Archives for January 2020

Screening for Postpartum Depression and Anxiety: A Perfect Pediatric Opportunity!

January 20, 2020 by
Jack Levine, MD, FAAP

Jack Levine, MD, FAAP

Dr. Levine is a pediatrician at Kew Gardens Hills Pediatrics and an Executive Committee member of the National AAP Section on Developmental Behavioral Pediatrics. 

Project TEACH has been working with pediatric practices in New York State since 2010. The project, funded by the New York State Office of Mental Health, has supported and strengthened the critical role that New York State pediatric primary care providers (PCP’s) can play in the early identification and treatment of mild-to-moderate mental health concerns for children ranging in age from 0 to 21.
One component of the Project TEACH /NYS American Academy of Pediatrics partnership in 2019 is a series of monthly newsletters touching on topics of concern to pediatricians and to parents.
2020 is the perfect time to begin screening for postpartum depression in the pediatric primary care setting! The American Academy of Pediatrics (AAP) recently published an extensive and comprehensive policy on “Incorporating Recognition and Management of Perinatal Depression into Pediatric Practice.” According to the AAP, pediatric providers can use CPT code 96161 and bill with the infant’s visit. New York State Medicaid billing guidance can be found at https://www.health.ny.gov/health_care/medicaid/program/update/2016/aug16_mu.pdf. Pediatric providers see new mothers earlier and more frequently than other physicians, giving multiple opportunities to assess and screen parental mental health.
Perinatal Mood and Anxiety Disorders: Different Terminology
Anxiety is a common characteristic of mothers’ feelings both during and after pregnancy and is very common in postpartum depression. Additionally, depression can effect up to 20% of pregnant woman. Along with “baby blues” and postpartum depression and anxiety disorders there is also psychosis, obsessive-compulsive disorder and PTSD. Fathers may also develop postpartum depression.
Why screen?
Postpartum depression is common (8%-25%) and in some low income populations may include close to 50% of all new mothers! It is the most common cause of infant toxic stress in the United States. There are significant and highly detrimental effects to developing infants (Table 1). Screening helps assess the baby’s environment and to establish a positive helpful relationship with the family.
Table 1. Effects of Postpartum Depression on Infants
Decreased breastfeeding
Failure to thrive
Developmental delay
  • Cognitive deficits
  • Less language stimulation
  • Less play time
  • Less reading stimulation
  • Less engagement with mother
School problems
Sleep problems
Mental health concerns
  • Social withdrawal
  • Fussy, irritable
  • Poor self control, impulsivity
  • Anxiety/depression
  • Attachment disorders
  • Aggression
Poor safety: car seats, plug covers, sleep
Over/under use of health care and ER
Difficulty managing health conditions
What to ask at every visit?
Assessing the risk factors for postpartum depression should be part of every well visit (Table 2). Maternal history of mood disorders and/or anxiety is an important risk factor and should be carefully assessed. Discontinuation of anti-depressant medication during pregnancy is a particularly important risk factor.
Table 2. Risk Factors for Postpartum Depression
Psychosocial Risk Factors
  • Poverty
  • Maternal chronic illness
  • History of depression, anxiety, mood disorder, substance abuse
  • Adolescent pregnancy
  • Social isolation
  • Stressful life events, miscarriage
Infant behavior
  • Decreased activity
  • Increased crying
  • Poor feeding
  • Failure to thrive
  • Sleeping problems
  • Increased accidents
Maternal behavior (observed or expressed by mother, father, grandparents)
  • Depressed affect
  • Sleeping more or trouble sleeping
  • Lack of enjoyment of usual activities/avoidance of usual activities
  • Withdrawal from family
  • Neglect of newborn or other children
  • Questions reflecting self-doubt/ severe anxiety
  • Inaccurate expectations of behavior and/or development
  • Punitive child rearing attitudes or discipline
  • Irritable/disruptive in office/frequent visits
Infant risk factors
  • Prematurity
  • Congenital problems
  • “Vulnerable child” syndrome
  • Fussy temperament
When to screen and what tools are available? 
Depressive symptoms peak at 6 weeks, 2-3 months and 6 months.  “Baby blues” usually resolve by two weeks so that earlier screening may over identify, but post-partum depressive symptoms can be delayed or persist for up to one year or longer!  Screening at one month, 2 months, 4 months and 6 months is recommended in the new AAP policy. Additional screening at 2 weeks and one year can be added. The Patient Health Questionnaire (PHQ-2, PHQ-9) or the Edinburgh Postnatal Depression Scale (EPDS) are commonly used, readily available, well researched, easy to administer, free, and have been translated into many languages (See References).
The EDPS has 10 questions and includes both anxiety and suicidal intent. The PHQ-2 is brief and contains only two questions. The PHQ-9 (which also includes suicidal intent but not anxiety) can be given alone or with the PHQ-2 to determine the extent of depression. The Survey of Well-Being of Young Children (SWYC) is a screening instrument that assesses a broad range of issues including maternal depression (PHQ-2 and EPDS), other family risk factors and child development and behavior.
Remember: Whenever inquiring about postpartum depression there must be a determination of suicide intent and safety of the mother and infant.
What are available resources?
Treatment for postpartum depression must include both treatment for the mother and the mother-infant dyad. Reassurance and parent education can be provided along with specific referrals. Medication is usually not needed but can be provided by obstetricians, internists or psychiatric providers. A pediatric office should have plans available for the rare event of emergency referral (911) or in case of safety issues.
Providers can use Project TEACH’s Maternal Mental Health Initiative (MMHI) – https://projectteachny.org/mmh/ for direct access to expert psychiatrists in maternal mental health, and for assistance with linkages to care and supports in the community. You can also access training – including two online trainings, “Diagnosis and Treatment of Depression during Pregnancy” and “Screening and Treatment of Postpartum Depression.”
Resource material, like the flyer shown here, and guidance for both providers and parents are available through the Postpartum Resource Center of NY www.postpartumny.org and Postpartum Support International www.postpartum.net. Resource material should be available for immediate referrals. Appointments should be confirmed in the pediatric office and frequent follow-up provided. Early treatment results in the best outcomes for mother and baby and should be obtained as quickly as possible (within a day or two).
Identifying and treating postpartum depression are effective ways to ensure optimal early infant brain development – which is after all, why we all do what we do!
References:
  1. Earls MF, Yogman MW, Mattson G, et al; AAP Committee on Psychosocial Aspects of Child and Family Health. Incorporating Recognition and Management of Perinatal Depression Into Pediatric Practice. Pediatrics. 2019;143(1):e20183259PHQ-2
  2. S. Kurtz, J Levine, M. Safyer. Ask the Question: Screening for Postpartum Mood and Anxiety Disorders in Pediatric Primary Care. Curr Probl Pediatr Adolesc Health Care. 2017: 47(10) 241-253.
  3. PHQ-2 download: https://brightfutures.aap.org/Bright%20Futures%20Documents/PHQ-2%20Questionnaire.pdf
  4. PHQ-2 scoring: https://brightfutures.aap.org/Bright%20Futures%20Documents/PHQ-2%20Instructions%20for%20Use.pdf
  5. PHQ-9 download: https://projectteachny.org/wp-content/uploads/2017/09/phq9_adult.pdf  
  6. Edinburgh Postnatal Depression Scale download: https://projectteachny.org/wp-content/uploads/2017/09/Edinburgh_Postnatal_Depression_Scale.pdf
  7. Survey of Well-Being of Young Children: https://www.floatinghospital.org/the-survey-of-wellbeing-of-young-children/overview

 

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Dealing with Climate Grief

January 9, 2020 by
Steven J. Goldstein, MD, FAAP

Steven J. Goldstein, MD, FAAP

(Dr. Steven J. Goldstein, MD, FAAP is a pediatrician in Brooklyn and Queens.  He is the immediate past president of the NYS AAP Chapter and serves as co-chair of its Pediatric Council and Committee on Environmental Health)

     Committed pediatricians address the problems and consequences of gun violence, hunger, homelessness, immigration status, healthcare coverage, and anti-vaccine sentiment daily, and there is progress, albeit slow, on many fronts.  But there is an over-riding issue with little progress being made that will affect all of us, and children disproportionately, and is inescapable on the daily news.  I am referring to Climate Change.
     As large portions of California burned, and now as Australia sees unprecedented destruction, there are daily reports that the early predictions of the effects of climate change were underestimates, and the response of our country (and others as well) to both these issues seems feeble at best.  And lest pediatricians think that in their locales the effects of climate change are going to be a long time coming, witness the respiratory issues in states adjacent to the wildfires, the rising sea levels in Miami and other coastal locales necessitating raising the streets, and the almost daily reports of extreme weather events both here and abroad-including flooding, tornadoes, high winds, and drought.  This global change will result in island nations that, if trends continue, will no longer exist or lose vast amounts of land due to rising seas.  And the slow northward march of tropical diseases previously unknown in North America will change how we practice medicine.  The devastation of pines in northern habitats killed by a blight that now overwinters successfully due to rising temperatures affects whole ecosystems.  These seemingly distant examples of climate change will cumulatively affect all of us and our patients, no matter where we live or practice.
     If these occurrences weren’t worrisome enough, we are also faced with a rollback of protections for clean air, water and food by an administration that fosters business interests over public health ones.  And this denial of science is not limited to our country.  This past week the Australian Prime Minister denied the role of climate change in the wildfires and pledged to support the coal industry (Washington Post).  In the US, the administration discounts daily the role of science in public policy, and those at the head of the EPA and other governmental organizations charged with protecting the public interest, including once sacrosanct National Parks, now protect the fossil fuel industry  ( NY Times).  Chipping away at the protections designed to protect future generations put in place by previous administrations and slowly replacing advocates for children and the future with advocates for fossil fuels is the new normal.  Two examples: Dr. Ruth Etzel, a pediatrician and epidemiologist well-known to many of us was removed from her position as head of the EPA’s Office of Child Protection in 2018 and efforts to undermine protections against asbestos exposure were detailed by Dr. Phil Landrigan in August in the New England Journal of Medicine .
     The psychological effects of climate change issues on children and families is profound, and only adds to the burden of already existing stressors.  Some populations, like the Inuit and Pacific Islanders, are already dealing with these issues on a daily basis as rising seas and melting ice threaten their way of life, their physical and mental health and their futures.  These issues and how to help our patients build resilience are addressed in a report from the American Psychological Association and ecoAmerica (Access the report here).  The report details recommendations we can use to help individuals, communities and leaders to foster resilience, action, and mental health.
     Undoubtedly there are children and families under our care that are worried and stressed by this issue-experiencing what has come to be known as Climate Grief.  I am proposing that we discuss these global issues at office visits and see this as an opportunity to educate and enlist families in adjusting their lifestyles, building resilience, and advocating for the future not only of themselves, but also the planet.
     I believe that pediatricians should make it a priority to learn more about environmental health, climate change, and ecology.  Joining the AAP Council on Environmental Health and working with the Chapters on their new initiative to raise consciousness about climate change will add our voices to the national conversation and help us chart the future for ourselves and future generations.
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