In Men, Depression is Different

Symptoms—and help—are unlike what women experience

Men become depressed much less often than women do, according to statistics. But that may be because many men resist talking about their feelings and avoid seeking help.
Men become depressed much less often than women do, according to statistics. But that may be because many men resist talking about their feelings and avoid seeking help.

I am worried about a friend. He’s stopped responding reliably to texts and calls from his friends and seems irritable and edgy when we do see him. He complains of insomnia, no energy and lack of motivation. Ask him how he’s doing and he says, “I’m not myself.” “I’m drowning.”

He’s depressed. I don’t know how to help him.

Statistics show that men become depressed much less often than women do. In 2014, 4.8% of men aged 18 or older in the U.S. had at least one major depressive episode in the past year, compared with 8.2% of women in the same age group, according to the National Survey on Drug Use and Health conducted by the Substance Abuse and Mental Health Services Administration.

 But experts worry that these figures don’t tell the whole story. Men are much less likely than women to report feeling depressed or to seek treatment for depression.

Psychiatrists and health care professionals define major depressive disorder as five or more of the following symptoms present for two weeks: depressed mood most of the day, irritability, decreased interest or pleasure in most activities, significant change in weight or appetite, change in sleep, change in psychomotor activity such as either agitation or sluggishness, fatigue or loss of energy, feelings of guilt or worthlessness, changes in concentration and recurrent thoughts of death.

That sense of defeat is why depressed men typically withdraw and isolate.

—Donald Malone, chairman of psychiatry and psychology at the Cleveland Clinic

Women often internalize depression—focusing on the emotional symptoms, such as worthlessness or self-blame, experts say. Men externalize it, concentrating on the physical ones. Men typically don’t get weepy or say they feel sad. They feel numb and complain of insomnia, stress or loss of energy. Often, they become irritable and angry.

Some men aren’t in touch with their feelings. But the larger problem is that men have been conditioned not to talk about them. “There is that sense that they should be in control of their emotions and that being depressed can be viewed as a sign of weakness,” says Jeffrey Borenstein, a psychiatrist and president of the Brain and Behavior Research Foundation in New York. Men are expected to handle problems on their own, he says.

This sense of weakness can make depression worse for men, therapists say. “For women, depression is a signal for getting help, that something needs to be addressed in a fundamental way,” says Nando Pelusi, a clinical psychologist in New York. “For men, it’s a signal that they are a failure and are submitting to defeat.”

That sense of defeat is why depressed men typically withdraw and isolate, says Donald Malone, a psychiatrist and chairman of psychiatry and psychology at the Cleveland Clinic.

And this can wreak havoc on a man’s relationships, as loved ones, especially spouses, can feel hurt and rejected. Research shows that marital problems can cause depression in both men and women. But one classic study, published in 1997 in the journal Psychological Science, showed that while for women the marital problems often come first, for men depression comes first and then causes the marital problems. “The male response to depression is to push away, which can lead a partner to feel helpless and alone,” says Wendy Troxel, a psychologist and senior behavioral and social scientist at the Rand Corp., in Pittsburgh.

How can you help a man who is struggling from depression?

Normalize the situation.

Insist that this isn’t his fault and he isn’t alone. “Look up men and depression on the internet—you will be amazed at what you see,” says Michael Addis, professor of psychology at Clark University, in Worcester, Mass., and director of the Research Group on Men’s Well-being. Many accomplished men have suffered from depression, including Abraham Lincoln,Winston Churchill,Buzz Aldrin and Bruce Springsteen.

If you’ve suffered from depression open up about your struggle. Explain that depression is treatable and it is important to get help, just as you would with any other illness.

Speak carefully.

Don’t be critical. He’s already beating himself up emotionally. And don’t express worry or concern. This suggests you don’t think he can handle the situation on his own.

“Be sensitive to the way his depression feels profoundly humiliating to him,” says Joshua Coleman, a psychologist and senior fellow at the Council on Contemporary Families, a nonprofit organization based at the University of Texas at Austin that distributes research about American families.

Therapists say the word “we” can be very powerful: “We are in this together.” “We will find a treatment that works.”

Ditch the “D” word.

Research shows that men can be defensive about the word depression, and that those who are the most traditionally masculine resist it the most. In a 2013 study in the journal Psychology of Men & Masculinity, men who said they weren’t depressed admitted to having some symptoms, such as anxiety.

Did he mention he had insomnia? No energy? Encourage him to seek help for the symptom he is describing. Seeing a primary-care physician is a good start.

Ask about suicide.

Men are about four times as likely as women to die from a suicide attempt, even though women attempt suicide more often. They use more lethal means.

Don’t be shy about asking a man if he has thoughts of hurting himself. Experts also recommend asking if he has a gun and offering to hang on to it until he feels better. “It’s like holding on to a friend’s car keys when he’s drunk,” says Rand’s Dr. Troxel.

Suggest a therapy that focuses on behavior changes.

Many men don’t want to talk. And they believe a therapist is going to tell them what they already believe: “You are a loser.”

There are several types of psychotherapy that have been shown to successfully treat depression and that focus on changing one’s behavior. These include Cognitive Behavioral Therapy, which helps a person change his thoughts, and Behavioral Activation, which helps him become more engaged in his day-to-day life. These may be more comfortable to many men.

Encourage him to do what he does well.

Activities a man excels at can produce a sense of mastery and satisfaction, says Dr. Troxel. If they are physical activities, they will produce endorphins. If they are social activities, they will give him a boost of the feel-good hormone, oxytocin.

Men also typically gain a sense of accomplishment from getting tasks done. But depression can make even a simple chore feel overwhelming. Dr. Troxel recommends breaking projects into smaller pieces to make them more achievable and to foster an immediate sense of accomplishment

Express your limits.

It is important to realize that you don’t need to be on the receiving side of a depressed man’s anger or blame—or be the only one showing up for the relationship. If you are reaching your limit, say that clearly. “I care about you. I am there for you. But I need you to get help.”

If your husband is depressed and you feel helpless, consider getting therapy for yourself. Therapy can also help you understand what is happening, and how you can better help.

Don’t give up.

Be persistent, even if he is pushing you away. “People do get better with treatment,” says Dr. Borenstein.

Men lose their minds speaking to pretty women.

Talking to an attractive woman really can make a man lose his mind, according to a new study.

Lucky man with two women: Men lose their minds speaking to pretty women

The research shows men who spend even a few minutes in the company of an attractive woman perform less well in tests designed to measure brain function than those who chat to someone they do not find attractive
The research shows men who spend even a few minutes in the company of an attractive woman perform less well in tests designed to measure brain function than those who chat to someone they do not find attractive.

Researchers who carried out the study, published in the Journal of Experimental and Social Psychology, think the reason may be that men use up so much of their brain function or ‘cognitive resources’ trying to impress beautiful women, they have little left for other tasks.

The findings have implications for the performance of men who flirt with women in the workplace, or even exam results in mixed-sex schools.

Women, however, were not affected by chatting to a handsome man.

This may be simply because men are programmed by evolution to think more about mating opportunities.

Psychologists at Radboud University in The Netherlands carried out the study after one of them was so struck on impressing an attractive woman he had never met before, that he could not remember his address when she asked him where he lived.

Researchers said it was as if he was so keen to make an impression he ‘temporarily absorbed most of his cognitive resources.’

To see if other men were affected in the same way, they recruited 40 male heterosexual students.

Each one performed a standard memory test where they had to observe a stream of letters and say, as fast as possible, if each one was the same as the one before last.

The volunteers then spent seven minutes chatting to male or female members of the research team before repeating the test.

The results showed men were slower and less accurate after trying to impress the women. The more they fancied them, the worse their score.

But when the task was repeated with a group of female volunteers, they did not get the same results. Memory scores stayed the same, whether they had chatted to a man or a woman.

In a report on their findings the researchers said: ‘We conclude men’s cognitive functioning may temporarily decline after an interaction with an attractive woman.’

Psychologist Dr George Fieldman, a member of the British Psychological Society, said the findings reflect the fact that men are programmed to think about ways to pass on their genes.

‘When a man meets a pretty woman, he is what we call ‘reproductively focused’.

‘But a woman also looks for signs of other attributes, such as wealth, youth and kindness. Just the look of the man would be unlikely to have the same effect.’

Do Men Have Hormonal Cycles?

Short answer: Ever heard of man-struation?

Men do go through hormonal cycles. That much is established. Their testosterone levels tend to peak first thing in the morning, perhaps in concert with circadian rhythms, and then diminish over the course of the day—though exercise can cause fleeting spikes. What science has yet to show is whether hormones dip and rise over weeks or months, as women’s do.

Some researchers believe that male hormones vary with the seasons. A 2003 study found that the testosterone levels of men in one Norwegian town bottomed out in summer and reached a high in late fall. A study of Danish men found similar seasonal variations (on a slightly different schedule). If these rhythms are real, they might have to do with sun exposure, summer workouts, or winter weight-gain. But studies done in sunny San Diego and snowy Boston failed to replicate the Scandinavian findings. In a 2012 review, urologists at Baylor College of Medicine in Houston concluded that some “evidence exists to support the notion” of seasonal cycles but cautioned that more research was needed.

Endocrinologist Peter Celec of Comenius University in Slovakia, thinks that men have a straight-up monthly hormonal cycle too. In 2002 he published a study showing that both men and women experience roughly lunar rhythms of testosterone; the levels in men’s saliva peaked dramatically on day 18 of a 30-day cycle. Celec’s findings have not been replicated or accepted in the field, yet he remains convinced: “I have searched the literature for negative findings, but I have not found anything.”

Celec adds that if women didn’t bleed, the research establishment would likely be skeptical of their monthly cycles too.

What Are the Most Common Cancers in Men?

Information about cancer risk can help you make informed decisions about screening and prevention strategies. As we recognize National Men’s Health Week, learn about the most common cancers in men in the United States and the options for prevention and treatment.

1. Prostate cancer

There will be an estimated 180,890 new cases in the U.S. in 2016.

One in six men will be diagnosed with prostate cancer in his lifetime. Doctors can screen for early signs of prostate cancer with prostate-specific antigen testing, which can detect elevated levels of a protein in the blood that may indicate prostate cancer. There are benefits and drawbacks to PSA testing; it can help detect and treat cancer at an early stage, but it is not always accurate. False readings can lead to unnecessary treatments, including biopsies that can increase the risk of impotence and incontinence.

Dana-Farber experts recommend:

  • Age 18-40: Screening is usually not required.
  • Age 40-49: You should discuss your risk level with your physician. Screening is recommended if you are considered high risk. African-American men and men who have a family history of prostate cancer are at a greater risk and should discuss PSA testing with their physicians.
  • Age 50+: Discuss screening with your physician.

The best protection against prostate cancer is a healthy lifestyle. Follow this game plan for preventing, screening, and treating prostate cancer.


2. Lung and bronchus cancer

There will be an estimated 117,920 new cases in men in the U.S. in 2016.

Both smokers and non-smokers are at risk for lung cancer. Talk to your physician about screening and prevention if you experience symptoms of chest discomfort, difficulty breathing, hoarseness, bloody mucus, and a lingering cough.

Smoking is the number one risk factor for lung cancer. You can call the Smoker’s Helpline (1-800-QUIT-NOW) to learn about programs to help you quit smoking, or you can discuss how to quit with your physician. The U.S. Preventative Services Task Force recommends annual lung cancer screenings for current smokers, those who have quit smoking within the last 15 years, and those ages 55-80 who have smoked a pack a day for 30 years. Screenings consist of a low-doseCT scan.

To further reduce the risk of lung cancer, maintain a healthy diet and avoid secondhand smoke and exposure to carcinogens such as radon, asbestos, and soot. Radon exposure is the main cause of lung cancer in non-smokers and can be detected inexpensively with an in-home testing kit.

3. Colon and rectal cancer

There will be an estimated 70,820 new cases in men in the U.S. in 2016.

Colorectal cancer is a common but preventable disease. Risk factors for colorectal cancer include age, a history of polyps, having inflammatory bowel disease (IBD), a family history of colorectal cancer, physical inactivity, obesity, and frequent consumption of red meat and processed meats. Studies show that a daily dose of aspirin may reduce the risk of colorectal cancer by up to 40 percent. Consult your physician before beginning an aspirin regimen.

When it is detected early, this disease is one of the most treatable forms of cancer, so it’s important to follow screening guidelines. Dana-Farber experts recommend the following guidelines:

  • Age 18-39: It is not necessary to have a screening unless you have IBD, a family history of colorectal cancer, or a hereditary condition like Lynch syndrome. Speak with your doctor about the pros and cons of screening and whether it’s right for you.
  • Age 40-49: Review your risks with your doctor. You may need to begin screening if you have an increased risk of colorectal cancer or if you’ve previously had polyps.
  • Age 50+: Everyone should be screened. Talk to your doctor about the options, including colonoscopies, sigmoidoscopies, and annual stool occult blood tests.


4. Urinary bladder cancer

There will be an estimated 58,950 new cases in men in the U.S. in 2016.

Blood in the urine, changes in bladder habits, or inability to urinate may be signs of bladder cancer, or signs of a less serious bladder problem.

According to the American Cancer Society, you may be able to reduce the risk of urinary bladder cancer by drinking lots of water, eating fruits and vegetables, quitting smoking, and limiting exposure to certain organic chemicals found in workplaces in the textile, paint, rubber, and leather industries.

A urinalysis, which tests for blood in the urine, can be used to detect bladder cancers early but may not be useful as a routine screening test. Urine cytology may be able to detect cancer cells in urine.


5. Melanoma

There will be an estimated 46,870 new cases in men in the U.S. in 2016.

Risk factors for melanoma include fair skin, a history of blistering sunburns, several large or many small moles, and a family history of unusual moles.

To detect melanoma as early as possible, check your skin once a month in front of a mirror in a well-lit room. Make note of any changes in patterns of moles, blemishes, and freckles over time, and use the “ABCDE rule” to help determine whether your physician should look at a mole.

  • Asymmetry. One half of the mole looks different than the other.
  • Border irregularity. The mole has blurry or jagged borders.
  • Color. The mole does not have a consistent color and may have shades of brown, black, pink, white, red, or blue.
  • Diameter. The mole’s diameter is greater than six millimeters (roughly the size of a pencil eraser).
  • Evolving. The mole changes in size, shape, or color.


Statistics and additional prevention information provided by the American Cancer Society

6 Ways to Help Your Child Deal with Anger.

Anger is a feeling that we all experience at some point or another. Yet, similarly to sadness or fear, it’s the kind of feeling we’d rather not be seen with in public. It’s what is classed as a ‘negative’ feeling, a ‘bad’ feeling and we don’t want to be around it.

For many years I worked with children who experienced their own emotions and social interactions as challenging and, as a result, displayed behaviour that was challenging for the adults who took care of them. Unfortunately, many common approaches that were and are still employed to try and help these children are based on this assumption that feelings such as anger are bad, thereby giving children bad messages about their feelings as well as themselves.

Most approaches merely manage the behaviour, i.e. the symptoms but and don’t offer much help in dealing with the cause, the feeling itself.

Here’s what I think would really help a child in dealing with their anger and other difficult feelings:

1. Distinguish between the person, the feeling and the behaviour

Let your child know that it is okay to experience anger and that you understand. Don’t reject them because they are angry. If they start to display behaviour that is harmful to themselves and/or others you need to intervene and possibly remove them from the situation but stay with them and make it clear that you are stopping them from hurting others and/or themselves and not punishing them.

2. Teach mindfulness

Instead of teaching children that anger is a bad feeling that they need to try and get rid of as soon as possible, teach them skills such as mindfulness that enable them to stay with it when it arises and to watch it disappear by itself. Teach them the skill when they are calm and sit with them and guide them through it when they are angry.

3. Facilitate a positive outlet for it

Teach children ways to express and explore their anger safely, for example write down how they are feeling or draw a picture of their anger. Alternatively, just take your child for a walk in nature.

4. Teach children to take responsibility for their feelings

No one makes anyone feel anything. It’s important for children to understand that although a situation might have triggered their anger, the cause of their anger is never the situation but a need of theirs that hasn’t been met. Help them understand that they need to become aware of and take responsibility for their needs and learn how to express them/request for them to be met. (Non-Violent Communication techniques can really help with this. Marshall Rosenberg’s book: ‘Non-violent communication. A language of life’ will give you a great introduction.)

5. Improve self-awareness and communication skills

A lot of anger in children is frustration that comes from the inability to be aware of and express their own needs. Mindfulness, non-violent communication and philosophy for children (P4C) are all great ways to improve these skills.

6. Be a good role model

Most importantly, show your child how to deal with anger by being a good role model. Don’t hide or suppress your own anger. Say that you are angry when you are angry and model self-awareness by explaining why you are angry. Explain the choices you are making as a result.

What do you do to help your child deal with anger?

Playing Pop and Rock Music Boosts Performance of Solar Cells.

Playing pop and rock music improves the performance of solar cells, according to new research from scientists at Queen Mary University of London and Imperial College London.

The high frequencies and pitch found in pop and rock music cause vibrations that enhanced energy generation in solar cells containing a cluster of ‘nanorods’, leading to a 40 per cent increase in efficiency of the solar cells.

The study has implications for improving energy generation from sunlight, particularly for the development of new, lower cost, printed solar cells.

The researchers grew billions of tiny rods (nanorods) made from zinc oxide, then covered them with an active polymer to form a device that converts sunlight into electricity.

Using the special properties of the zinc oxide material, the team was able to show that sound levels as low as 75 decibels (equivalent to a typical roadside noise or a printer in an office) could significantly improve the solar cell performance.

“After investigating systems for converting vibrations into electricity this is a really exciting development that shows a similar set of physical properties can also enhance the performance of a photovoltaic,” said Dr Steve Dunn, Reader in Nanoscale Materials from Queen Mary’s School of Engineering and Materials Science and co-author of the paper.

Scientists had previously shown that applying pressure or strain to zinc oxide materials could result in voltage outputs, known as the piezoelectric effect. However, the effect of these piezoelectric voltages on solar cell efficiency had not received significant attention before.

“We thought the soundwaves, which produce random fluctuations, would cancel each other out and so didn’t expect to see any significant overall effect on the power output,” said James Durrant, Professor of Photochemistry at Imperial College London, who co-led the study.

“We tried playing music instead of dull flat sounds, as this helped us explore the effect of different pitches. The biggest difference we found was when we played pop music rather than classical, which we now realise is because our acoustic solar cells respond best to the higher pitched sounds present in pop music,” he concluded.

The discovery could be used to power devices that are exposed to acoustic vibrations, such as air conditioning units or within cars and other vehicles.

Co-author Dr Joe Briscoe also from Queen Mary’s School of Engineering and Materials Science, commented: “The whole device extremely simple and inexpensive to produce as the zinc oxide was grown using a simple, chemical solution technique and the polymer was also deposited from a solution.”

Dr Dunn added: “The work highlights the benefits of collaboration to develop new and interesting systems and scientific understanding.”

CLOTBUST-Hands Free.

Pilot Safety Study of a Novel Operator-Independent Ultrasound Device in Patients With Acute Ischemic Stroke

Background and Purpose—The Combined Lysis of Thrombus in Brain Ischemia With Transcranial Ultrasound and Systemic T-PA-Hands-Free (CLOTBUST-HF) study is a first-in-human, National Institutes of Health–sponsored, multicenter, open-label, pilot safety trial of tissue-type plasminogen activator (tPA) plus a novel operator-independent ultrasound device in patients with ischemic stroke caused by proximal intracranial occlusion.

Methods—All patients received standard-dose intravenous tPA, and shortly after tPA bolus, the CLOTBUST-HF device delivered 2-hour therapeutic exposure to 2-MHz pulsed-wave ultrasound. Primary outcome was occurrence of symptomatic intracerebral hemorrhage. All patients underwent pretreatment and post-treatment transcranial Doppler ultrasound or CT angiography. National Institutes of Health Stroke Scale scores were collected at 2 hours and modified Rankin scale at 90 days.

Results—Summary characteristics of all 20 enrolled patients were 60% men, mean age of 63 (SD=14) years, and median National Institutes of Health Stroke Scale of 15. Sites of pretreatment occlusion were as follows: 14 of 20 (70%) middle cerebral artery, 3 of 20 (15%) terminal internal carotid artery, and 3 of 20 (15%) vertebral artery. The median (interquartile range) time to tPA at the beginning of sonothrombolysis was 22 (13.5–29.0) minutes. All patients tolerated the entire 2 hours of insonation, and none developed symptomatic intracerebral hemorrhage. No serious adverse events were related to the study device. Rates of 2-hour recanalization were as follows: 8 of 20 (40%; 95% confidence interval, 19%–64%) complete and 2 of 20 (10%; 95% confidence interval, 1%–32%) partial. Middle cerebral artery occlusions demonstrated the greatest complete recanalization rate: 8 of 14 (57%; 95% confidence interval, 29%–82%). At 90 days, 5 of 20 (25%, 95% confidence interval, 7%–49) patients had a modified Rankin scale of 0 to 1.

Conclusions—Sonothrombolysis using a novel, operator-independent device, in combination with systemic tPA, seems safe, and recanalization rates warrant evaluation in a phase III efficacy trial.

Source: Stroke

Active Versus Passive Cooling During Neonatal Transport.

BACKGROUND AND OBJECTIVE: Therapeutic hypothermia is now the standard of care for hypoxic-ischemic encephalopathy. Treatment should be started early, and it is often necessary to transfer the infant to a regional NICU for ongoing care. There are no large studies reporting outcomes from infants cooled passively compared with active (servo-controlled) cooling during transfer. Our goal was to review data from a regional transport service, comparing both methods of cooling.

METHODS: This was a retrospective observational study of 143 infants referred to a regional NICU for ongoing therapeutic hypothermia. Of the 134 infants transferred, the first 64 were cooled passively, and 70 were subsequently cooled after purchase of a servo-controlled mattress. Key outcome measures were time to arrival at the regional unit, temperature at referral and arrival at the regional unit, and temperature stability during transfer.

RESULTS: The age cooling was started was significantly shorter in the actively cooled group (46 [0–352] minutes vs 120 [0–502] minutes; P <.01). The median (range) stabilization time (153 [60–385] minutes vs 133 [45–505] minutes; P = .04) and age at arrival at the regional unit (504 [191–924] minutes vs 452 [225–1265]) minutes; P = .01) were significantly shorter in the actively cooled group. Only 39% of infants passively cooled were within the target temperature range at arrival to the regional unit compared with 100% actively cooled.

CONCLUSIONS: Servo-controlled active cooling has been shown to improve temperature stability and is associated with a reduction in transfer time.


Narrow-Spectrum Antibiotics Effective for Pediatric Pneumonia.

Narrow-spectrum antibiotics have similar efficacy and cost-effectiveness as broad-spectrum antibiotics in the treatment of pediatric community-acquired pneumonia (CAP), according to the findings of a retrospective study.

Derek J Williams, MD, MPH, from Vanderbilt University School of Medicine in Nashville, Tennessee, and colleagues published their findings online October 28 in Pediatrics.

“The 2011 Pediatric Infectious Diseases Society/Infectious Diseases Society of America…guideline for the management of children with [CAP] recommends narrow-spectrum antimicrobial therapy for most hospitalized children,” the authors write. “Nevertheless, few studies have directly compared the effectiveness of narrow-spectrum agents to the broader spectrum third-generation cephalosporins commonly used among hospitalized children with CAP.”

Therefore, the researchers used the Pediatric Health Information System database to assess the hospital length of stay (LOS) and associated healthcare costs of children aged 6 months to 18 years who were diagnosed with pneumonia between July 2005 and June 2011 and treated with either narrow-spectrum or broad-spectrum antibiotics. The authors excluded children with potentially severe pneumonia, those at risk for healthcare-associated infections, and those with mild disease requiring less than 2 days of hospitalization.

Narrow-spectrum therapy consisted of the exclusive use of penicillin or ampicillin, whereas broad-spectrum treatment was defined as the exclusive use of parenteral ceftriaxone or cefotaxime.

The median LOS for the entire study population (n = 15,564) was 3 days (interquartile range, 3 – 4 days), and LOS was not significantly different between the narrow-spectrum and broad-spectrum treatment groups (adjusted difference [aD], 0.12 days; P = .11), after adjustments for covariates including age, sex, and ethnicity.

Similarly, the investigators found no differences in the proportion of children requiring intensive care unit admission in the first 2 days of hospitalization (adjusted odds ratio [aOR], 0.85; 95% CI, 0.25 – 2.73) or hospital readmission within 14 days (aOR, 0.85; 95% CI, 0.45 – 1.63) were noted between the groups.

Narrow-spectrum treatment was also linked to a similar cost of hospitalization (aD, −$14.4; 95% CI, −$177.1 to $148.3) and cost per episode of illness (aD, −$18.6; 95% CI, −$194 to $156.9) as broad-spectrum therapy.

The researchers note that the limitations of the study were mostly related to its retrospective nature, including potential confounding by indication, the absence of etiologic and other clinical data, and a relative lack of objective outcome measures.

“Clinical outcomes and costs for children hospitalized with CAP are not different when empirical treatment is with narrow-spectrum compared with broad-spectrum therapy,” the authors write. “Programs promoting guideline implementation and targeting judicious antibiotic selection for CAP are needed to optimize management of childhood CAP in the United States.”

Many Children Killed by Influenza Were Not High Risk.

Nearly half of pediatric influenza deaths occur in otherwise healthy children, according to an 8-year Centers for Disease Control and Prevention study published online October 28 in Pediatrics.

“[T]hese data, which reveal that any child can be at risk of influenza-associated death regardless of age or high-risk medical conditions, support the recommendation that all children ≥6 months of age receive annual vaccination,” Karen K. Wong, MD, MPH, from the Epidemic Intelligence Service assigned to the Influenza Division, Centers for Disease Control and Prevention, Atlanta, Georgia, and colleagues write. They note that the national coverage rate (52% in 2011-2012) remains far below the Healthy People 2010 objective of 80%.

The investigators reviewed data for 830 pediatric influenza-related deaths that occurred between October 2004 and September 2012. Of the 794 children with an available medical record, 341 (43%) had no high-risk medical conditions such as neurologic disorders, asthma, or diseases of the heart, kidney, liver, or immune system, and 453 (57%) did. Among the entire study population, the median age of death was 7 years (interquartile range [IQR], 1 – 12 years), with 35% of cases occurring before hospital admission.

As expected, the study data confirmed the increased risk for complications, including mortality, among children with comorbidities: 33% of high-risk deaths occurred in children with neurologic disorders, and 12% had genetic or chromosomal disorders.

However, researchers also found that otherwise healthy children were almost twice as likely to die before hospital admission as their high-risk counterparts (relative risk [RR], 1.9; 95% confidence interval [CI], 1.6 – 2.4) and were 1.6 times more likely to die within 3 days of symptom onset (95% CI, 1.3 – 2.0).Although the cause remains unclear, a doubled prevalence of bacterial coinfection may have factored in the observed acceleration of clinical course (relative risk [RR], 2.0; 95% CI, 1.5 – 2.5), the authors write.

Otherwise healthy children were also more likely to be younger than 5 years (RR, 1.3; 95% CI, 1.1 – 1.6; P < .001), with a median age of 5 years (interquartile range [IQR], 1 – 11 years), compared with 8 years (IQR, 3 – 13 years) in the high-risk group.

According to the authors, the findings underscore the need for clinicians to be more aggressive with antiviral therapy.

“[I]influenza antiviral medications can reduce the severity of illness and complications associated with influenza virus infection…. [H]owever, antiviral treatment was reported in less than half of the children who died during the 2010-2011 and 2011-2012 seasons in this study,” the authors point out.

Children with signs or symptoms of severe or progressive illness and those who are hospitalized should be started on antivirals without waiting for laboratory results, even if they have no other risk factors for influenza-related complications, the authors write. Oseltamivir can be used in infants as young as 2 weeks, they note. In addition, antivirals are recommended regardless of illness severity for children younger than 2 years and for those with high-risk medical conditions.

“The potential for severe outcomes from influenza should be recognized in all children, both those with conditions that place them at higher risk of influenza-associated complications as well as healthy children,” the authors conclude.