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Imaging, Neuroscience, Patient Care, Pediatrics, Research

Stanford-led study suggests changes to brain scanning guidelines for preemies

Stanford-led study suggests changes to brain scanning guidelines for preemies

preemieOne big challenge of having a premature baby: the uncertainty. With good medical care, a great many preemies do very well, but some face long-term disabilities, medical complications and developmental delays, and others, sadly, die in infancy. Unfortunately, doctors can’t always tell how a baby will fare in the long term.

A new study, led by a Stanford team and conducted at 16 sites around the country, is part of the ongoing effort to change that. The researchers examined what type and timing of brain scans give doctors the greatest ability to predict preemies’ neurodevelopmental outcomes in toddlerhood. The research, published online today in Pediatrics, found that for babies born more than 12 weeks early who survive to near their original due dates, brain scans performed near their due date are better predictors than scans done near birth.

Most preemies already get at least one brain scan. That’s because national guidelines recommend that preemies’ doctors perform a cranial ultrasound seven to 14 days after birth to look for immediate problems such as bleeding into the brain. (Ultrasound is a good fit for the needs of fragile infants: Babies’ fontanelles provide “acoustic windows” to the brain, and ultrasound is non-invasive, uses no radiation, requires no sedation, and can be performed with a portable scanner brought to the bedside.) Some prior research has shown that these early scans can also give information about an infant’s risk of cognitive, motor and behavioral deficits or delays in childhood, but the predictive value of these early scans can be fairly low.

The new study examined both cranial ultrasound and MRI performed close to the baby’s due date, which is also when most preemies are ready to go home from the hospital. A lot changes in the brain during those first few weeks, perhaps explaining why later scans did a significantly better job of predicting which children would have persistent neurodevelopmental problems when the doctors checked in with them at 18 to 22 months of age.

“Neuroimaging may help us understand what a child’s outcome may look like, and ultimately help us focus our attention in terms of the type of follow-up and specific interventions that could best support a child after discharge from the hospital,” said Susan Hintz, MD, the study’s lead author and a neonatologist at Lucile Packard Children’s Hospital Stanford.

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Nutrition, Pediatrics, Research, Stanford News

Taking a bite out of food allergies: Stanford doctors exploring new way to help sufferers

Taking a bite out of food allergies: Stanford doctors exploring new way to help sufferers

allergen powdersPeople with food allergies and their families live lives of unremitting worry.  They are perfectly healthy unless they eat an allergen and then suddenly they are at death’s door.

When 9-year-old Maya Bodnick went on a skiing trip with her cousin, her aunt let her pick out some malt balls from a candy bin.  Within minutes her face began to swell, her throat hurt, and she vomited. When Tessa Yates Grosso was eight, she ate some spring rolls that turned out to contain wheat, which was one of her allergies – soon she began to lose consciousness. Her mother watched, terrified, as a medical team struggled to revive her by injecting two syringes of epinephrine and an array of other drugs. When my son Kieran was a toddler, he got hold of a cookie that contained eggs and nuts – both of which he was allergic to – and although I got the cookie out of his mouth before he bit down, and I rinsed his mouth out with water, he stopped breathing on the way to the hospital.

But for all three kids and their families, that life is now over after participating in a trial of a radical treatment for food allergies, headed by Kari Nadeau, MD, PhD. The treatment, known as oral immunotherapy, retrains the immune system by giving the patients micro-doses of the allergen and gradually working up – over months or years – to a full serving.  Nadeau has recently discovered that oral immunotherapy actually causes epigenetic changes – physical changes in patients’ genes that affect the way they are expressed.

Food allergic people are initially astonished – and terrified – by the suggestion they should eat the foods that had once poisoned them. But it turns out that – no matter how severe the allergy – everyone’s immune system can be retrained. Moreover, Nadeau discovered, the treatment works equally well for children and adults. At the newly created Food Allergy Center, Nadeau and her team will continue to research not only oral immunotherapy, but treatments for food allergies that do not involve eating the food. The center will also treat food sensitivities and intolerances, which patients frequently confuse with food allergies.

Read more about Maya, Tessa and Kieran’s treatment – and their new lives – here.

Melanie Thernstrom is a freelance writer.

Previously: Stanford Medicine magazine traverses the immune system, Simultaneous treatment for several food allergies passes safety hurdle, Stanford team shows, Researchers show how DNA-based test could keep peanut allergy at bay, A mom’s perspective on a food allergy trial and Searching for a cure for pediatric food allergies
Photo of allergen powders by Art Streiber

In the News, Medicine and Society, Mental Health, Pediatrics

Advice and guidance on teen suicide

Advice and guidance on teen suicide

12389778613_ed6496a72f_zNot again, I thought as I read the opening line of a recent Palo Alto Weekly op-ed: “As a community we are grieving.” Reading further, my fears were confirmed: Now, additional teens have died by suicide in this California city.

A handful of years ago, I was a reporter for the Weekly. I was so grateful to cover city government, rather than schools — what a pressure cauldron, I thought at the time. As a teen, I too struggled with perfectionism, the drive to earn straight As and attend a top college, while excelling at extracurriculars. How awful to be surrounded by others like me, I thought.

Of course this is a one-dimensional glimpse at the problem. Suicides aren’t explained by perfectionism or academic stress and they certainly aren’t a Palo Alto-only problem. Shashank Joshi, MD, a child psychiatrist with Lucile Packard Children’s Hospital; Palo Alto Medical Foundation physician Meg Durbin, MD; and Sami Harley, a mental-health specialist, discuss this and other issues in a piece written to offer guidance to the saddened community. “Suicide does not have a single ’cause.’ Many factors and life circumstances must be taken into account,” they write.

They go on to clarify misperceptions about depression, an underlying condition that can make suicide or suicidal thoughts more likely:

Depression isn’t something you can or must just ‘deal’ with on your own… Though positive thinking can be an important part of having a healthy and resilient life, positive thinking by itself does not treat clinical depression. Talk therapy with antidepressant medications, if needed, are the only proven treatments for teen depression.

These local experts have held depression education and suicide-prevention training sessions with several thousand students at the two Palo Alto public high-schools since 2010. “Solutions must come from all those who interact with youth, including schools, parents and family, friends, medical and mental health providers, community and faith leaders and mentors,” they conclude.

Previously: “Every life is touched by suicide:” Stanford psychiatrist on the importance of prevention, Lucile Packard Children’s Hospital partners with high schools on student mental health programs  and Volunteers watch train crossings to prevent suicides
Photo by jimmy brown

Aging, Chronic Disease, Pediatrics, Research

"The child is father of the man": Exploring developmental origins of health and disease

"The child is father of the man": Exploring developmental origins of health and disease

3801281145_1f3fb2c8bf_z Among scientific communities, there is a small but growing segment of research concerned with “DOHaD” – the developmental origins of health and disease. The work usually focuses on how childhood, including birth, the fetal period, and sometimes even pre-conception events, affects a person’s lifelong health and well-being and is the topic of a recent article (subscription required) published in Pediatrics by researchers at the Eunice Kennedy Shriver National Institute of Child Health and Human Development. The phrase “the child is father of the man” is a line from William Wordsworth’s “My Heart Leaps Up” and also the title of the article, whose authors added, commendably, “and the mother of the woman.”

DOHaD gained acceptance within the medical community starting with the “Barker Theory” in 1995, when David Barker, MD, showed that babies with low birth weights were at higher risk for coronary heart disease later in life. Prior to his work, the dominant model was that the health of those who survived childhood without major disease or disability was sort of “reset” in adulthood, to decline from then into old age. This is increasingly understood to be a simplistic model.

Resistance to the idea stems from the fact that links between child and adult health are associative and not proven to be causative; therefore, the article’s authors Alan E. Guttmacher, MD, and Tonse N.K. Raju, MD, call for scientists to do more mechanistic research investigating causation, and “more importantly, to devise treatments and preventions, for the many “adult-onset” conditions that actually are rooted in much earlier exposures and events.” Such research is difficult because of the incredible number of variables that occur over an entire lifespan, and even within the category “perinatal risk factors.”

In the piece, the authors describe the importance of DOHaD and how a better understanding of it could affect pediatrics and health care:

Arguably the most important advance in the health care of children, and in establishing pediatrics as a medical specialty, was the cultural awakening that children were not simply small adults. Ironically, DOHaD greatly expands the impact of pediatrics by reversing that shift and focusing on how children actually are smaller versions of the adults they will become.

Once the biological and behavioral pathways that underlie DOHaD are identified and understood, the role of pediatrics should expand in fundamental and powerful ways. Anticipatory guidance in the future will not be just about the next 6 weeks or 6 months or even 6 years of the child’s life, but the entire life span. The pediatrician and other children’s health care providers will inform parenting and behaviors, including diet and exercise, and even prescribe presymptomatic medication targeted to the individual child. The pediatrician will become the gatekeeper to lifelong health.

Photo by Brad Brundage

Parenting, Pediatrics, Stanford News, Technology

Using texting to boost preschool reading skills

Using texting to boost preschool reading skills

Stanford researchers find promising results from program that uses text messages, like this one, to support parents in helping their children learn to read.

A new program that sends weekly texts to parents to  remind them to engage in simple activities to boost their preschooler’s literacy skills appears to help children read. The program, called READY4K! and developed at the Stanford School of Education by education professor Susanna Loeb, PhD, and graduate student Benjamin York and tested at preschools at the San Francisco Unified School District, underwent an 8-month pilot conducted in 2013-2014. In a release describing the pilot program, Loeb described the challenges faced by parents:

The barrier to some of these positive parenting practices isn’t knowledge or desire, but it’s the crazy, busy lives… It’s difficult to have the time or focus to make all these choices as parents, and we’re helping parents do what they know they should do and what they want to do.

The program enrolled 440 parents, half of whom got literacy building tips by text and the other half got placebo announcements about the district. Parents who received literacy tips were more likely to engage in literacy activities such as reading to their children, reviewing rhyming words and playing word puzzles. Moreover, the authors note in a report that the preschool-age children scored higher on literacy assessment tests at the end of the pilot program than those whose parents had not gotten weekly texts. In the release, a representative of SFUSD notes:

I believe that all families want to be involved in their child’s learning, but many feel they don’t have the time or perceive that supporting their child’s learning might be labor intensive or something that the teacher is better at. The texting program offered some simple nuggets around literacy strategies and validated that families do want to be involved, if given information that is easy to receive and useful.

The READY4K! program was developed with accessibility and scalability in mind. York and Loeb carefully parsed early childhood literacy standards from the state into text-size bites, with the aim that they would be helpful and not add another layer of stress to the already busy parents’ lives.

SFUSD has expanded the program this year to all preschool and kindergarten parents. Loeb and York have heard from other interested school districts and have also added early math skills into the weekly texts.

Previously: Reading, book sharing less common in immigrant families, Stanford study finds, Researcher shows how preschoolers are, quite literally, little scientists and This is your 4-year-old on cartoons
Photo by L.A. Cicero/Stanford News Service

Obesity, Parenting, Pediatrics, Research

Study shows that toddlers benefit from rules about eating habits

Study shows that toddlers benefit from rules about eating habits

toddler_eatingA recent study from pediatrics researchers at the University at Buffalo suggests that toddlers who are faced with parental rules about what to eat develop better eating habits later in their childhood, regardless of the self-restraint they demonstrate. The connection between self-restraint and eating habits has been studied widely in adults and adolescents, but this research is among the first to investigate it in very young children.

The findings suggest that self-restraint in two year-olds doesn’t itself lead to healthier habits by the time the child is four; it must be combined with parental rules about eating. Neha Sharma, a co-author of the paper, explained the significance when presenting the research at ObesityWeek 2014 in Boston, as quoted in a University of Buffalo news release:

It is amazing to see that a parental rule about which types of food a child can and cannot eat could have such a great impact on child eating habits. Without these boundaries set by caregivers, the benefits of high self-regulation on weight gain and childhood obesity could be diminished. This illustrates just how important parental involvement is in influencing child eating habits.

Seventeen percent of American children age 2-19 are obese, as are nearly 35 percent of adults, according to the Center for Disease Control and Prevention. Obesity is well-known as a pressing public health issue, and children who are obese are much less likely to attain healthy weights as adults.

Furthermore, a study published this week in Pediatrics suggests that obese youth are very likely to become obese teens, contrary to a popular idea that overweight adolescents have “baby fat” that will disappear with puberty. Researchers found that a child’s weight at age 11 is a good indicator of his or her weight at age 16: 83 percent of obese fifth-graders remained obese, and 87 percent of normal-weight fifth graders remained at a normal weight five years later.

By setting guidelines and rules for toddlers, parents and caretakers can play a key role in guiding society’s very youngest members towards healthy eating habits with life-long impacts.

Previously: No bribery necessary: Children eat more vegetables when they understand how food affects their bodies, Examining why instilling healthy eating and exercise habits in children may not prevent obesity later in life and How to combat childhood obesity? Try everything
Photo by David Goehring

Patient Care, Pediatrics, Stanford News

Eightysomething "neonatology superhero" still at it

Eightysomething "neonatology superhero" still at it

archive Sunshine pic

Several years ago, as I’ve recalled here before, I was assigned a story for Stanford Medicine magazine on the evolution and importance of children’s hospitals – and there was one interview I was particularly excited to score. It was with neonatologist Philip Sunshine, MD, a physician I wanted to talk with in part because of how long he had been here and how much he knew about children’s hospitals and the field of pediatrics, and in part because he had what I considered one of the most amazing last names for a doctor ever. (Dr. Sunshine? How cool is that?)

Fast forward to earlier this week, when I came across a Healthier, Happier Lives blog post noting that Sunshine has been caring for preemies for more than five decades now. Has been – as in, still is! At the age of 84, he’s still at it, as I learned from the piece:

Sunshine started at Stanford in the 1950s, back when the Stanford University School of Medicine was located in San Francisco. What this gentle giant has accomplished since then not only forms a narrative of modern-day neonatal care, but also provides a legacy for modern medicine to follow.

Sunshine is the discoverer of a rare and deadly metabolic disorder, a member of the team that first implemented mechanical ventilation at Stanford, and originator of a scoring system for selecting infants needing assisted ventilation. He has authored several groundbreaking research papers and has received countless awards, including the prestigious Virginia Apgar Award in Perinatal Pediatrics from the American Academy of Pediatrics. The list of his accomplishments continues — all very deep, all very scientific and all very lifesaving.

Burned out from glory? Nope. This pioneer is still excited to come to work — even on days he isn’t on duty — to check in on his patients in the Packard Intermediate Care Nursery and keep in touch with colleagues.

Oh, and as for my interview with Sunshine back in 2006: He was knowledgeable, helpful (he plucked an out-of-print book on a Canadian hospital from his bookshelf and let me take and read it for background), easy to talk to, and clearly a kind man. Just what you would expect with someone in his line of work. Or with that last name.

Previously: A pioneer of modern-day neonatology and Neonatologist celebrates 50 years of preemie care
Photo courtesy of Lucile Packard Children’s Hospital

Global Health, Pediatrics, Public Health, Public Safety, Research, Stanford News

Child-mortality gap narrows in developing countries

Child-mortality gap narrows in developing countries

MATERNAL & INFANT MORTALITY IN DEVELOPING COUNTRIESChild-mortality rates in developing countries are decreasing. In 2012, the United Nations estimated that worldwide mortality rates for children under the age of five have dropped by 47 percent since 1990. But what does this decline indicate about the mortality gap between the poorest and wealthiest families within those countries?

Stanford researcher Eran Bendavid, MD, answers this question in a study published today in Pediatrics. As our press release describes:

To compare wealth status and under-5 child-mortality within a country, Bendavid used data from the demographic and health surveys for 1.2 million women living in 929,224 households in 54 developing countries. The women provided information about their children’s survival status.

His findings showed that the child-mortality gap has narrowed between the poorest and wealthiest households in the majority of over 50 developing countries between 1995 and 2012.

The converging mortality gap was mostly driven by the fact that under-5 child-mortality rates declined the fastest among the poorest families. Bendavid said the finding supports international aid efforts that target communicable diseases such as malaria, diarrhea and respiratory illness that disproportionately affect the poorest families in developing countries. Davidson Gwatkin, a senior fellow at the Results for Development Institute who was not involved in the study, agreed saying:

Dr. Bendavid’s study is an important contribution to knowledge about child health improvements in the developing world … It makes a persuasive case that these improvements have often begun to benefit the poor even more than the better-off.

Yet not all the developing countries experienced this positive trend. In a quarter of the countries involved in the study, under-5 mortality inequality actually increased. Bendavid found a common theme among these countries: poor governance.

Bendavid noted in the release that his findings are important for making decisions about how to effectively promote health equality by prioritizing global health investments. He said:

We have the technologies, we have the means, we have the know-how to reduce child mortality dramatically … Even for such low-hanging fruit, however, implementation is not always easy. You have to have government that enables basic safety, and the ability to reach poor and rural communities that benefit from these kinds of programs.

Previously: Foreign health care aid delivers the goods, Foreign aid for health extends life, saves children, Stanford study finds, Stanford researchers say evidence doesn’t support claims that international aid is wasted and PEDFAR has saved lives — and not just from HIV/AIDS, Stanford study finds,
Photo by: United Nations Photo

Chronic Disease, Obesity, Parenting, Pediatrics

Getting a handle on screen time: tips for parents

Getting a handle on screen time: tips for parents

child watches TV

Most parents know that they should keep screen time to a minimum, but how much is too much? Moreover, with the advent of many educational apps for tablets and smartphones, it’s easy as a parent to get confused about managing their childrens’ use of televisions, computers and tablets. Watching “Frozen” for the hundredth time is clearly entertainment, but what about playing with a Dora the Explorer app that teaches vocabulary? Should that count against a child’s screen time “budget?”

The Lucile Packard Children’s Hospital Stanford blog, Healthier, Happier Lives, had a post earlier this week that offers concrete tips from Thomas Robinson, MD, MPH, director of Packard’s Center for Healthy Weight. Robinson notes that educational screen time doesn’t need to count toward entertainment screen time, which he recommends keeping to less than an hour a day. But he cautions that parents should distinguish between real educational programs and entertainment disguised as education.

He also says that it’s easier to get kids to follow screen-time rules if parents are judicious about their own screen use (this includes time in front of a computer or with a smart phone, as well as TV time). One of the key reasons to turn off the TV (and other screens) is to avoid bad habits associated with screen time like eating high-fat, high-sugar snacks, especially while in front of a TV or computer. Another is simply to get kids to move more and be more active.

The bottom line? Robinson says:

More than anything else, just having family rules about how much, what, when, where, and with whom is the most important step in making screen time and technology work for your family, instead of against it.

Previously: Examining the effects of family time, screen time and parenting styles on child behavior, Childhood obesity expert to parents: Reduce your child’s screen time and Study: Too much TV, computer could hurt kids’ mental health
Photo by Vidmir Raic

Patient Care, Pediatrics, Research, Stanford News

Better communication between caregivers reduces medical errors, study finds

Better communication between caregivers reduces medical errors, study finds

Miscommunication between caregivers is one of the largest causes of medical errors, but a new study published this week in the New England Journal of Medicine suggests that the problem is at least partly preventable.

The study at nine children’s hospitals, led by Boston Children’s Hospital and including our own Lucile Packard Children’s Hospital Stanford, tested the effects of a standardized method for medical residents to hand off information about their patients at shift changes. Shorter shifts for residents have increased the number of such hand-offs, putting the hand-offs themselves under more scrutiny in recent years.

At each participating hospital, medical residents were trained to use an acronym that reminded them what information to share about each patient, and in what order. The hand-off process included both oral and written communication, and ended with the person who was receiving the information repeating back a summary of what was shared with the person who gave it. The program also included other supports to ensure that the hand-off procedure was embedded in the hospital’s culture and did not have a negative effect on the doctors’ overall workflow.

The participating hospitals reduced their rate of medical errors by 23 percent, and preventable adverse events dropped by 30 percent. From a Boston Children’s press release about the research:

“Because we know that miscommunications so commonly lead to serious medical errors, and because the frequency of handoffs in the hospital is increasing, there is no question that high-quality handoff improvement programs need to be a top priority for hospitals,” says [lead study author Amy] Starmer. “It’s tremendously exciting to finally have a comprehensive and rigorously tested training program that has been proven to be associated with safer care and that meets this need for our patients.”

The program tested in the new research is available for free to any hospital that wants to implement it.

Previously: New study shows standardization makes hospital hand-offs safer, Less burnout, better safety culture in hospitals with hands-on executives, new study shows and Automated safety checklists prevent hospital-acquired infections, Stanford team finds

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