P    E    A    R    L    S
 
This document is provided as a post-conference review of topics covered during the April 28, 2018 Symposium at the Sheraton Universal Hotel. We have asked speakers to provide take-home pearls to share with you, which serve as review material for ABP MOC Part 2 credit.

Thank you again for your attendance. We look forward to seeing you again in 2019.
2018 ADVANCES IN PEDIATRICS SYMPOSIUM  - PEARLS
Michael T. Brady, MD, FAAP

TALES FROM THE RED BOOK 
 
PEARL 1. In an effort to improve completion of the complete series of the HPV vaccine in children prior to the onset of sexual debut, the wording of the new AAP recommendation for initiation of the HPV vaccine series will include the following wording "The AAP recommends starting the series between 9 and 12 years, at an age that the provider deems optimal for acceptance and completion of the vaccination series."  This replaces the following wording found in the 2015 Red Book and recently approved by ACIP in 2018 "recommends starting the series at age 11 or 12 years of age and states that vaccination can be administered starting at age 9 years. When HPV vaccine is begun at 9 or 10 years of age, other adolescent vaccines (e.g., MenACWY and Tdap) are still recommended to be administered only at 11 to 12 years of age."
 
Discussion:  The completion of the HPV vaccine series by adolescents in 2016 was 41% in females and 28% in males.  Reducing the number of doses needed for adolescents who initiated HPV vaccine series at < 15 years of age from 3 doses to 2 doses (with the second dose at least 6 months following the first dose of the HPV vaccine) should improve the completion rate.  In addition, there is evidence that initiating the first dose of the HPV vaccine at age 9 years (the earliest that the HPV vaccine may be given) can improve the likelihood of completing the HPV vaccine series before sexual debut.
 
References: 2018 Red Book and Preventive Medicine 2016;89:327-333.
 
PEARL 2. The live, attenuated influenza vaccine (LAIV) was NOT recommended for use for the 2016-17 and 2017-18 influenza seasons.  This prohibition of the use of LAIV for these 2 seasons was based on evidence of poor to no efficacy against H1N1 influenza seasons for 2 prior seasons.  The manufacturer presented studies to the CDC (ACIP) which showed that a new H1N1 strain to be used in LAIV to be used for the 2018-19 season had better replication in eggs and shedding in recipients than was noted for the H1N1 strain that was used for the 2 seasons with poor efficacy for LAIV against H1N1 strains.  Given this data, CDC (ACIP) stated that LAIV was an option for the 2018-19 season.
 
Discussion: The lack of availability of LAIV during the 2016-17 and 2017-18 influenza seasons did not adversely affect receipt of an influenza vaccine in children and adolescents.  There was a minimal increase in influenza vaccine uptake in children 6 months through 5 years of age and a minimal decrease in influenza vaccine uptake in 6 through 17 years of age.  The data presented by the manufacturer on shedding was limited to children of 2 through 3 years of age who were influenza vaccine naïve (either inactivated or live influenza vaccine).  Due to limitation to influenza vaccine naïve children, there was no ability to assess whether prior receipt of influenza vaccine might have been responsible for the poor efficacy of this live vaccine that requires replication in the nasal mucosa to stimulate protective immunity.  The AAP Committee on Infectious Diseases (COID) reviewed the evidence and concurred with ACIP that LAIV could be an option for influenza vaccine for the 2018-19 influenza season.  But since the lack of LAIV did not significantly impact vaccine uptake and there are still some unresolved about LAIV effectiveness, COID recommended to AAP Board that inactivated influenza vaccine (IIV) should be preferred.
 
References: COID 2018-19 seasonal influenza vaccine policy statement.  This will be published in September 2018.  However, as soon as the AAP Board approves the statement, an AAP News and/or a RED Book Online Alert will be published.
 
 
Michael T. Brady, MD, FAAP 
MATERNAL IMMUNIZATIONS: PROTECTING MOTHER, FETUS AND NEWBORN
 
PEARL 3. There has been association of Tdap or influenza vaccine given during pregnancy during any trimester and maternal, fetal abnormalities or infant hospitalization or mortality.  Tdap and the influenza vaccine are recommended for women during ALL pregnancies.
 
Discussion: During pregnancy, medication administration during pregnancy is typically limited to only essential medications due to a concern that medications administered during pregnancy could produce harm in the mother, the fetus or the newborn infant.  The CDC Vaccine Safety Datalink has monitored more than 413,000 pregnancies and determined that neither the influenza vaccine nor Tdap was associated with an increased risk in mothers, fetuses nor infants of adverse events including still births, premature births, fetal demise, infant hospitalizations nor infant mortality.  Rather, what has been determined is that influenza vaccine reduces influenza-like illness in pregnant women.  This is particularly important since pregnant women experience more severe disease if infected with influenza during pregnancy; and the risk for severe disease increases during the duration of the pregnancy.  Pregnant women who are immunized with the influenza vaccine during pregnancy have fewer still births and prematurely born infants.  Offspring of mothers who received influenza vaccine during pregnancy have reduced incidence of febrile episodes, respiratory tract infections and influenza compared to infants whose mother did not receive the influenza vaccine. Tdap given to pregnant women has been shown to be safe for mothers, fetuses and infants.  Infants whose mothers received Tdap during pregnancy have significantly fewer hospitalizations, and especially pertussis-associated hospitalizations in the first 6 months of life than infants born to mothers who did not receive Tdap during their pregnancy.  There is no evidence that repeated influenza vaccines or Tdaps during pregnancy has any additional adverse effects than receiving a single dose.  However, prior Tdaps do not provide the same level of protection of infants as when the Tdap is given during the infants pregnancy.
 
References : 2018 Red Book and Dodds L CMAJ 2007: 176:463-468; Louie JK NEJM 2010: 362: 27-3; Haberg SE NEJM 2013; 368: 333-340; Thompson MG Clin Infect Dis 2014; 58: 449-457; Regan AK Clin Infect Dis 2016; 62: 1221-1227; MMWR 2011; 60: 1193-1196 
 
PEARL 4. Vaccines in development that may soon be in clinical trials in pregnant women include RSV, group B strep and meningococcal B.
 
Discussion:   Success and safety of Tdap and influenza vaccines given to women during pregnancy has led to consideration of additional vaccines that might be able to prevent infections that cause disease in very young infants (prior to the ability of vaccines to provide adequate immunity to prevent disease). 
The success of palivizumab in reducing RSV infection in select high-risk children has provided a proof of concept that specific RSV antibodies can protect against RSV disease.  While the high risk children can benefit from palivizumab administration, the majority of children hospitalized for RSV bronchiolitis are previously healthy full term infants.  These infants are not recommended to receive palivizumab.  Providing palivizumab to all 4 million children in the annual birth cohort would be cost prohibitive.  However, a reasonably priced RSV vaccine might be able to be administered to pregnant women in order to provide RSV protective immunity though the most vulnerable period of time, i.e. the first 3 months of life. 
Early onset group B strep infections have been dramatically decreased by screening and prophylactic antibiotics given during labor.  However, some at risk infants may be missed and late onset group B strep disease is not reduced by prophylactic antibiotics given during labor.  There is evidence that a risk factor for perinatal group B strep disease is a lack of maternal antibodies.  Maternal group B strep immunization could provide protection against both early and late onset disease. 
The highest incidence of meningococcal disease, and especially meningococcal B disease, is in the first year of life with the majority occurring in the first 4 months of life.  The recently licensed MenB vaccine if given to pregnant mothers might be able to provide protective antibodies to reduce meningococcal disease in young infants.
 
References: Omer SB NEJM 376: 1256-1267, 2017; Glenn GM J Infect Dis 2016; 213; 411-422; Edmund KM Lancet 379:547-556, 2012; Heyderman RS Lancet Infect Dis 16: 546-555, 2016
 
 

 
Alice Kuo, MD, PhD, Med., FAAP

HOW TO HANDLE PARENTS ON SOCIAL MEDIA 
SEX, DRUGS, AND ROCK 'N' ROLL FOR A NEW GENERATION - THE CONCEPT OF EMERGING ADULTHOOD 

 
 
PEARL 5. Use the HEADSSS assessment to get a more extensive social history for emerging adults (18-25 yo).  
 
Discussion: Remember, they are engaging in similar high-risk behaviors as adolescents, just now without parental supervision. The HEADSS assessment can uncover issues such as multiple sexual partners, substance use, mental health issues that focusing just on the USPSTF guidelines might not reveal.
 
Reference: Weinstein S, Bixenstine P, Karlin D, Saab F, Schuttner L, Zen A, and Kuo AA. (2016). Care of the emerging adult. In Care of Adults with Chronic Childhood Conditions: a Practical Guide, M Pilapil, DE DeLaet, AA Kuo, N Sharma and C Peacock, eds. Springer: New York, pp. 17-35.

PEARL 6. A paradigm shift needs to happen for primary care of emerging adults, including exploring healthy relationships and reproductive planning, thinking biopsychosocially to understand sources of stress and anxiety, and engaging in motivational interviewing techniques to address substance use.
 
Discussion: Primary care of emerging adults should promote healthy behaviors for the long-term, to set emerging adults on a trajectory for optimal health in the future.
 
Reference: Weinstein S, Bixenstine P, Karlin D, Saab F, Schuttner L, Zen A, and Kuo AA. (2016). Care of the emerging adult. In Care of Adults with Chronic Childhood Conditions: a Practical Guide, M Pilapil, DE DeLaet, AA Kuo, N Sharma and C Peacock, eds. Springer: New York, pp. 17-35.


Marshall "Buzz" L. Land Jr., MD, FAAP

ABP - MOC OVERVIEW AND INNOVATIONS 
 
   
 
PEARL 7. MOC points can now be obtained for CME activities.
 
 
PEARL 8.  Beginning in 2019, pediatricians have the option of doing a continuous, take-at-home assessment (MOCA-Peds) rather than the proctored exam for Part 3 MOC credit.
 
INNOVATIONS AND IMPROVEMENTS IN MOC: AN OPPORTUNITY FOR YOUR IDEAS 
(Breakout session) 
 
PEARL 9.  The overwhelming majority of those pediatricians who participated in the new MOCA-Peds pilot would choose to do this format rather than the every 10 year proctored exam.
 
PEARL 10.  The average total time spent for the year (including time spent studying, looking up reference materials, taking the questions, reviewing the feedback) by pediatricians participating in the MOCA-Peds assessment was less than 4 hours.
 
Reference for all of these is the ABP website ABP.org

Mark Del Monte, JD

STAY IN THE BOAT - ADVOCACY FOR CHILDREN IN TURBULENT TIMES
 
 
 
PEARL 11. Advocacy for children is an integral part of the profession of pediatrics and always has been.
 
Discussion: From the earliest days of pediatrics, advocacy has been an important foundational part. Children need a "cadre of physicians" dedicated to their care.  This is also true of the American Academy of Pediatrics where advocacy was a critical element of its formation.  
 
Reference: PEDIATRICS Vol. 112 No. 2 2003

PEARL 12.Challenges of gun violence, bias and discrimination, opioid misuse, care of immigrant children and access to appropriate health insurance are no different from previous challenges to children's.  
 
Discussion: Advocacy for passage of Medicaid and CHIP at the federal level, access to immunizations, or reducing infant mortality are examples of hard challenges that have been addressed through advocacy. Though complex and difficult, today's challenges can be solved by pediatricians with other child health advocates pushing to make a difference.  
 
 


Paula J. Whiteman, MD, FACEP, FAAP

MINDFULNESS FOR MEDICAL PROFESSIONALS


 
 
 
 
 
 
PEARL 13. Burnout may lead to depression, substance or alcohol abuse, broken relationships, and even suicide.
         
The incidence of suicide in physicians is higher than the general population. About 400 physicians commit suicide each year.
 
 

PEARL 14. Resilience is multifactorial. Applying the concept of 'strategic stopping' allows one to stop and recharge as opposed to continuing to endure stressors. Resilience allows one to develop the capacity to recover from difficult situations and includes learning self-management skills. Feeling that one has a connection to meaning and purpose is another tool of resilience.
 

Edward Curry, MD, FAAP

34 YEARS OF PEDIATRICS - CASES, LEARNINGS AND PERSPECTIVES
 
 
 
 
 
PEARL 15. TOURETTE'S SYNDROME

A. Is a muscular disorder

B. Is five times more common in girls than boys

C. Coprolalia occurs in more than 50%

D. Occur in 1:100 children

 
The correct answer is: D
  • A. Tourettes is a neurologic disorder
  • B. T.S. is 5 times more common in boys and girls
  • C. Coprolalia occurs in only 10% of patient with T.S.
Reference: Singer HS. "Tourette syndrome and other tic disorders". Handb Clin Neurol. 2011;100:641-57. 
Singer HS. "Tourette's syndrome: from behaviour to biology". Lancet Neurol.2005 Mar;4(3):149-59.
 
 
 
 
PEARL 16. AUTISM SPECTRUM DISORDER
A: Prevalence has remained stable over the past 20 years.
B: DSM-5 Criteria for ASD, the diagnosis of Asperger's Syndrome remains.
C: DSM-5 Criteria requires both social communication and restricted/fixated interest to be present for diagnosis.
D: Decreased risk of ASD in mothers with gestational diabetes under 26 weeks gestation.
 
The correct answer is: C
  • A. Prevalence of ASD has been increasing.
  • B. DSM 5 eliminated the diagnosis of Asperger which is now under the umbrella of Autism Spectrum Disorder
  • D. Increase risk of ASD in Mother with Gestational Diabetes under 26 week

 

References:
A. Deborah L. Christensen, PhD1; Prevalence and Characteristics of Autism Spectrum Disorder Among Children Aged 8 Years - Autism and Developmental Disabilities Monitoring Network, 11 Sites, United States, 2012 MMWR Surveill Summ. April 1, 2016 / 65(3);1-23
B. American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (Fifth ed.). Arlington, VA: American Psychiatric Publishing. pp. 5-25.
D. Anny H. Xiang, PhD; Association of Maternal Diabetes With Autism in Offspring, JAMA April 14, 2015, Vol 313, No. 14