	Urinalysis is extremely sensitive and specific for screening for urinary tract infections (UTIs) in febrile infants aged 60 days and younger, especially when the UTI is associated with bacteremia, a recent study showed.

	Investigators evaluated the test characteristics of the urinalysis in aggregate and of 3 individual components-leukocyte esterase (LE), nitrites, and pyuria-for diagnosing UTIs with and without associated bacteremia. They used 2 definitions of UTI: growth of 50,000 or more or of equal to or greater than 10,000 colony-forming units (CFU) per mL of a pathogen.

	The study was in almost 4500 febrile infants aged 60 days or younger from whom blood cultures were obtained as part of an emergency department evaluation for bacterial infection; 289 (7%) had UTIs with equal to or greater than 50,000 CFU/mL, including 27 (9.3% of the 289) with bacteremia. A positive urinalysis showed perfect sensitivity when accompanied by bacteremia (100%) and an excellent 94% sensitivity without bacteremia. Specificity was 91%. For UTIs defined by colony counts equal to or greater than 10,000 CFU/mL, sensitivity of the urinalysis was 87% and specificity 91%.

Next: BRUE in infancy does not increase risk of death

Most infants with UTIs had urinalyses positive for LE or pyuria, although nitrites generally were absent irrespective of UTI status. All patients with UTIs with bacteremia had either moderate or large concentrations of LE. Infants without bacteremia whose urine colony counts were below 100,000 CFU/mL were less likely than infants with higher counts to have LE, nitrites, or pyuria (Tzimenatos L, et al. 

	My takeaway here is that the urinalysis is often predictive of a UTI, even in a very young child, but, as with any test, we need to leave room for some clinical judgment when deciding which febrile infants have a UTI. No test is perfect.

Articles

Urinalysis is extremely sensitive and specific for screening for urinary tract infections (UTIs) in febrile infants aged 60 days and younger, especially when the UTI is associated with bacteremia, a recent study showed.

Urinalysis identifies the youngest infants with UTIs

A meta-analysis of 12 studies of the risk of death after a brief resolved unexplained event (BRUE) found that such an event does not increase an infant’s risk of dying during his or her first year. The American Academy of Pediatrics (AAP) introduced BRUE, a sudden alteration in an infant’s breathing, color, tone, or responsiveness, as a replacement for “apparent life-threatening event” (ALTE) in a 2016 clinical practice guideline.

The 12 studies involved 3005 children whose parents sought emergency care for a BRUE (termed ALTE in the pre-2016 studies). Twelve babies died, several in the hospital, within a few days of the event, but most weeks, months, or years later. Specifically, 8 infants died within 3 months of the BRUE and the remaining 4 between 4 months and 5.5 years after the event. The mortality rate after a BRUE, therefore, was 3.1 postevent deaths per month per 10,000 events.

Further analysis, using a 4-month time horizon, determined that the upper bound of the probability of death after a BRUE is about 1 in 800. This compares with a baseline risk of death during a 4-month period in the first year of life of 1 in 1200 for all infants (after excluding neonatal deaths), according to US infant mortality statistics (Brand DA, et al. 

This analysis of existing studies is meant to allow physicians to offer reassurance with minimal evaluation to parents of infants with low-risk BRUEs as defined in the 2016 AAP guideline (

). Low-risk BRUE infants include those who were not premature, were aged 2 months or older at diagnosis, had a first-time BRUE that lasted less than 1 minute, and did not require cardiopulmonary resuscitation by a healthcare professional. This guideline is one to keep close at hand.

BRUE in infancy does not increase risk of death

An 11-month-old boy was brought to the doctor by anxious parents for the evaluation of persistent diaper dermatitis. Despite trying multiple barrier creams and over-the-counter antifungal products, the rash did not resolve.

Psoriasis is a chronic inflammatory condition that has a prevalence of approximately 1% in children.

 Of those who develop psoriasis, up to 30% start with psoriasis in the diaper area, also known as napkin psoriasis, within the first 2 years of life.

 Infantile psoriasis is more commonly preceded by an infection or trauma than in adult psoriasis, and the Koebner phenomenon from repeated wiping and rubbing on a diaper is a likely culprit for napkin psoriasis.

 Family history of psoriasis is also a risk factor for developing this entity, and those who have dissemination of psoriatic plaques beyond the diaper area are at a higher risk of having psoriasis later in life.

Infantile psoriasis typically presents as a persistent, well-demarcated red plaque with absent or scant scale distributed in the diaper area. The plaques can involve the skinfolds. Some infants may have psoriatic plaques elsewhere on the body, but the groin involvement often precedes the more widespread eruption. Some infants exclusively have involvement of the diaper area.

Infantile psoriasis is often confused with irritant contact dermatitis, allergic contact dermatitis, seborrheic dermatitis, or candidiasis.

Irritant contact dermatitis is the most common cause of diaper dermatitis, and it results from wet, soiled diapers rubbing against the skin. This only affects the areas of skin exposed to the diaper, and it often affects the prominent skin most in contact with the diaper while sparing the skin folds.

Allergic contact dermatitis may occur after using a product that contains an ingredient to which the infant is sensitized. This outbreak may involve skin beyond the confines of the diaper area, and it will subside 2-4 weeks after the discontinuation of the culprit product.

Seborrheic dermatitis presents as erythematous, well-demarcated patches in the diaper area, but it is often erythematous with an overlying greasy scale when present in the scalp, face, ears, and neck. Erythematous plaques may also be present in intertriginous areas in infants, including in the skin folds on legs and arms.

Candidiasis presents as a bright red eruption that starts in the inguinal folds and may involve the entire diaper area. Erythematous or pustular satellite lesions may be scattered around the periphery of the involved areas.

Infantile psoriasis is characteristically resistant to standard diaper dermatitis treatments. Topical therapies, including low potency topical steroid ointments and barrier creams often provide temporary control, but lesions often return. Short courses of mid- or high-potency steroids can be used for recalcitrant lesions if necessary. Topical calcineurin inhibitors such as tacrolimus and pimecrolimus can also be used safely and effectively in the diaper area.

The patient was prescribed hydrocortisone 2.5% ointment to apply twice daily for up to 2 weeks, and tacrolimus 0.03% ointment to apply thereafter. His parents were counseled to use a barrier cream during every diaper change.

1. Tollefson MM, Crowson CS, McEvoy MT, et al. Incidence of psoriasis in children: a population based study. J Am Acad Dermatol 2010;62(6):979–87.

2. Morris A, Rogers M, Fischer G, et al. Childhood psoriasis: a clinical review of 1262 cases. Pediatr Dermatol 2001;18(3):188–98.

3. Ozden MG, Tekin NS, GÃ¼rer MA, Akdemir D, DoÃ§ramacÃ± C, Utas S, et al: Environmental risk factors in pediatric psoriasis: a multicenter case-control study. 

4. Benoit S, Hamm H. Childhood psoriasis. 

5. Cohen BA. “Neonatal Dermatology.” 

, 4th ed., Elsevier Saunders, 2013, pp. 14–67.

6. Cohen B. Differential Diagnosis of Diaper Dermatitis. 

7. Morrell DS, Cathcart SD, Carder KR. “Fungal Infections, Infestations, and Parasitic Infections in Neonates and Infants.” 

, 3rd ed., Elsevier Saunders, 2015, pp. 198-215. 

More than stubborn diaper rash?

In nearly 30 years of visiting independent pediatric practices all over the country, I’ve learned that the biggest challenges that confront you are self-inflicted. That’s right-more than the insurance companies who behave like organized crime, more than the government mandates that force you to click nonsensical boxes in your electronic health record (EHR), and even more than all the ridiculous paperwork and cuts to Medicaid-the most important business problems you face start in your own office.

Too many pediatricians fail to operate like the small service businesses you really are. In your exam room, you are in control and get immediate, positive feedback about the work you do. However, making changes to your small business isn’t easy and your practice gets stuck in a rut.

Being a good, or even great, pediatrician is no longer enough to be a successful pediatrician.

Why do good independent pediatricians fail to be successful? How can you get out of the rut?

1. Focus on preventive care and chronic disease management.

This topic alone could fill an entire issue of 

. If your practice depends on 100ÃÅ¡F fevers, runny noses, and diaper rashes to fill your schedule, your days are numbered. The retail and minute clinics of the world will gladly take those visits from you. You need to focus on the distinctive competency of pediatrics: well visits and, to a growing extent, helping children manage their chronic conditions such as asthma, obesity, and mental health.

Your connection to parents and helping them raise healthy children are the most important things you can do to stay clinically and financially viable. Preventive care pays well; fills your schedule; is required by your payors; is a crucial part of being a patient-centered medical home; establishes your position as the trusted medical source for your families; and, most of all, it is good for your patients.

Do the small businesses you see on your way to work ignore the data that drive their businesses? Not if they want to stay open for long. Every real estate agency, gas station, and restaurant does its homework to survive. They look at their financial reports on a daily, weekly, monthly, and annual basis. They benchmark their performance against themselves and their peers. They know their targets and they can predict future success and challenges.

If you don’t understand your data, you are in trouble. Who really is your best payor? How much revenue do you generate per visit? What is your well-visit coverage really like? How many opportunities do you miss to provide screening? When is the last time you calibrated your pricing? Are you paying too much for vaccines? What are your staffing ratios? Is your billing staff adjusting off too many charges?

Most importantly, don’t answer any of these questions about your practice based on how you feel. It’s time for evidence-based practice management. You use many different measures to care for your patients, from vital signs to lab results. Can you imagine working without that data? Apply the same thinking to your business.

Every year, there are a limited number of amazing opportunities to get real, pediatric-specific practice management training and instruction. In addition to the American Academy of Pediatrics (AAP) services, such as the 

Section on Administration and Practice Management (SOAPM)

 and their website, there are publications, including 

, and a variety of pediatric practice management blogs you must read.

More importantly: get out of your office. Go to the AAP National Conference and Exhibition or one of the state chapter meetings with good practice management content. Attend one of the handful of private pediatric-specific conferences and events. Check out your EHR vendor users’ meeting. It doesn’t really matter where you go, just get out of your office and away from the safety net of your exam room. All it takes is one good coding or management tip to pay for a few years’ worth of meetings.

Don’t stop there. Have a friend from residency you haven’t seen in years? Call him or her and go visit. Spending a day or 2 in an office that isn’t yours will overwhelm you with ideas for change in your practice. Problems you’ve never been able to solve (or, worse, never knew you had!) will suddenly have solutions. Stop practicing in a silo; go visit a peer.

In 2018, it’s obvious to remind people to check their websites and Facebook pages. Your primary audience is mothers, especially young mothers, most of whom are tied to their smartphones.

Is your website up to date? Do your parents have to use the 2-fingered pinch-and-swipe and squint just to see your page? Is your Facebook page active and helpful? Are you sharing good, online pediatric content with your patients?

You are? Good. Then head out into your waiting room, sit in one of your chairs, and look around. Feel under the chair-is there gum? Are there rips or tears? Anything stained? Is this a practice you want to visit?

How are your handouts? Are they up-to-date? Do they look nice, include your contact information, and are they easily shared on your patient portal?

Sit in every chair and visit every room your patients will see in your office. From your patients’ literal perspective, what do they see, hear, feel, smell? Is there a desk that needs to be cleaned, a 4-year-old sign that needs to be removed, a carpet that needs cleaning?

Have a friend visit your office in the middle of the day and ask to meet you without an appointment. Ask parents you know how the experience of booking the appointment and being checked in felt for them. Find out how your staff, the face of your practice, treats people when you aren’t looking.

Don’t forget that only a small part of the experience patients have with your office is with you.

Nearly every struggling practice I meet suffers from this malady: They work with the wrong people.

The “wrong” people almost always fall into 1 of 3 categories:

·      The incompetent-or wildly divisive-high-ranking employee who has been there forever but whom you “just can’t do without.” You 

 do without, and the sooner, the better. I’ve never, even once, had a practice call me to say, “I wish I had taken longer to fire my office manager.” It’s always, always, recognition that it should have been done sooner.

·      The underpaid, underorganized, low-ranking employee whom no one takes the time or effort to shape up because they ship out on their own every couple of months. I hear it all the time: “We can’t find good people!” You know why? Because smart businesses create and keep their good people. Good people don’t just turn up-you have to make them.           

·      The last and most important category: your partners. At least a half-dozen times a year I meet with practices that should consider “breaking up” but just don’t want to face it. Do you disagree strongly with any of your partners, clinically or financially? Is someone a bully or not at all attentive to partner duties? Do you feel like you do all the management work? Are you ready to embrace the changes facing your practice, but others want to keep doing things the way they’ve always been done?

If you and your partner(s) aren’t working well together, fix it or move on. Life is too short to be miserable or to be forced to practice in a manner you don’t enjoy. A business partnership is not like a marriage. There are no moral implications of promises made at the altar. Now is the time to create the work environment that you want.

Over the last few years, the consultants I know have been busy with startup practices born from pediatricians with high standards leaving their large healthcare systems or hospitals. For most communities in the United States, this is an amazing time to be a pediatrician. Don’t let that opportunity slip by because you were tethered to the wrong people.

Owning a small business is not easy, especially with the increasing demands of your customers, new daily paperwork requirements, and what feels like diminishing financial return. For pediatricians, at least, the rewards, both intrinsic and external, are substantial. Think about each of the common business mistakes above and pick one to address this quarter. I promise that you won’t regret it. Measure the impact, share your victory, and keep moving forward.

For Chip Hart’s webinar series about the 5 biggest business mistakes independent pediatricians make, visit 

For more about remaining independent, visit 

Independent pediatricians truly are small service business owners. Expert advice can help your practice avoid problems and achieve success.

The 5 biggest business mistakes independent pediatricians make

It is well known that early puberty in girls is associated with a myriad of psychosocial effects that make them vulnerable to depression and antisocial behavior during adolescence. Less known is how these effects play out over time and into adulthood.

 that tracked the psychosocial effects of early puberty beyond adolescence and into adulthood to look at how long the psychosocial effects of early puberty may last.

“Our study tracks girls through adolescence into their late 20s, far longer than other studies, and we see that girls who went through earlier puberty are still showing higher rates of depressive symptoms and antisocial behavior than their peers,” says Jane Mendle, PhD, associate professor, Department of Human Development, College of Human Ecology, Cornell University, Ithaca, New York, and lead author of the study.

To examine the associations of age at menarche with development and duration of depressive symptoms and antisocial behaviors, Mendle and colleagues collected and analyzed data on 7802 female participants taken from the National Longitudinal Study of Adolescent to Adult Health (Add Health). Conducted between 1994 and 2008, Add Health is a 

 that assessed adolescent health and risk behavior in a large socioeconomically, ethnically, and racially diverse cohort.

Data was collected by interviewing participants over 14 years (in 4 different time periods or waves) to determine the age at menarche (used as a proxy for pubertal development) and development and duration of depressive symptoms and antisocial behaviors. To assess depressive symptoms, participants completed the Center for Epidemiologic Studies Depression Scale (CES-D) during the first and last time periods of the study. The CES-D is a self-report evaluation that measures cognitive, affective, and physiologic symptoms of depression experienced by the participant over the past week. Antisocial behaviors (ie, doing damage to property, stealing, breaking into building, selling drugs) were also assessed twice (during the first and last time periods).

The study found that the onset of menarche was about 12 years for most of the girls (31%) followed by age 13 (24%) and age 11 (19%), but ranged from 7 to 24 years. About 10% of girls reported age of menarche at age 10 or younger.

Using various regression models to assess associations of age at menarche to depressive symptoms and antisocial behaviors, the investigators found a significant association between later ages of menarche and lower levels of depressive symptoms during adolescence and over time. For example, compared with a girl with an onset of menarche at age 12 years (the average age), a girl who has an onset of menarche at age 10 years is 8% more likely to have depressive symptoms in adolescence and 6% more likely to still have depressive symptoms in her 20s. When looking at a girl who begins menarche at age 8 years, the percentages of depressive symptoms increase to 25% in adolescence and 20% into her 20s.

Similar findings were seen for antisocial behavior, with younger age at onset of menarche associated significantly and linearly with a higher frequency of antisocial behavior. For example, the study found that compared with a girl with an onset of menarche at age 12 years, girls with early menarche at age 10 years had a 5% greater chance of displaying antisocial behavior in adolescence that persisted into their 20s (although only marginally significant).

Highlighting that these findings show that the magnitude of the association between puberty and depressive symptoms and antisocial behavior remain stable over time, Mendle underscored that psychological vulnerability of earlier puberty lingers longer than previously expected.

“It’s not simply a question of adolescent ‘growing pains,’” she says.

Given that more girls are entering puberty at a younger age, Mendle and colleagues highlight that a better understanding of the long-term psychosocial effects of early puberty are needed. Their study provides a needed step in that direction by showing that the psychosocial vulnerabilities associated with early puberty can extend into adulthood. This finding shines a light on the importance of pediatricians and other healthcare providers who care for children and adolescents to recognize the potential adverse psychosocial effects of early puberty on the psychosocial well-being of children long after they’ve shed their adolescence.

Emphasizing that puberty is a complicated psychological experience, as well as a biological transition, Mendle underscores the need to recognize the effect of puberty on all domains of life both during adolescence and in what it portends for adulthood.

“The best thing that pediatricians can do is to be sensitive to the psychological importance of puberty for early maturing girls, and recognize the duration of its effects,” she says.

1. Mendle J, Ryan RM, McKone KMP. Age at menarche, depression, and antisocial behavior in adulthood. 

2. Harris KM. The National Longitudinal Study of Adolescent to Adult Health (Add Health), Waves I & II, 1994-1996; Wave III, 2001-2002; Wave IV, 2007-2009 (machine-readable data file and documentation). Chapel Hill, NC: Carolina Population Center, University of North Carolina at Chapel Hill; 2009. DOI: 10.3886/ICPSR27021.v9.

Pediatricians need a better understanding of the effects of early puberty for girls beyond adolescence into adulthood.

Early puberty in girls has long-term psychosocial effects

The term “failure to thrive “(FTT) first appeared in the literature more than 80 years ago, and although it continues to be widely used, it has no precise definition. Recent terms to describe FTT include undernutrition, malnutrition, and faltered growth. In 2017, guidelines by the National Institute for Healthcare and Excellence in the United Kingdom were published to aid in recognizing, assessing, and monitoring of “faltering growth” in infants and children in the United Kingdom.

 With a lack of any other formal practice recommendations, however, clinical practice is variable, with an overuse of resources, including unnecessary laboratory testing, subspecialist referrals, and hospitalization.

Historically, FTT has been classified as organic and nonorganic, but it is now recognized that only a small minority of children with FTT have an underlying organic cause. Instead, FTT often has a multifactorial etiology involving a complex interaction between medical, nutritional, emotional, and social issues. Although this range of contributing factors can pose a diagnostic challenge, the evaluation and coordination of a management plan for FTT can often be done successfully by providers across the continuum of pediatric care when guided by findings from a detailed history and thorough physical examination.

With a focus on promoting high-value care for patients, this article presents a practical, systematic approach that pediatric providers can use for the differential diagnosis and management of FTT.

Failure to thrive has classically been identified when a child’s weight drops off the standardized weight curve before and to a greater extent than the length/height (Figure).

 Its recognition depends on reliable serial measurements for growth assessment. Individuals gathering data must be properly trained and use appropriate equipment with a standardized technique. Stature (length/height) should be measured with the child lying supine on a length board for children aged 0 to 2 years and using a stadiometer for older children. Weight should be determined using a digital scale, and head circumference also should be measured in children aged younger than 3 years.

Data should be recorded and plotted on a standardized growth chart for age and gender or using another appropriate chart when special circumstances exist (eg. premature birth, genetic syndrome). The Centers for Disease Control and Prevention (CDC) recommends using the World Health Organization’s weight-for-length growth chart for children aged younger than 2 years and the CDC body mass index (BMI) growth chart for older children.

Diagnostic evaluation is key in determining underlying cause(s) for FTT and appropriate management. Pediatric providers should initiate the diagnostic evaluation for FTT by taking a detailed feeding/eating history and performing a clinical, developmental, and social assessment that aims to identify issues that can lead to undernutrition. These etiologies can then be categorized as inadequate caloric intake, inadequate caloric absorption/usage, and/or increased metabolic demands (Table 1).

A dietary history may be obtained through a 24-hour recall provided by the parent/caregiver. Whenever possible, providers should enlist the help of a dietitian who can conduct a more formal assessment including calorie counts.

The patient history should identify types of foods and calories consumed along with frequency of meals and snacks. It also should include questions to determine the child’s behavior at feedings/meal times and parental reactions and ideas about nutrition. Some common issues underlying inadequate calories include excessive intake of juice or other beverages that provide poor nutrition and limit appetite for other foods, and improper formula preparation. Mothers who are breastfeeding should be asked about their diet and use of medications, alcohol, or other substances that can affect milk production and let-down.

Psychosocial issues should be investigated to determine if the child is not being provided with adequate food because of neglect/abuse or as a consequence of parental economic, intellectual, or mental health problems.

A good history also can help identify clues of an underlying medical cause for FTT by asking about symptoms of gastrointestinal illnesses-vomiting, reflux, diarrhea, constipation, blood or mucus in the stool; respiratory signs-breathing difficulty, chronic cough, snoring; or recurrent infections. In addition, a thorough family history should be obtained to understand the stature and growth pattern of siblings, parents, and grandparents as well as identifying illnesses such as food allergies, genetic diseases, inflammatory bowel disease, celiac disease, asthma, and cystic fibrosis.The physical examination should include looking for physical impediments to feeding and swallowing, such as cleft lip/palate, oral abscesses, or enlarged tonsils/adenoids; dysmorphic features indicative of a genetic disorder; abdominal distention or organomegaly; neurologic signs of developmental delay; and bruises or other evidence of trauma and abuse. Observation of the parent-child interaction in general and during feeding is also a key part of the physical examination.

Laboratory testing in the workup of a child with FTT only rarely adds useful information unless the assessments are indicated based on the clinical findings.

 If a medical cause is suspected, then testing should be guided by clinical assessment. Examples of targeted studies to consider only when a thorough history and physical suggest a specific diagnosis include transglutaminase antibodies if celiac disease is suspected; a sweat chloride test for cystic fibrosis; stool analysis for suspected malabsorption or infestations; and thyroid function tests for hypothyroidism.

Inborn errors of metabolism are often considered for children with FTT, but it is an unlikely diagnosis in most children with mild-to-moderate FTT.

 Anthropometric criteria for classifying malnutrition in pediatric patients as mild, moderate, or severe were described in a consensus statement from the Academy of Nutrition and Dietetics and the American Society for Parenteral and Enteral Nutrition.

 Before pursuing a more comprehensive investigation for an inborn error of metabolism, clinicians should look for relevant clues in the history and physical (Table 2

). If any of these clues are not present, an inborn error of metabolism is less likely.

Management for FTT integrates creation of a nutritional plan and attention to the causes for undernutrition. Ideally multifactorial management includes a multidisciplinary team with a pediatric provider, dietitian, social worker, and other services as indicated.

The nutritional plan targets provision of sufficient calories, protein, and micronutrients, including iron and zinc. The following formula can be used to determine the daily caloric intake (kcal/kg) required for catch-up growth:

Ideal body weight in kg (50th percentile weight/height) X
[kcal/kg/d (Dietary Reference Intake)]

Strategies for achieving the target weight depend on the child’s age and problems underlying FTT and may involve giving supplementary formula to breastfed infants and seeking lactation support for the mother; supplementation with energy dense formula for formula-fed babies; and dietary fortification with energy-dense foods or nutritional supplements in toddlers and older children.

Ideally, the required nutrition can be provided orally, but tube feeding should be considered if the child is unable to obtain the desired intake through the oral diet alone. Delivery through a nasogastric tube is preferred over a gastrostomy tube unless it is anticipated that the duration will exceed 6 months or if the child is not tolerating the tube feeding after a trial. Decisions on providing continuous versus bolus feeding are individualized.

When a child is very malnourished, caloric intake should be increased gradually as aggressive nourishment can lead to refeeding syndrome, a dangerous complication related to electrolyte and fluid shifts. A child with severe FTT/malnutrition is at risk for refeeding syndrome and should be admitted to the hospital for close clinical monitoring.

Parents should be instructed to keep a log of dietary intake and bring the child in for frequent weight checks to monitor progress. Although it is reasonable to expect that early intervention for FTT should mitigate long-term deficits associated with malnutrition, there is a paucity of longitudinal data in this area and findings from available studies are equivocal. Therefore, follow-up of children with FTT should also include attention to their intellectual and emotional development and referrals as needed to resources that can optimize their outcomes.

Children with FTT should be admitted to the hospital if outpatient management fails. In addition, hospitalization is indicated when there is concern about abuse; if close observation of the parent-child interaction is deemed necessary; and for children with severe FTT or malnutrition, moderate or severe dehydration or electrolyte disturbances; or serious infection. The inpatient setting allows for coordinated delivery of multidisciplinary care, including appropriate educational counseling and social support services for parents.

When hospitalization is deemed appropriate, significant cost savings may be accrued by avoiding nonurgent weekend admissions. One recent study analyzed data from more than 20,000 children aged younger than 2 years with FTT and calculated that converting one-half of Friday admissions to Monday would save more than $500,000 over a 1-year period.

Hospitalized children may be discharged once diagnostic testing and consultations are complete and they show consistent weight gain. A plan for continuing care and follow-up also must be in place and parents must demonstrate understanding of the management recommendations.

The role of the outpatient pediatric provider is fundamental to the ongoing monitoring and care of a child with FTT. Routine growth assessments allow providers to identify FTT, and by using history-taking and physical examination skills alone, providers can often determine its etiology in a timely, cost-effective manner.

Specific diagnostic findings guide the need for further evaluation and appropriate management, and multidisciplinary treatment is often needed as FTT tends to be multifactorial. A standardized approach to care of children with FTT would allow pediatric providers to optimize the care for these patients.

1. National Institute for Health and Care Excellence. Faltering growth: recognition and management of faltering growth in children. NICE guideline. Available at: 

https://www.nice.org.uk/guidance/ng75/resources/faltering-growth-recognition-and-management-of-faltering-growth-in-children-pdf-1837635907525

. Published September 27, 2017. Accessed March 19, 2018.

2. Adedoyin O, Gottlieb B, Frank R, et al. Evaluation of failure to thrive: diagnostic yield of testing for renal tubular acidosis. 

4. Berwick DM, Levy JC, Kleinerman R. Failure to thrive: diagnostic yield of hospitalisation. 

5. Al Nofal A, Schwenk WF. Growth failure in children: a symptom or a disease? 

6. Centers for Disease Control and Prevention. National Center for Health Statistics. Growth charts. Available at: 

. Updated September 9, 2010. Accessed March 19, 2018.

7. Vachani JG. Failure to thrive. In: American Academy of Pediatrics Section on Hospital Medicine; Gershel JC, Rauch DA, eds. 

. 2nd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2017:569-576.

8. Ficicioglu C, An Haack K. Failure to thrive: when to suspect inborn errors of metabolism. 

9. Becker P, Carney LN, Corkins MR, et al; Academy of Nutrition and Dietetics: American Society for Parenteral and Enteral Nutrition. Consensus statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: indicators recommended for the identification and documentation of pediatric malnutrition (undernutrition). 

10. Thompson RT, Bennett WE Jr, Finnell SM, Downs SM, Carroll AE. Increased length of stay and costs associated with weekend admissions for failure to thrive. 

Outpatient pediatric providers have an essential role in the ongoing monitoring and care of a child with failure to thrive (FTT). Here’s how routine growth assessments help to identify FTT and determine effective multidisciplinary treatment.

Failure to thrive: Early intervention mitigates long-term deficits

FluMist will return to the pediatrician’s arsenal next year, thanks to a vote last month by the Centers for Disease Control and Prevention’s (CDC’s) Advisory Committee on Immunization Practices (ACIP) to reinstate the live-attenuated influenza vaccine (LAIV).

ACIP members voted in favor of reinstating the recommendation for LAIV at its Feb. 21 meeting, and also voted unanimously in favor of including the formulation in the Vaccines for Children program for the 2018-19 flu season.

The LAIV-an intranasal vaccine marketed as FluMist-was popular among pediatric patients due to ease of administration and as an alternative to the traditional injected vaccine. However, reduced effectiveness in recent years led ACIP and numerous stakeholders to recommend against the use of this formulation since 2016. Despite recommendations against the LAIV formulation in the United States, FluMist remained available and recommended for use in Canada and Europe, according to AstraZeneca.

Chris Ambrose, MD, MBA, franchise head of US Medical Affairs, Respiratory for AstraZeneca says the company began investigating the cause of the vaccine’s decreasing performance in 2014, and noted that 1 of the strains in LAIV, the H1N1 strain, did not replicate as well after 2009.

“As a result, we enhanced our strain selection process ahead of the 2017-18 influenza season, and a new H1N1 LAIV strain with better replication in laboratory tests was selected and included in the vaccine,” Ambrose says. “A randomized clinical study evaluating post-vaccination antibody responses in US children demonstrated that the new 2017-18 H1N1 LAIV strain performed significantly better than the 2015-16 H1N1 LAIV strain that was associated with reduced effectiveness. Importantly, the antibody responses induced by the new H1N1 LAIV strain were comparable to responses observed with a highly effective H1N1 LAIV strain included in the vaccine before the 2009 influenza pandemic. The results of the study affirm that we have successfully improved our strain selection process, which we will apply to all strains in future seasons.”

The H1N1 component in 2015-16 (A/Bolivia strain) in particular was ineffective in the LAIV, but that component has been replaced (with A/Slovenia strain) in new formulations of the vaccine, according to AstraZeneca. As to how the new formulation will perform in comparison to its predecessor, there won’t be any data until after the 2018-19 flu season but a study of 200 children aged 2 to 4 years found responses to the new formulation were similar to those in earlier, highly effective LAIV formulations. The study compared administration of the 2015-16 FluMist formulation with the 2017-18 formulation, and antibody levels to the H1N1 strain increased 4-fold in 23% of participants after the first dose of the 2017-18 formulation compared to just 5% with the 2015-16 formulation. After the second dose, antibody rise was 45% in children who received the new formulation compared to 12% who received the old formulation.

At the ACIP meeting, CDC presented studies evaluating the effectiveness of LAIV, as well as traditional injected vaccines, in addition to data on how pulling the LAIV vaccine impacted vaccination rates. According to 

, flu vaccination rates did not change after FluMist was discontinued-at least not in Oregon.

 The study evaluated state-wide data comparing vaccination rates in children during the 2015-16 flu season and the 2016-17 season. While there were no significant changes noted in the overall vaccination rates from 1 year to the next, the researchers did note that children who had previously received a flu shot were more likely to return for 1 in the second year of the study, moreso than children who had previously received the intranasal vaccine.

, involving more than 12,000 children in Pennsylvania, found different results. In that study, researchers found a decline in the end-of-season vaccination rates among children once the LAIV was no longer available.

Administration for the reintroduced LAIV vaccine will be the same as before the change in formulation. Individuals aged 2 to 49 years who are healthy, non-pregnant, and not immunocompromised may receive the LAIV formulation, although 2 doses may be required in children aged younger than9 years based on previous influenza vaccination status.

1. Robison SG, Dunn AG, Richards DL, Leman RF. Changes in influenza vaccination rates after withdrawal of live vaccine. 

2. Fogel B, Hicks S. Influenza vaccination rates in children decline when the live attenuated influenza vaccine is not recommended. 

A change in the H1N1 component may have solved efficacy problems from prior formulations of the intranasal vaccine.

LAIV will return for next flu season

	The opioid crisis is in full swing, and young adults are among the top abusers of prescription drugs. Now, the US Food and Drug Administration (FDA) is taking a step to try and curb pediatric opioid use in an effort to prevent cases of abuse or overdose.

 restrict pediatric opioid prescribing, specifically, in the use of cough and cold medicines containing opioids for children.

 The agency announced the changes to its safety labeling on January 11. The changes affect opioid cough and cold medicines with codeine or hydrocodone for children aged younger than 18 years. The changes mean that these products can no longer be prescribed in children aged younger than 18 years because of the FDA’s concerns that the safety risks of these medications outweigh any potential benefits.

Recommended: Children still prescribed postop codeine despite warnings

	The FDA says the changes were made after extensive review of safety data and expert advice on the use of pediatric medications containing opioids. The new move 

expands previous restrictions put in place by the FDA in 2016

as a move last year to restrict the use of codeine and tramadol

 to treat pain or cough in children aged younger than 12 years.

	Typically, the FDA’s advisory committees have broken their recommendations on opioid use into 2 pediatric categories-ages 6 to 12 years, and ages 12 to 18 years. This new recommendation covers both groups.

	Tara Rabin, a spokesperson for the FDA, says the agency developed the recommendations based on an expert roundtable

 and a meeting of its Pediatric Advisory Committee.

	Rabin says pediatric providers should review the new recommendations and alter their treatment practices accordingly.

	“Healthcare professionals should be aware that the FDA is changing the age range for which prescription opioid cough and cold medicines are indicated. These products will no longer be indicated for use in children, and their use in this age group is not recommended,” Rabin says.

	Pediatrics isn’t the only population being targeted. The FDA is also updating labeling on adult medications, expanding the Black Box Warning about the risk of misuse, overdose, and addiction related to codeine and hydrocodone.

	“Given the epidemic of opioid addiction, we’re concerned about unnecessary exposure to opioids, especially in young children. We know that any exposure to opioid drugs can lead to future addiction. It’s become clear that the use of prescription, opioid-containing medicines to treat cough and cold in children comes with serious risks that don’t justify their use in this vulnerable population,” the FDA Commissioner Scott Gottlieb, MD, wrote in a statement on the changes: “It’s critical that we protect children from unnecessary exposure to prescription cough medicines containing codeine or hydrocodone. At the same time, we’re taking steps to help reassure parents that treating the common cough and cold is possible without using opioid-containing products.”

	The FDA acknowledges that some pediatric cough symptoms may require advanced treatment, but says most do not. The agency encourages parents who have outstanding prescriptions that fall under the new restriction to contact their clinician for updated instruction.

	For parents who feel their children need advanced care, Rabin says clinicians should offer guidance and alternatives.

	“Healthcare professionals should reassure parents that cough due to a cold or upper-respiratory infection is self-limited and generally does not need to be treated,” she says. “For those children in whom cough treatment is necessary, alternative medicines are available. These include over-the-counter (OTC) products such as dextromethorphan, as well as prescription benzonatate products.”

	When asked whether off-label uses will still be permitted, Rabin says there is still some discretion left to the provider.“ From the FDA perspective, with few exceptions, healthcare professionals generally may choose to prescribe or use a legally marketed human drug or medical device for an unapproved or uncleared use when they judge that the unapproved use is medically appropriate for an individual patient,” she says.

Next: 13 tips for tackling parental concerns

	More than anything, however, Rabin says that the FDA is hopeful that the new mandate will increase safeguards for children. 

	“It’s important that parents and healthcare providers have the best information available regarding safety and effectiveness of particular medications, as well as understand their risks, to inform the decisions they make about a child’s health,” Rabin says. “Among other priorities related to the opioid epidemic, the FDA is focused on decreasing exposure to opioids, including in children, and continuing to look at how opioid drugs that are already on the market are used, in both medical settings and also illicit ones, and take action where needed.”

	1. US Food and Drug Administration. FDA Drug Safety Communication: FDA requires labeling changes for prescription opioid cough and cold medicines to limit their use to adults 18 years and older. Available at: 

https://www.fda.gov/Drugs/DrugSafety/ucm590435.htm

. Published January 11, 2018. Updated January 22, 2018. Accessed February 5, 2018.

	2. Zimlich R. AAP recommends against codeine use. 

http://contemporarypediatrics.modernmedicine.com/contemporary-pediatrics/news/aap-recommends-against-codeine-use

. Published October 20, 2017. Accessed February 5, 2018.

	3. US Food and Drug Administration. FDA Drug Safety Communication: FDA restricts use of prescription codeine pain and cough medicines and tramadol pain medicines in children; recommends against use in breastfeeding women. Available at: 

https://www.fda.gov/Drugs/DrugSafety/ucm549679.htm

. Published April 20, 2017. Updated January 30, 2018. Accessed February 5, 2018.

	4. US Food and Drug Administration. Use of cough suppressants in children. Expert Roundtable meeting. April 27, 2017. Available at: 

https://www.fda.gov/downloads/Drugs/DrugSafety/InformationbyDrugClass/UCM570959.pdf

New FDA restrictions on medications for children that contain codeine and other opioids aim to prevent cases of misuse, abuse, and overdose.

Vol 35 No. 04