Rachael Zimlich, RN, BSN

Although sports have long been linked to sudden cardiac arrest in younger patients, a recent report reveals that obesity may actually play a larger role.

 investigated cardiac arrest in individuals aged 5 to 34 years, reviewing circumstances around the event, resuscitation outcomes, clinical records, and autopsy results. Overall, the research team found that obesity was a factor in over 60% of sudden cardiac arrest cases in persons aged younger than 35 years.

Sumeet S. Chugh, MD, Price professor and associate director of the Heart Institute, and director of the Heart Rhythm Center, at Cedars-Sinai Smidt Heart Institute, Los Angeles, California, says the study demonstrates that obesity and other traditional cardiovascular risk factors may play a larger role in sudden cardiac arrest in young persons than previously thought.

âEfforts to reduce cardiovascular risk in the young are known to translate into reduction of adult cardiovascular disease burden, but these findings suggest that the benefit could extend to sudden cardiac arrest in younger age groups,â Chugh says.

The research team found that 5% of the nearly 4000 cases of sudden cardiac arrest studied occurred in the young, and that warning signs were present in only about a third of those cases. Sports was found to be a trigger in 39% of sudden cardiac arrest in patients aged 10 to 18 years, and 13% of cases in those aged 19 to 24 years. Shockable rhythms were found more often in sports-related sudden cardiac arrest, and survival was 2.5-fold higher in sports-related cases than in nonâsports-related cases.

In sports-related sudden cardiac arrest, researchers found that more cases were witnessedâ92% compared with just 40% of nonâsports-related cardiac arrest. Warning signs occurred in only about 30% of sudden cardiac arrest cases overall, but were even less frequent in sports-related cases than in nonâsports-related cases. In cases where warning signs were present, angina was the chief symptom in both sports-related and nonâsports-related cardiac arrest. No particular sport was linked to sudden cardiac arrest over another, but males were more likely to experience sudden cardiac arrest whether in the sports or nonâsports-related group, according to the report.

In terms of intervention, resuscitation was attempted in 82% of sudden cardiac arrest cases in youths, and 14% survived to discharge. Bystander cardiopulmonary resuscitation (CPR) occurred in less than half of the sudden cardiac arrest cases overallâ42% in sports-related cases, and 32% in nonâsports-related casesâand CPR by emergency medical personnel was performed in 100% of all sports-related cardiac arrests compared with 79% in nonâsports-related cases, according to the study. Resuscitation efforts, as well as survival rates at discharge, were higher in sports-related cases than in nonâsports-related cases, the research team found, with 28% of sports-related cases surviving to discharge compared with just 11% of nonâsports-related cases.

In all cases of sudden cardiac arrest, researchers were able to identify some common causesâ31% of cases were attributed to sudden arrhythmic death syndrome; 22% to coronary artery disease; and 14% to hypertrophic cardiomyopathy. The research team also concluded that the âunexpectedly highâ prevalence of classic cardiovascular risk factors in cases of sudden cardiac arrest in youths suggests there may be cause for a greater focus on risk stratification at younger ages. There is still more work to be done, however, to find the best ways to identify cardiovascular risk in children.

âSince the majority of cases did not experience warning symptoms, significantly more work is needed to improve the sudden cardiac arrest risk stratification process in the younger population,â Chugh says.

Chugh adds that despite the study finding of sports as a potential trigger of cardiac arrest in the young, the overall frequency was low at just 14% of all sudden cardiac arrests in individuals aged younger than 35 years. More research is needed before the study findings should be used to justify widespread routine screenings, he notes. Instead, Chugh says he hopes the report will generate more interest in uncovering causative and risk factors for cardiovascular problems in the young.

âWe hope that it will focus attention on the more common and rapidly rising contributors to risk of sudden death in the young. We generally expect risk factors such as diabetes, obesity, hyperlipidemia, and smoking to create problems for older populations,â Chugh says. âIn this regard, the high rates of these factors among young individuals who experienced sudden cardiac arrest came as a surprise. More research is needed to understand prevalence of these risk factors among the general population in this age group before we can deploy specific plans for screening and prevention.â

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Sports have long been linked to cases of sudden cardiac arrest in the young, but a recent report shows that obesity may play a larger role than activity.

Sudden cardiac death in kids: What's the culprit?

	Only about half of teenagers with depression receive a diagnosis before they become adults, and about two-thirds go without help, according to a report that has spurred the release of revised guidelines on depression screening and management for children from the American Academy of Pediatrics (AAP). 

, GLAD PC (Guidelines for Adolescent Depression in Primary Care), include a new recommendation that all children aged older than 12 years be screened for depression at least once per year.

	Rachel Zuckerbrot, MD, a board-certified child and adolescent psychiatrist and associate professor of Clinical Psychology at Columbia University, New York City, and coauthor of the report, also helped to craft the AAP’s updated guidelines. She says the report and the guidelines highlight the need to address mental health in pediatric well-child care.

Recommended: Risk of depression jumps in teens and young adults

	“I think it is important for pediatricians to know that the American Academy of Pediatrics, as well as many other organizations, think it is standard of care for pediatric primary care providers to screen, assess, diagnose, and manage-including treatment and referral-adolescent depression,” Zuckerbrot says. “Pediatric primary care providers should feel supported by these guidelines.”

	Researchers began investigating this issue in 2007 when the GLAD-PC steering group was unable to reach consensus on a universal adolescent depression screening recommendation, Zuckerbrot says. Instead, the AAP-endorsed GLAD PC guidelines at that time recommended assessment for depression risk factors, with screening advised only for those who were identified with risk factors. Following the 2007 recommendation, work started on updating the guidelines to the current form.

	“In these guidelines, we finally endorse universal adolescent depression screening with a formal self-report tool,” she says. “This aligns with the current US Preventive Services Task Force recommendations, as well as the current AAP Bright Futures Preventive Pediatric Health Care table.”

	In the 2 GLAD-PC manuscripts, Part I on Practice Preparation, Identification, Assessment, and Initial Management, and Part II on Treatment and Ongoing Management, Zuckerbrot and her Canadian counterpart Amy Cheung, MD, MSc, highlight evidence- and consensus-based methodologies for youths aged 10 to 21 years.

 The report reveals that half of teenagers with depression are not diagnosed in the pediatric primary care setting before reaching adulthood, resulting in two-thirds going without needed treatment. Even in cases in which adolescent depression is diagnosed, about half of teenagers still go without appropriate intervention, according to the report. Given the shortage of mental health professionals and the large numbers of adolescents that go either undiagnosed or untreated, the report stresses the need for primary care pediatricians to learn how to identify and manage depression in teenagers.

	In addition to the recommendation that all teenagers aged older than 12 years are screened at least once a year for depression, the guidelines also urge pediatricians to identify high-risk patients and educate parents and patients about their options for managing depression in adolescence. Moving into management, the guidelines suggest that pediatricians work with patients and families to develop a treatment plan that is age appropriate and that matches the severity of the patient’s diagnosis. Management plans also should include referrals and/or support with community mental health services, and include a safety plan and emergency management measures for acute episodes and suicidality, according to the researchers.

	Suicide is the third-leading cause of death in adolescents, and even when depression doesn’t lead to suicide, it can have lifelong effects on an individual’s health and well-being. According to data from the nonprofit depression and suicide education awareness program 

, roughly 20% of all teenagers experience depression at some point before adulthood, and depression will translate into a substance abuse problem for 30% of those adolescents. Depressed teenagers are also more withdrawn and suffer socially, academically, and in career preparation than their peers, according to INAL.

Next: Implementing mental health services in primary care

	Pediatricians may have trouble addressing mental health needs in their practice due to the extra staff and time screenings and management require, but the report reveals that many practices have already incorporated mental health into well visits as part of the medical home practice model. Zuckerbrot says she hopes the guidelines will help motivate those practitioners who have yet to take this step.

	“We hope that adolescents are better able to access the care that they need to have a happier adolescence. We hope that pediatric primary care providers feel supported in their efforts to deal with behavioral health problems,” she says. “Lastly, we hope that families recognize that their pediatric primary care providers can be a source of help and support for these types of issues, and not just for vaccines and sore throats.”

	1. Zuckerbrot RA, Cheung A, Jensen PS, Stein REK, Laraque D; GLAD-PC Steering Group. Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part I: Practice Preparation, Identification, Assessment, and Initial Management. 

http://pediatrics.aappublications.org/content/141/3/e20174081.long

. Published February 26, 2018. Epub ahead of print.

	2. Cheung AH, Zuckerbrot RA, Jensen PS, Laraque D, Stein REK; GLAD-PC Steering Group. Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part II: Treatment and Ongoing Management. 

http://pediatrics.aappublications.org/content/141/3/e20174082.long

Too many children with depression go undiagnosed and untreated, according to the American Academy of Pediatrics. Updated guidelines should address this standard of care.

New guidelines highlight pediatric mental health needs

	In some cases, pediatricians don’t offer education about children’s oral health. In others, parents might not take it. Either way, parents who aren’t prompted by their pediatrician or other health professional don’t get their children the early dental care they need.

 from C.S. Mott Children’s Hospital, University of Michigan, Ann Arbor, reveals that of nearly 800 parents polled on oral health for their children, less than half were educated by a physician or dentist. Of the parents who were not educated by a healthcare provider on dental care, 17% believed their child didn’t need to see a dentist until age 4 years.

 (AAP) recommend children begin visiting a dentist around age 1 year as teeth begin to emerge, but this poll makes it clear that education aimed at parents about dental care is lacking.

	“For many families, the pediatrician is key to making sure parents understand the importance of early dentist visits, but this study shows that over half of parents don’t recall any recommendation from the pediatrician,” says Sarah J. Clark, MPH, associate research scientist for the Department of Pediatrics at the University of Michigan’s Child Health Evaluation and Research Center (CHEAR) and co-director of the C.S. Mott Children’s Hospital National Poll on Children’s Health. “Pediatrician guidance is particularly important because many parents don’t make routine dental visits themselves, so they are not in a position to get that information and guidance from the dentist.”

Recommended: How you can tackle oral healthcare

	Clark says early dental care is important for establishing good dental health, and for early detection and treatment of tooth decay in children. However, there seem to be pockets of parents who are not receiving education about dental care.

	According to the poll, 45% of parents reported receiving information from their child’s dentist or doctor about initiating regular dental visits, but parents in this group were typically from higher income and education brackets with private dental insurance. This divide is concerning, according to the poll researchers.

	Tooth decay occurs in up to 40% of children by the time they reach kindergarten, according to the AAP, and poll researchers note that dental caries occur at higher rates in low-income populations. Many 

state Medicaid programs already fall short

 when it comes to dental coverage, and additional proposed cuts may exacerbate the problems further.

	Whereas state programs are mandated to cover dental care for children, parents may not receive coverage or have restrictions in place in order to receive care. Poor dental health can not only affect an individual’s appearance and oral health, but it can also lead to infection and a host of other health problems. For these reasons, it’s important to educate all patients, particularly in cases in which parents also may not be receiving the dental care or education they need.

	The poll also notes, however, that even when education is offered, parents might get outdated information or misunderstand the recommendations given to them.

	Among parents who say they did receive education from a pediatrician or other physician about dental care, 47% reported that they believed children should first see a dentist at age 1 year or younger; another 47% thought the first dental visit should be between ages 2 and 3 years; and 6% of parents who received education from a provider thought dental visits should be delayed until age 4 years or later.

	In comparison, among parents who received no education or information on dental care from a healthcare provider, just 35% believed dental visits should begin at age 1 year or younger; 48% reported dental care should begin between ages 2 and 3 years; and 17% stated that dental care should begin at age 4 years or older.

	As far as overall compliance with dental care, 60% of the parents polled had taken their child for a dental visit, and the age at which they first took their child to the dentist matched the parents’ belief about when to start dental care 85% of the time. Nearly 80% of parents reported feeling that their child’s dental visit was worthwhile.

	For the 40% of parents polled who had not ever taken their child to the dentist, researchers investigated why. Forty-two percent of parents who had not taken their child to the dentist believed that the child was not yet old enough; 25% believed their child’s teeth were healthy; and 15% felt their child would be afraid of the dentist.

	In a statement about the poll results, researchers say that parents’ lack of awareness of dental care recommendations is understandable, considering how much guidelines have changed over the years. “Parents get much less guidance on when their child should go to the dentist compared to the doctor,” the statement continues.

	Well visits for children begin immediately after birth, and the first few years of a child’s life are filled with scheduled assessments and vaccinations. Parents can easily become overwhelmed with all the information they receive at these visits, or physicians may run out of time to discuss dental care.

	“A likely barrier is the time crunch to include all recommended elements of anticipatory guidance at well-child visits in the second year of life (ages 12, 15, and 18 months),” Clark says. “A related barrier is the challenge that parents have remembering all that advice-so a handout or ‘prescription’ to make a dentist appointment might be helpful.”

Next: Health literacy, a challenge in diverse populations

	Clark says this poll is a good reminder to pediatricians to discuss dental care and to find new ways to educate parents.

	“This is a great reminder for pediatricians that guidance to parents makes a difference,” Clark adds. “We don’t assume that parents know when to seek well-child visits and other aspects of preventive care-we guide them; the same is true for dental care. I hope this research encourages pediatricians to communicate clearly about the importance of early dental visits.”

 A new poll shows that there is a lot of misunderstanding about when is the right time for children to start seeing a dentist.

What you need to be doing about oral health

A new study refutes a popular claim by opponents of vaccination that vaccines weaken a child’s natural immunity.

Journal of the American Medical Association

, outlines a case-control study performed on children aged 2 to 4 years with 193 cases with non–vaccine-targeted infections and 751 controls with non–vaccine-targeted infections. Researchers found no statistically significant difference in the level of immunity against non–vaccine-targeted infections between the 2 groups.

“Essentially, what this study confirms is that vaccines don’t ‘weaken’ a child’s immune system,” says Sean O’Leary, MD, MPH, associate professor of pediatrics at the University of Colorado Denver School of Medicine, Anschutz Medical Campus, investigator for the Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), director of the Pediatric Practice-Based Research Network (COCONet), and author of an 

. “Children who receive vaccines aren’t any more likely to get sick from illnesses that are not targeted by the vaccines.”

According to the researchers, the mean cumulative antigen exposure for children enrolled in the study was 240.6 for cases and 242.9 for controls. The study was performed with the intent of determining whether parental concerns that multiple vaccines in early childhood could weaken their child’s immune system were valid.

“Our study marks the first time the association between multiple vaccines and non–vaccine-targeted infections has been tested in the United States with the current recommended immunization schedule,” says Jason Glanz, PhD, epidemiologist and investigator in the Institute for Health Research at the Colorado School of Public Health, Aurora, and co-author of the study. “We did not observe an association between cumulative vaccine antigen exposure in the first 23 months of life and the risk of nontargeted infections between ages 24 and 47 months. We hope this study helps parents understand the safety of vaccinating their children on time.”

In his editorial published with the report, O’Leary recounts a 2013 request from the Institute of Medicine (IOM) to increase research into the safety of the childhood vaccine schedule. Previous work had been done to examine the safety of individual vaccines, but not the safety of the whole schedule in its entirety. The number of routine vaccinations for children increased from 8 in 1994 to 14 by 2010, and polls have shown that parents have been concerned since the 1990s that children receive too many vaccines and that the number of immunizations given in childhood may weaken the immune system. That concern has grown over the years as the number of vaccines increased and, in recent years, has manifested into a movement of parents rejecting recommended vaccines for their children.

“We understand the concerns parents have about vaccine safety. Nothing in medicine is 100% safe, but vaccines are one of the more well-studied areas of medical research,” Glanz says. “Patients are usually surprised to learn that the safety of vaccines has been much more thoroughly studied than the safety of giving ibuprofen for fever or amoxicillin for an ear infection. Because vaccines are recommended for all children in the United States, their safety is constantly being evaluated.”

Numerous studies, as well as internal reports by IOM, have largely refuted these concerns, but this new study is the first to look specifically at the relationship between multiple vaccines on the US immunization schedule and the development of non-targeted infections.

O’Leary writes in the editorial that this new research should serve as reassurance to parents that the US childhood immunization schedule is safe and does not increase a child’s risk of developing non–vaccine-targeted diseases. He also cautions, however, that this data might not be enough to convince some parents that it is safe to vaccinate.

“Simply providing scientific information and assuming parents will make the decision to vaccinate is not enough,” O’Leary says. “Delivering evidence-based information to parents and clinicians in ways that inspire confidence in the robust and safe childhood immunization schedule is critical for maintaining the health of children.”

 that the proportion of parents who refuse vaccinations altogether is small-less than 1%-and that the vast majority of parents vaccinate their children according to the recommendations. Still, the medical community must remain vigilant in providing education and resources to parents.

“We are also hearing more from parents who are supportive of vaccination-parents who recognize the importance of vaccinations and are speaking out in support of them. Organizations such as 

Colorado Parents for Vaccinated Communities

 are giving a voice to the vast majority of parents who vaccinate their children,” O’Leary says. “On the other hand, the small group of antivaccine activists continue to spread misinformation about vaccines, often through social media. The difference I see now is that there is more pushback from provaccine parents.”

A popular claim in the antivaccination movement that too many vaccines can set children up for poor immunity overall has been refuted in a new study.

Author | Rachael Zimlich, RN, BSN

Articles

Sudden cardiac death in kids: What's the culprit?

New guidelines highlight pediatric mental health needs

What you need to be doing about oral health

Study reveals vaccinations don’t weaken natural immunity