AAP Statement on Suicide in Adolescents

The Committee on Adolescence of the American Academy of Pediatrics (AAP) has issued a policy statement on suicide and attempted suicide in adolescents. The statement updates a previous AAP statement and is intended to help the physician in the identification and management of the adolescent at risk for suicide. The statement appears in the April 2000 issue of Pediatrics.

According to data from the Centers for Disease Control and Prevention, suicide is the third leading cause of death among persons 15 to 19 years of age. Young persons at high risk for suicide are often depressed, have attempted suicide before, have a family history of psychiatric disorders, have family disruption and have certain chronic or debilitating physical disorders or psychiatric illness. Physicians can help prevent suicide in adolescents by being able to recognize the symptoms of depression and other presuicidal behavior.

The AAP committee makes the following recommendations for physicians dealing with adolescents and suicide:

• Physicians should be able to recognize the risk factors associated with adolescent suicide and serve as a resource for parents, teachers and others who work with young persons.

• During routine history-taking throughout a patient's adolescence, physicians should ask questions about depression, suicidal thoughts and other risk factors associated with suicide.

• Physicians should ask adolescent patients if firearms are kept in the home and discuss with parents the risks of firearms as related to adolescent suicide. Parents of adolescents at risk of suicide should be advised to remove guns and ammunition from the home.

• Physicians should recognize the medical and psychiatric needs of the suicidal adolescent and work closely with the families and health care professionals involved in the management and follow-up of adolescents who are at risk or have attempted suicide.

• Physicians should become familiar with resources that are concerned with youth suicide, such as mental health agencies, family and children's services, crisis hotlines and crisis intervention centers.

Preventing Pregnancy Loss in Women with Diabetes

The American Diabetes Association (ADA) has issued guidelines on preconception care of women with diabetes. According to the guidelines, optimal medical care and patient education must begin before conception to prevent early pregnancy loss and costly congenital malformations in infants of women with diabetes. The position statement appears in a supplement to the January 2000 issue of Diabetes Care.

The purpose of the ADA position statement is to define the elements of a program for preconception care. This program should be sufficient to minimize congenital malformations, substantially reducing health care costs. The recommended intensive outpatient treatment plan described in the guidelines is based on risk assessment, health promotion and intervention, and outlines effective teamwork strategies to implement the plan before and during early pregnancy.

According to the guidelines, the initial office visit should include the patient's medical and obstetric history, physical examination, laboratory evaluation and management plan. The history should include duration and type of diabetes; acute complications; chronic diabetic complications; diabetes management; concomitant medical conditions and medications; menstrual/pregnancy history and contraceptive use; and family and work support systems.

The physical examination should emphasize blood pressure management; dilated retinal examination; cardiovascular examination in those who have had diabetes for more than 10 years; neurologic assessment; lower extremity examination; and pelvic examination, including a Papanicolaou smear.

The laboratory evaluation may include glycated hemoglobin testing; baseline assessment of renal function; and measurement of serum thyroid stimulating hormone levels and/or free thyroxine levels in women with type 1 diabetes (formerly called insulin-dependent diabetes).

The statement outlines specific goals for treatment, continuing care, visit frequency and laboratory determinations. Special considerations, such as hospitalizations, hypoglycemia, retinopathy, hypertension, nephropathy, neuropathy, cardiovascular disease and early pregnancy management are also discussed.

Climatic Heat Stress and Exercise in Children

The Committee on Sports Medicine and Fitness of the American Academy of Pediatrics (AAP) has published a statement on climatic heat stress in the exercising child. The AAP statement appears in the July 2000 issue of Pediatrics.

According to the committee, exercising children do not adapt to extremes of temperature as effectively as adults when exposed to high climatic heat. This is because children have a greater surface area-to-body mass ratio than adults, causing greater heat gain from a hot environment and greater heat loss in a cold environment. Children produce more metabolic heat per mass unit during physical activities that include walking or running, and a child's capacity to sweat is considerably lower than an adult's.

Heat intolerance often increases with conditions associated with excessive fluid loss, suboptimal or excessive sweating, diminished thirst, inadequate drinking, abnormal hypothalamic thermoregulatory function and obesity.

The AAP committee makes the following recommendations for children and adolescents:

• When participating in activities that last 15 minutes or more, children should exercise at a lower intensity whenever relative humidity, solar radiation and air temperature are above critical levels. The committee suggests that players be substituted frequently on hot days to increase rest periods.

• When starting a strenuous exercise program or after traveling to a warmer climate, the intensity and duration of exercise should be limited initially and then gradually increased over 10 to 14 days to acclimatize children to the heat. If this time period is not available, the length of time for participants during practice and competition should be curtailed.

• Before engaging in prolonged physical activity, the child should be well hydrated. During exercise, periodic drinking should be enforced, even when the child is not thirsty. Weighing the child before and after exercise can verify hydration status if the child is weighed wearing little or no clothing.

• Clothing should be light-colored and lightweight and limited to one layer of absorbent material to facilitate evaporation of sweat. Sweat-saturated clothes should be replaced with dry garments. Rubberized sweat suits should never be used for weight loss.