This week, the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry (AACAP), and the Children's Hospital Association have declared a national state of emergency in child and adolescent mental health. 

 spoke with Dr. Matthew Biel, assistant professor of clinical psychiatry and Director of Child and Adolescent Psychiatry at MedStar Georgetown University Hospital, and AACAP member and expert about the current state of emergency and what pediatricians can do to help this national crisis.

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The AAP, AACAP, and CHA call on policymakers to act quickly to address the children's mental health crisis 

National emergency in children's health declared

Ms. Hester is Content Specialist with Contemporary OB/GYN and Contemporary Pediatrics.

Over the past decade, cities and counties have enacted taxes on sodas and sugary beverages, with the intent of reducing consumption of them. One of them was Philadelphia, Pennsylvania, which went into effect in January 2017. A 

 looked at whether this tax led to less soda consumption by high school students.

Investigators performed an economic evaluation of school district-level of Youth Risk Behavior Surveillance System data from September 2013 to December 2019 to compare soda intake of high school students in Philadelphia to 7 other cities that did not have beverage taxes. A secondary analysis also compared changes in 100% juice and milk intake to examine potential substitutions for soda. The data included all high school students in grade 9 to 12 who attended school in districts that participated in the Youth Risk Behavior Surveillance System from 2013 to 2019.

A total of 86,928 high school students with an average age of 15.8 years from Philadelphia and 7 other comparison cities were included in the investigation. Before the January 2017 start date for the tax, there was an average weekly intake of 5.4 servings of soda in Philadelphia and 4 servings in the other 7 cities. Two years after the implementation of the soda tax, it was linked to a reduction of 0.81 servings of soda per week (95% CI, −1.48 to −0.14 servings; 

 = .02). No major difference was seen in 100% juice or milk intake following the implementation of the tax, but the investigators did note that students in Philadelphia drank more juice than the other cities. A look at subgroups found that the tax was linked to a reduction of 1.13 weekly servings in Hispanic adolescents (95% CI, −2.04 to −0.23 servings; 

 = .01) and 1.2 servings per week in teenagers with obesity (95% CI, −2.33 to −0.13 servings; 

The investigators concluded that the soda tax in Philadelphia was linked to reduced consumption of soda by teenagers. These results indicate that soda taxes could be a tool to improve diet.

1. Edmondson E, Roberto C, Gregory E, Mitra N, Virudachalam S. Association of a sweetened beverage tax with soda consumption in high school students. 

. October 18, 2021. Epub ahead of print. doi:10.1001/jamapediatrics.2021.3991

Articles

Taxing soda and other sugar sweetened beverages has been seen as a tool to encourage more healthy behaviors. A look at soda consumption in Philadelphia, Pennsylvania provides insight into whether it works.

Did Philadelphia soda tax lead to less consumption?

Rachael Zimlich is a freelance writer in Cleveland, Ohio. She writes regularly for Contemporary Pediatrics, Managed Healthcare Executive, and Medical Economics.

Most people don’t make it through childhood without some degree of trauma. Some people have the resilience to handle this trauma without ongoing effects, but for others it’s more difficult.

Pediatricians are one of the most consistent forces in the lives of many children, and the American Academy of Pediatrics (AAP) has released 2 new guidelines to help them guide families on how to manage and move on from trauma.

“For a long time, pediatrics was trauma informed. We would know what happens, but pediatricians weren’t really sure how to respond,” said Heather Forkey, MD, FAAP, a pediatrician at UMass Memorial Health, in Worcester, Massachusetts.

Forkey helped to write both papers and said there’s a big difference between knowing that trauma has occurred and knowing how to treat it.

In many cases, symptoms of pediatric trauma can be difficult to distinguish from other problems because they can share so many origins. Trauma presents as a spectrum, she explained, and it can look different at every point on that spectrum. Pediatricians are often taught that post-traumatic stress disorder looks like the reaction of a solider returning from war, but trauma can look different in every person—especially in children.

“That’s what you’re trained to look for,” Forkey said. “If a baby has a mom with postpartum depression and can’t interact with baby, the baby will have developmental challenges that don’t really fit the picture of trauma.”

—cover some things to look for in children in terms of developmental, behavioral, and physical signs of trauma.

“It’s a spectrum of symptoms overlaid on a spectrum of development,” she said. “When you see these symptoms, one of the things you want to be thinking about is, can trauma be a piece of what you are seeing?”

The mnemonic FRAYED that can help with these assessments, Forkey said.

Y: Yawning and sleep problems or yucky feelings

These signs can point to trauma, and that is important to acknowledge, Forkey explained. Perhaps the best thing a pediatrician can do when they see trauma is to promote resilience. Resilience can help children move on from trauma and has a protective effect on their overall mental health and functioning. Pediatricians can do this by promoting things like:

“Those are things we are trying to promote when we see kids who are affected by trauma,” she said.

Pediatricians are used to looking out for developmental and physical delays, but behavioral cues can be more difficult to recognize in these assessments because they can be attributed to so many other causes. What can help is to do regular surveillance, behavioral screenings, and to ask open-ended questions that might encourage a child to share how he or she is feeling. Forkey said she likes to lead with, “has anything scary or difficult happened that’s concerning you?”

“If you don’t let them know that it’s something you can talk about, they might not bring it up,” Forkey said. “Pediatricians normally ask kids historical questions. Has anything bad happened? Have there been illnesses in the family? In those questions, we are opening the door to finding out if something traumatic has happened.”

Some pediatricians talk about using the adverse childhood events (ACE) screening, but these tools haven’t really been validated to use in clinical care, she said. Clinicians shouldn’t be looking at this screening as a diagnostic guide, but more as an opportunity to begin a discussion. The follow-up is key.

“If you’re going to use [ACE], it’s not something the front desk hands somebody and nobody follows up with,” Forkey warned. “If we don’t validate and address that, we are not really doing our job.”

Although the papers provide a detailed guide for pediatricians to use in practice, Forkey said it’s important to remember that first and foremost, connection is key. Engaging and connecting with your patient is the only way to begin.

“Be there for them,” she explained. “Curiosity, respect, and empathy are key. This work requires us to connect at a human level.

The next step is to decide what kind of response is needed. Is there a need for more investigation into what caused the trauma? Having the knowledge and tools to respond are important and can be used to help guide families on continuing care at home, she said. Referrals to behavioral health or trauma specialists can help, too, Forkey added.

Perhaps most important, she noted, is to leave families with a sense of hope.

“One of the things we can be accused of is leaving families overwhelmed,” Forkey stated. “Sometimes with trauma, we forget that our positive expectation of recovery is what families need to hear from us.”

Pediatricians need to be providing validation, too. They need to get the message across to families that trauma is difficult to work through, but it is possible to move forward.

“That is how we promote recovery. Fundamentally, what we are talking about it the fact that in trauma you have a dysregulation of the stress response,” she explained.

Humans rely on the affiliate response as their first stress response, Forkey said. They look for people who can help them with their problems. When that doesn’t happen, the traumatized person will move on to fight-or-flight responses and other stress reactions that have more serious physical and behavioral consequences.

“What we need to do as humans is to reach out and say ‘who can help me?’ And we need to be that affiliate support for them so they can reduce that stress and begin to heal,” Forkey said, adding that recovery happens when relationships that provide that support begin. “It’s so important for kids to get the message that reaching out to others is the things to do. Some kids get the message that reaching out to others isn’t safe, and this leads to a lifelong struggle with taking support and accepting help.”

1. Forkey H, Szilagyi M, Kelly E, et al. Trauma-informed care. 

. 2021;148(2):e2021052580. doi:10.1542/peds.2021-052580

2. Duffee J, Szilagyi M, Forkey H, et al. Trauma-informed care in child health systems. 

. 2021;148(2):e2021052579. doi:10.1542/peds.2021-052579

Guidelines from the American Academy of Pediatrics help guide families on how to manage and move on from trauma.

Why providing care informed by trauma is important

The COVID-19 pandemic continues to impact the healthcare industry as supply chain issues, patient volumes, and staff shortages restrain the sector’s recovery.

Kaufman Hall 2021 State of Healthcare Performance Improvement Report

 reveals an industry in need of transformative operational changes with bold, new thinking needed in nearly every area of operations.

The survey found that 99 percent of respondents have experienced challenges in supply procurement leading to shortages of key items and significant price increases. All respondents say that they have faced staff burnout, trouble filling vacancies, wage inflation, and high turnover rates. A further 92 percent say it is difficult to attract and retain support staff, while nearly 90 percent have increased base salaries.

Experts are pushing hospital leaders to rethink the approach to performance improvement by revisiting the premise that nor-for-profit hospitals and health systems can lower costs while maintaining control over all aspects of operations, the release says.

“The pandemic has created a perfect storm of increasing expenses and decreasing revenues,” Kaufman Hall Managing Director Lance Robinson, who leads the firm’s performance improvement practice, says in the release. “For most institutions, navigating today’s financial and operational challenges and positioning for future growth requires radical change that is achieved only with new thinking and partnerships. Now more than ever, hospitals need to build relationships with physician groups, insurers, retailers, vendors, and other providers. It’s increasingly apparent that most organizations don’t have the resources they need to evolve on their own.”

Other notable findings in the survey results include:

Patient volumes remain low in many service lines with only 44 percent of respondents in cardiology and cardiovascular services reporting a return to pre-pandemic levels

23 percent of respondents say the ratio of administrative staff working remotely is likely to return to pre-pandemic levels, 66 percent say that ratio will remain the same as during the pandemic, and 11 percent saying it will increase

52 percent say the pandemic has driven their organization to adopt new processes, positions, or departments which will continue beyond the public health emergency

75 percent of respondents say they’ve seen adverse revenue cycle impacts during the pandemic including an increased number of Medicaid patients and increased insurance denials

The results of this survey comes hot on the heels of another 

 which estimated that hospitals across the country will lose about $54 billion in net incomes this year.

Specifically, the analysis projects that median hospital margins could be 11 percent below pre-pandemic levels by the end of the year, but warns that the recent increase in COVID-19 cases tied to the Delta variant was not a factor considered in the study.

The actual performance results show that the percentage of hospitals with negative operating margins had decreased from 

, the analysis see it improving to 35 percent in the third quarter and then stay flat in the fourth. It’s worth noting that the surge in cases tied to the Delta variant was also not included in this analysis, according to the report.

Contributing factors to the continued losses are:

More high acuity, inpatient cases which require longer stays than before the pandemic.

Increasing costs for labor, drugs, purchased services, personal protective equipment, and other supplies have led to higher expenses for hospitals.

Profitable outpatient visits have continued to grow from the depths of the early pandemic but are still below 2019 levels.

This article was originally published by Medical Economics.

Nearly all respondents to a Kaufman Hall survey have experienced challenges in supply procurement.

The supply chain causes issues in health care

The Delta variant of SARS-CoV-2 continues to surge throughout the United States, especially in unvaccinated populations, resulting in critical hospital bed shortages in many areas of the country. This has led to a major increase in COVID-19 infections and hospitalizations among children, coinciding with a surge of respiratory syncytial virus infections that also places a strain on available pediatric hospital beds. The COVID-19 pandemic is not over, and everyone who can get vaccinated should do so.

This month’s journal has a number of must-read articles:

The cover story provides a review of new 

 that help clinicians with the screening and diagnosis of children with autism spectrum disorder. This was written by Andrew J. Schuman, MD, a Contemporary Pediatrics® editorial advisory board member.

 and how to determine who should receive antibiotic therapy. The decision to use antibiotics remains challenging in patients that present with symptoms of pneumonia, even though viruses are the most frequent cause of CAP. Jane M. Carnazzo, MD , FAAP, also a Contemporary Pediatrics® editorial advisory board member, wrote this article.

The Infectious Disease news brief discusses 

how many lives have been saved by COVID-19 vaccines

—a sobering reminder of vaccination’s critical role in reducing the mortality associated with COVID-19 infection.

The Nutrition section offers a practical guide to meeting the 

 who have a history of intestinal injury or resection.

Thank you for providing outstanding care to your patients during these rapidly changing times. Please make time to take care of yourselves—the importance of which I was recently reminded of when a family medical emergency arose. Consider this anonymous quotation: “When life gives you a hundred reasons to break down and cry, show life that you have a million reasons to smile and laugh. Stay strong.” As always, I welcome your suggestions, comments, and questions.

Dr. Tan shares her must-reads from the October issue.

October greetings from Dr. Tan

It’s no secret that girls are entering puberty earlier and earlier, but a new study suggests that it’s happening as rapidly as 3 months earlier with each decade of women.

How the onset of puberty for women is gauged can be debated, with many studies focusing on a woman’s recall of her age at her first period (menarche) as a benchmark. New literature, however, turns the focus to breast development as the most reliable tool for measuring progress through puberty in girls.

Katherine Kutney, MD, a pediatric endocrinologist at Rainbow Babies and Children’s Hospital in Cleveland, Ohio, said that, like in boys, physical indicators are a better way to diagnose the onset of puberty in the clinical setting.

For both boys and girls, the puberty process is triggered by the activation of the hypothalamic-pituitary-gonadal (HPG) axis. For boys, this causes testicular growth, which is the first clinical sign that a male has entered central puberty. For girls, although first menstruation might traditionally have been considered to be a sign that puberty has begun, it actually begins with thelarche, or breast development.

Tanner staging, also known as the Sexual Maturity Rating (SMR) scale, is the standard system for measuring progress through puberty, Kutney said. For boys, this scale assigns stages to signify progress through puberty based on pubic hair and genitalia development. For girls, the scale uses measurements of breast tissue and public hair development.

Pubic hair development, a process called adrenarche, can occur at the same time as thelarche, but it doesn’t always. This process, which is triggered with the release of female sex hormones, spurs the growth of pubic and axillary hair, the development of adult body odors, and acne.

Stage 3: Thicker, darker (terminal) hair begins to develop

Stage 4: Terminal hair covers the entire triangle of the pubic region

Stage 5: Terminal hair covers the entire triangle of the pubic region and extends past the inguinal crease to the thigh

Stage 1: No palpable glandular breast tissue

Stage 2: A breast bud can be felt under the areola

Stage 3: Breast tissue can be felt outside the areola, but there is no further development of the areola itself

Stage 4: The areola develops above the contour of the breast

Stage 5: The areola recedes back into the contour of the rest of the breast and takes on a darker pigmentation, papillae development, and protrusion of the nipple

Earlier onset of puberty in girls has been noted for some time, but the 2020 study suggests that it has progressed to such a point that guidelines may need to be adjusted to redefine precocious, or “early,” puberty designations. Kutney said the average onset of puberty for girls is around age 10 years, but it can occur in as young as 8 years of age for girls from African American and Hispanic ethnicities. The upper age limit for puberty onset in girls is age 12 years, she added.

1. Eckert-Lind C, Busch AS, Petersen JH, et al. Worldwide secular trends in age at pubertal onset assessed by breast development among girls: a systematic review and meta-analysis. 

 2020;174(4):e195881. doi:10.1001/jamapediatrics.2019.5881

2. Emmanuel M, Bokor BR. Tanner stages. StatPearls Publishing. 2021.

Age of first menarche has long been seen as a girl's start to puberty, but breast development may be a better fit.

Puberty in girls is a moving target

With cool temperatures becoming more common, the skin of an infant may need special care to maintain the moisture barrier. Later this week check out our article on protecting infant skin in the fall and winter.

Vaping and cannabis use can be combined, posing additional concerns. A new meta-analysis offers insight into the prevalence of cannabis vaping among adolescents.

 podcast Small Talk provides a bite-size look at the 2021 American Academy of Pediatrics conference.

A look at what to expect from Contemporary Pediatrics this week

What's new on Contemporary Pediatrics: October 25 to 29

Both major depression and substance use disorders commonly co-occur in teenagers, but the treatment used for patients where they co-occur is still relatively unknown. Building an understanding of the trends in treating co-occurring depression and substance use disorder is important to understanding how well the effort to reach teenagers who require such services is performing. A report 

The investigators conducted a survey study that used publicly available data from the annual cross-sectional surveys of the National Survey on Drug Use and Health from 2011 to 2019. The data were used to assess the co-occurrence of major depressive episodes and substance use disorders in teenagers aged 12 to 17 years along with prevalence of treatment for either condition.

A total of 136,262 teenagers participated in the study. Throughout the survey period, the annual prevalence of co-occurring major depressive episodes and substance use disorders was stable, between 1.4% and 1.7%. Among the teenagers with co-occurring conditions, the prevalence of treatment for major depressive events only significantly increased from 28.5% in 2011 to 42.5% in 2019 (odds ratio [OR], 1.07; 95% CI, 1.02-1.11; 

 = .005), and treatment prevalence for substance use disorder decreased from 4.8% to 1.5% (OR, 0.92; 95% CI, 0.85-0.99; 

 = .04). The treatment use for both conditions varied between 4.5% and 11.6% and no significant linear trend over time was noted (OR, 0.95; 95% CI, 0.87-1.03; 

 = .24). The investigators found extensive disparities in a number of demographic conditions including boys for substance use disorder and co-occurrence, older teenagers with major depressive episodes, Hispanic teenagers with co-occurring conditions (adjusted OR, 0.52; 95% CI, 0.27-0.98; 

 = .04), and Asian, Native Hawaiian, or Pacific Islander adolescents for both co-occurring conditions (adjusted OR, 0.04; 95% CI, 0.01-0.33; 

 = .003) as well as major depressive episodes. Moving households 3 or more times over the past years was linked to higher odds of receiving treatment for both conditions (adjusted OR, 2.52; 95% CI, 1.26-5.05; 

The investigators concluded that from 2011 to 2019 less than 12% of teenagers who have major depression and substance use disorder were given treatment for both conditions. They believe that these findings should lead to improved coordination between service delivery system, expanded service provision, and increased support for teenagers who have unmet needs.

1. Lu W, Muñoz-Laboy M, Sohler N, Goodwin R. Trends and disparities in treatment for co-occurring major depression and substance use disorders among US adolescents from 2011 to 2019. 

. 2021;4(10):e2130280. doi:10.1001/jamanetworkopen.2021.30280

When a patient has both substance use disorder and major depression, how likely is it that both will be treated successfully, and what populations may not be getting all of the needed treatment?

Treating substance use disorder and major depression that co-occur

performed a systematic review of supplemental data from the last 10 years from January 2009 to April 2020.1

The scientific literature was searched by using the key words “acne” or “acne vulgaris” and “diet,” “nutrition,” “food”, “chocolate,” “dairy,” “whey protein,” “fatty acid,” or “drink” in the PubMed database.

Of the available papers, 53 met the eligibility criteria and were reviewed. These articles included 11 interventional clinical trials (7 randomized controlled trials and 4 controlled open label studies) and 42 observational studies (17 case-control, 22 cross-sectional, and 3 descriptive studies).

After reviewing the literature, the researchers found a growing trend of interest in the subject of diet and acne in the scientific community.

The acne promoting factors that were determined were high glycemic index foods, dairy products, fat foods, and chocolate. The acne promoting factors found were fatty acids, fruits, and vegetables.

When it comes to milk, which includes whole, reduced-fat, low-fat, dairy products, and chocolate, the specific roles they play in acne are still unknown and will require more research, according to the study authors.

This article was originally published by Dermatology Times.

1. Dall’Oglio F, Nasca MR, Fiorentini F, Micali G. Diet and acne: review of the evidence from 2009 to 2020. International Journal of Dermatology. 2021;60(6):672-685. doi:10.1111/ijd.15390

A study investigated the role diet habits have in the development, duration, and severity of acne. 

How diet may impact acne

Many children and teenagers either have or can access a smartphone and tablet, which means lots of time spent using a number of apps. Although social media platforms require a user to be 13 years of age or older, younger children also want to be able to use them, just like their older siblings, cousins, and friends. The

 from the C .S. Mott Children’s Hospital in Ann Arbor, Michigan asked 1030 parents who had at least 1 child in the home that was 7 to 12 years of age about their child’s use of social media apps.

Parents reported different app use in the group. Among children who were 10 to 12 years of age, 49% had reported social media app use in the previous 6 months; 28% had only used educational apps; and 23% indicated no app usage. Fifty percent of children 7 to 9 years used only educational apps; 32% also used social media apps; and 18% reported no app usage. Roughly one third of the parents stated that their child had been educated on safe use at school. These parents were more likely to indicate their child used social media apps.

There are many factors that can come into play when a parent is deciding whether an app is safe and appropriate for their child. Top aspects included whether the app has parental controls (74%), deemed age appropriate (64%), and needed for school (63%). Parental control features that were used included parental blocks (66%), parental approval needed for new contacts (60%), privacy settings (57%), creating a daily time limit (56%), and requiring a passcode to access certain content in an app. However, 17% of children are using apps without any form of parental control. When asked about the nonuse of parental controls, 21% of the parents said that they couldn’t find information on setting up the controls; 39% find it too time-consuming to monitor use; and 32% stated that their child would just find a way around any form of parental controls.

Discussing their concerns for their child on social media apps, parents worried that their child would share private information and not realize it (69%); encounter a sexual predator (69%); be exposed to adult images or videos (64%); or be unable to differentiate true from false information (63%). When asked specifically about their child, 47% were not confident in their own child’s capability in telling whether another app user was an adult or child. Thirty-one percent of the parents were not confident that their child’s ability to differentiate what’s true from what’s false on social media apps. Parents of children who had been taught safe use in school were more confident about their child’s abilities in both areas.

The poll investigators had 2 recommendations to help better protect children who are just beginning to be exposed to social media. The first is that parental controls are only the start for keeping children safe. Parents should discuss the apps used with children, including asking them how an app works and what content they find funny. They should also look at what their child is posting and who they’re interacting with. To tackle the issue of learning to differentiate between what’s true and false, instruction at school could help give younger children the necessary tools and even offer programs for parents that help explain parental controls.

1. C.S. Mott Children’s Hospital. National Poll on Children's Health: Sharing too soon? children and social media apps. 2021;39(4). Published October 18, 2021. Accessed October 18, 2021

 https://mottpoll.org/reports/sharing-too-soon-children-and-social-media-apps

Social media apps have found a new audience in the many children who now carry a smartphone to keep in touch with parents and want to emulate older siblings and peers. A poll looks at whether they are using it safely.