AAP Behind the Scenes 2020 (Part 2): AAP Agenda, Safe Sleep, Encouraging Physician Diversity, APEX Mental Health

More from our recent AAP Board Meeting –more highlights:

Dr Sally Goza, AAP National President reviewed some of the AAP’s initiatives:

  • Healthcare coverage & Change in ‘public charge’
  • Gun violence
  • Climate Change
  • Early Childhood Programs
  • Suicide Prevention
  • E-cigarettes
  • Social Media.  She noted that Pinterest and Google have made efforts to curb harmful inaccurate posts, especially with regard to immunization information, whereas Facebook has not been cooperative.

2020 Georgia Blueprint for Children:

Dr. Sarah Lazarus, a terrific ED physician and an advocate for safe sleep, described updates and obstacles related to reducing sudden unexpected death infant death.

Key points:

  • NASPGHAN 2018 GERD recommendations (33 page PDF) with regard to positioning:  “The working group recommends not to use positional therapy (ie, head elevation, lateral and prone positioning) to treat symptoms of GERD in sleeping infants”
  • CPSC has removed many inclined sleepers.  Commentary from Dr. Lazarus from WebMD (November 2019): Sleeping on an Incline Not Safe for Baby

The Consumer Product Safety Commission is warning parents not let a baby sleep in rockers, pillows, car seats, or any other product that holds an infant at an incline — with their head higher than their feet.

“I do think it should have happened a while ago when we saw there were deaths from them, but I’m glad they did it now,” says Sarah Lazarus, DO, a pediatric emergency medicine physician at Children’s Healthcare of Atlanta. Dr. Lazarus is also an injury prevention researcher at Emory University and reviews infant deaths for the state of Georgia.  And what about putting the crib mattress at an incline to help with reflux?

Lazarus says she knows pediatricians used to recommend that, but she says new studies show that it doesn’t really help and may be unsafe. “We do not recommend any sort of wedging or propping or positioning at this point,” she says. In addition to avoiding inclined surfaces, the commission is reminding parents that babies can suffocate if they sleep with blankets, pillows, or other items. The safest way for a baby to sleep is flat on their back, in a bare crib, and on a flat, firm surface.Related blog posts:

Dr. Heval Kelli introduced a program called young physician initiative.  “Getting into medical school can be a long process and difficult to navigate particularly for students from underserved communities due to the lack of access to medical mentorship and network.  The Young Physicians Initiative provides early and interactive guidance to underserved middle school, high school and college students. We inspire students to pursue careers in medicine and pursue pipeline’s opportunities by Being Present in their communities.”

Here are links to his website and to one of the articles covering this project:

My take: This is a terrific program, though there are many other challenges that need to be addressed to encourage applicants from a wide range of socioeconomic groups.

Related blog post: Hidden Costs of Medical Schools

The final speaker, Dante McKay, discussed the APEX program which is a school-based program to address mental health issues in children.

Integrating Mental Health into Pediatric IBD Care

WE Bennett, MD Pfefferkorn. JAMA PediatrPublished online August 19, 2019. doi:10.1001/jamapediatrics.2019.2669

Full Link: Editorial: “Mental Health Screening as the Standard of Care in Pediatric Inflammatory Bowel Disease” Thanks to Ben Gold for this reference.

An excerpt:

Butwicka and colleagues1 have published a fascinating, landmark cohort study in this issue of JAMA Pediatricsassessing the prevalence of psychiatric diagnoses and symptoms among children with inflammatory bowel disease (IBD) in Sweden. The authors used a rigorous design that compared a cohort of more than 6000 pediatric patients with IBD with hundreds of thousands of healthy controls, as well as a separate cohort comprising the patients’ own siblings who did not have IBD. Butwicka et al1 computed hazard ratios for any psychiatric disorder, as well as for multiple specific disorders, and found a hazard ratio of 1.6 for any psychiatric diagnosis when comparing children with IBD with healthy controls. The statistical analysis is stellar and represents the best data we currently have on the intersection of pediatric IBD and mental health. Their study highlights a substantial risk in a vulnerable population and should trigger revision of guidelines and allocation of resources to support widespread screening and treatment for these dangerous conditions.

Related Article:

A Butwicka et al. JAMA Pediatr. Published online August 19, 2019. doi:10.1001/jamapediatrics.2019.2662 

Full Text Link: Association of Childhood-Onset Inflammatory Bowel Disease With Risk of Psychiatric Disorders and Suicide Attempt

Related blog posts:

Crater Lake, OR

Gun Carrying Adolescents –Why We Are Going to See More School Shootings

A recent cross-sectional study (RMC Kagawa et al. J Pediatr 2019; 209: 198-203) shows a high rate of gun carrying among adolescents in the U.S.

Key findings:

  • Based on a sample of 10,112 adolescent who completed surveys, 2.4% of adolescents reported carrying a gun in the prior 30 days.
  • Carrying a gun was more common among adolescents with a conduct disorder (adjusted prevalence ratio 1.88), drug use disorders (APR 1.91) and patients with specific phobias (APR 1.54)
  • The authors estimate that 1.1% of adolescents with a disorder associated with self- or other-directed violence also carry guns.  This extrapolates to 272,000 adolescents with both risk factors.
  • Nearly two-thirds of adolescents who report gun carrying had a mental health disorder

My take:

  1. Guns are everywhere.  Gun carrying among adolescents, while only a small percentage of all adolescents, represent a grave risk; especially, since the majority who report carrying guns (in this study) have mental health issues.
  2. Safe storage needs to be a requirement of gun ownership.  Gun access and misuse by adolescents is a ‘clear and present danger’ (apologies to Tom Clancy).

Related blog posts:

El Retiro Park, Madrid

Quitting Smoking Associated with Better Mental Health

Given the amount of information about the negative consequences of smoking that is currently available, some might say that you would have to be mentally-ill to start smoking.  The good news is that stopping smoking has been associated with improvements in mental health (BMJ 2014; 348: g1151 dii 10.1136/bmj.g1151 -thanks to Mike Hart for this reference).  Free full-text BMJ article PDF

From Abstract:

Design Systematic review and meta-analysis of observational studies.

Eligibility criteria for selecting studies Longitudinal studies of adults that assessed mental health before smoking cessation and at least six weeks after cessation or baseline in healthy and clinical populations.

Results 26 studies that assessed mental health with questionnaires designed to measure anxiety, depression, mixed anxiety and depression, psychological quality of life, positive affect, and stress were included…. the standardised mean differences (95% confidence intervals) were anxiety −0.37 (95% confidence interval −0.70 to −0.03); depression −0.25 (−0.37 to −0.12); mixed anxiety and depression −0.31 (−0.47 to −0.14); stress −0.27 (−0.40 to −0.13). Both psychological quality of life and positive affect significantly increased between baseline and follow-up in quitters compared with continuing smokers 0.22 (0.09 to 0.36) and 0.40 (0.09 to 0.71), respectively). There was no evidence that the effect size differed between the general population and populations with physical or psychiatric disorders.

Conclusions Smoking cessation is associated with reduced depression, anxiety, and stress and improved positive mood and quality of life compared with continuing to smoke. The effect size seems as large for those with psychiatric disorders as those without. The effect sizes are equal or larger than those of antidepressant treatment for mood and anxiety disorders.

Figure 2 shows the relationship of the individual studies and the mental health outcomes.  In every study except one, there was improvement in those who quit smoking, though many of the studies had confidence limits that indicated that the results did not meet statistical significance.

Bottomline: This study indicates that quitting smoking can improve rather than worsen mental health.

The burden of being a physician

The following link comments on a study regarding the high rate of physician burnout:

The Widespread Problem of Doctor Burnout – NYTimes.com

Among my physician friends, the topic of emotional fatigue comes up infrequently.  While there are different difficulties for every type of job, I think if you are not a physician it is hard to understand the emotional toll of the job.  If you care about what you do, it is hard to disassociate from the obvious suffering that some patients endure.  In addition, in many cases the decisions that we help families reach often have unexpected outcomes.

Though some physicians may not struggle with these issues, the link above indicates that this problem is pervasive.

If you have a practical solution, let me know.  Happy New Year.

Related blog (more upbeat):

“It is never boring to be a physician” | gutsandgrowth