and pediatric medical and surgical specialists to deliver inpatient and outpatient care, educate physicians and patients, and conduct medical research. It also describes the importance of t­elemedicine

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in responding to emergencies and disasters and providing access to pediatric care to remote and underserved populations. Barriers to telemedicine expansion are explained, such as legal issues, inadequate payment for services, technology costs and sustainability, and the lack of technology infrastructure on a national scale. Although certain challenges have constrained more widespread implementation, telemedicine’s current use bears testimony to its effectiveness and potential. Telemedicine’s widespread adoption will be influenced by the implementation of key provisions of the Patient Protection and Affordable Care Act, technological advances, and growing patient demand for virtual visits. (6/15)

http://pediatrics.aappublications.org/content/136/1/e293

TESTING FOR DRUGS OF ABUSE IN CHILDREN AND ADOLESCENTS (CLINICAL REPORT) Sharon Levy, MD, MPH, FAAP; Lorena M. Siqueira, MD, MSPH, FAAP; and Committee on Substance Abuse ABSTRACT. Drug testing is often used as part of an assessment for substance use in children and adolescents. However, the indications for drug testing and guidance on how to use this procedure effectively are not clear. The complexity and invasiveness of the procedure and limitations to the information derived from drug testing all affect its utility. The objective of this clinical report is to provide guidance to pediatricians and other clinicians on the efficacy and efficient use of drug testing on the basis of a review of the nascent scientific literature, policy guidelines, and published clinical recommendations. (5/14)

http://pediatrics.aappublications.org/content/133/6/e1798

TOBACCO USE: A PEDIATRIC DISEASE Committee on Environmental Health, Committee on Substance Abuse, Committee on Adolescence, and Committee on Native American Child Health ABSTRACT. Tobacco use and secondhand tobacco-smoke (SHS) exposure are major national and international health concerns. Pediatricians and other clinicians who care for children are uniquely positioned to assist patients and families with tobaccouse prevention and treatment. Understanding the nature and extent of tobacco use and SHS exposure is an essential first step toward the goal of eliminating tobacco use and its consequences in the pediatric population. The next steps include counseling patients and family members to avoid SHS exposures or cease tobacco use; advocacy for policies that protect children from SHS exposure; and elimination of tobacco use in the media, public places, and homes. Three overarching principles of this policy can be identified: (1) there is no safe way to use tobacco; (2) there is no safe level or duration of exposure to SHS; and (3) the financial and political power of individuals, organizations, and government should be used to support tobacco control. Pediatricians are advised not to smoke or use tobacco; to make their homes, cars, and workplaces tobacco free; to consider tobacco control when making personal and professional decisions; to support and advocate for comprehensive tobacco control; and to advise parents and patients not to start using tobacco or to quit if they are already using tobacco. Prohibiting both tobacco advertising and the use of tobacco products in the media is recommended. Recommendations for eliminating SHS exposure and reducing tobacco use include attaining universal (1) smoke-free home, car, school, work, and play environments, both inside and outside, (2) treatment of tobacco use and dependence through employer, insurance, state, and federal supports, (3) implementation and enforcement of evidence-based tobaccocontrol measures in local, state, national, and international jurisdictions, and (4) financial and systems support for training in and research of effective ways to prevent and treat tobacco use and SHS exposure. Pediatricians, their staff and colleagues, and the American Academy of Pediatrics have key responsibilities in

SECTION 5/CURRENT POLICIES

tobacco ­control to promote the health of children, adolescents, and young adults. (10/09, reaffirmed 5/13)

http://pediatrics.aappublications.org/content/124/5/1474

TOWARD TRANSPARENT CLINICAL POLICIES Steering Committee on Quality Improvement and Management ABSTRACT. Clinical policies of professional societies such as the American Academy of Pediatrics are valued highly, not only by clinicians who provide direct health care to children but also by many others who rely on the professional expertise of these organizations, including parents, employers, insurers, and legislators. The utility of a policy depends, in large part, on the degree to which its purpose and basis are clear to policy users, an attribute known as the policy’s transparency. This statement describes the critical importance and special value of transparency in clinical policies, guidelines, and recommendations; helps identify obstacles to achieving transparency; and suggests several approaches to overcome these obstacles. (3/08, reaffirmed 2/14)

http://pediatrics.aappublications.org/content/121/3/643

TRAMPOLINE SAFETY IN CHILDHOOD AND ADOLESCENCE Council on Sports Medicine and Fitness ABSTRACT. Despite previous recommendations from the American Academy of Pediatrics discouraging home use of trampolines, recreational use of trampolines in the home setting continues to be a popular activity among children and adolescents. This policy statement is an update to previous statements, reflecting the current literature on prevalence, patterns, and mechanisms of trampoline-related injuries. Most trampoline injuries occur with multiple simultaneous users on the mat. Cervical spine injuries often occur with falls off the trampoline or with attempts at somersaults or flips. Studies on the efficacy of trampoline safety measures are reviewed, and although there is a paucity of data, current implementation of safety measures have not appeared to mitigate risk substantially. Therefore, the home use of trampolines is strongly discouraged. The role of trampoline as a competitive sport and in structured training settings is reviewed, and recommendations for enhancing safety in these environments are made. (9/12, reaffirmed 7/15)

http://pediatrics.aappublications.org/content/130/4/774

THE TRANSFER OF DRUGS AND THERAPEUTICS INTO HUMAN BREAST MILK: AN UPDATE ON SELECTED TOPICS (CLINICAL REPORT) Hari Cheryl Sachs, MD, FAAP, and Committee on Drugs ABSTRACT. Many mothers are inappropriately advised to discontinue breastfeeding or avoid taking essential medications because of fears of adverse effects on their infants. This cautious approach may be unnecessary in many cases, because only a small proportion of medications are contraindicated in breastfeeding mothers or associated with adverse effects on their infants. Information to inform physicians about the extent of excretion for a particular drug into human milk is needed but may not be available. Previous statements on this topic from the American Academy of Pediatrics provided physicians with data concerning the known excretion of specific medications into breast milk. More current and comprehensive information is now available on the Internet, as well as an application for mobile devices, at LactMed (http://toxnet.nlm.nih.gov). Therefore, with the exception of radioactive compounds requiring temporary cessation of breastfeeding, the reader will be referred to LactMed to obtain the most current data on an individual medication. This report discusses several topics of interest surrounding lactation, such as the use of psychotropic therapies, drugs to treat substance abuse, narcotics, galactagogues, and herbal products, as well as immunization of breastfeeding women. A discussion regarding the global implications of maternal medications and lactation in the

POLICY TITLES AND ABSTRACTS

developing world is beyond the scope of this report. The World Health Organization offers several programs and resources that address the importance of breastfeeding (see http://www.who. int/topics/breastfeeding/en/). (8/13)

http://pediatrics.aappublications.org/content/132/3/e796

TRANSITIONING HIV-INFECTED YOUTH INTO ADULT HEALTH CARE Committee on Pediatric AIDS ABSTRACT. With advances in antiretroviral therapy, most HIV-infected children survive into adulthood. Optimal health care for these youth includes a formal plan for the transition of care from primary and/or subspecialty pediatric/adolescent/ family medicine health care providers (medical home) to adult health care provider(s). Successful transition involves the early engagement and participation of the youth and his or her family with the pediatric medical home and adult health care teams in developing a formal plan. Referring providers should have a written policy for the transfer of HIV-infected youth to adult care, which will guide in the development of an individualized plan for each youth. The plan should be introduced to the youth in early adolescence and modified as the youth approaches transition. Assessment of developmental milestones is important to define the readiness of the youth in assuming responsibility for his or her own care before initiating the transfer. Communication among all providers is essential and should include both personal contact and a written medical summary. Progress toward the transition should be tracked and, once completed, should be documented and assessed. (6/13, reaffirmed 4/16)

http://pediatrics.aappublications.org/content/132/1/192

TRANSPORTING CHILDREN WITH SPECIAL HEALTH CARE NEEDS Committee on Injury and Poison Prevention ABSTRACT. Children with special health care needs should have access to proper resources for safe transportation. This statement reviews important considerations for transporting children with special health care needs and provides current guidelines for the protection of children with specific health care needs, including those with a tracheostomy, a spica cast, challenging behaviors, or muscle tone abnormalities as well as those transported in wheelchairs. (10/99, reaffirmed 1/03, 1/06, 3/13)

http://pediatrics.aappublications.org/content/104/4/988

THE TREATMENT OF NEUROLOGICALLY IMPAIRED CHILDREN USING PATTERNING Committee on Children With Disabilities ABSTRACT. This statement reviews patterning as a treatment for children with neurologic impairments. This treatment is based on an outmoded and oversimplified theory of brain development. Current information does not support the claims of proponents that this treatment is efficacious, and its use continues to be unwarranted. (11/99, reaffirmed 11/02, 1/06, 8/10, 4/14)

http://pediatrics.aappublications.org/content/104/5/1149

ULTRAVIOLET RADIATION: A HAZARD TO CHILDREN AND ADOLESCENTS Council on Environmental Health and Section on Dermatology ABSTRACT. Ultraviolet radiation (UVR) causes the 3 major forms of skin cancer: basal cell carcinoma; squamous cell carcinoma; and cutaneous malignant melanoma. Public awareness of the risk is not optimal, overall compliance with sun protection is inconsistent, and melanoma rates continue to rise. The risk of skin cancer increases when people overexpose themselves to sun and intentionally expose themselves to artificial sources of UVR. Yet, people continue to sunburn, and teenagers and adults alike remain frequent visitors to tanning parlors. Pediatricians should

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provide advice about UVR exposure during health-supervision visits and at other relevant times. Advice includes avoiding sunburning, wearing clothing and hats, timing activities (when possible) before or after periods of peak sun exposure, wearing protective sunglasses, and applying and reapplying sunscreen. Advice should be framed in t