by Jessica Pupillo • Correspondent
High-quality preschool programs
provide a foundation for a child’s
academic, social and emotional success. Research also shows those who
attend preschool are more likely to
graduate from high school and less
likely to be involved in the criminal
justice system. Yet recent data show
young children are being expelled
from preschool at an alarming rate.
Data collected by Walter S. Gilliam, Ph.D., child psychologist at
the Yale Child Study Center, found
that 6. 7 children per 1,000 enrolled
in state-funded preschool programs
faced expulsion compared to 2.1 in
grades K- 12. Surveys of non-state-funded child care centers have found
even higher expulsion rates.
Of preschoolers receiving out-of-school suspensions,
78% are boys, according to the U.S. Department of
Education’s Office of Civil Rights. There are racial dis-parities as well: Black children are 3. 6 times more likely
to receive one or more out-of-school suspensions as
white preschool children.
Anecdotally, Dr. Gilliam has found children
with aggressive behaviors who are bigger than
their peers are more likely to be expelled. “Big,
black and boy,” Dr. Gilliam said. “If you have
one of those, you’re at risk for expulsion. If you
have all three, you’re at the greatest risk of all.”
www.aapnews.org Volume 37 • Number 8 • August 2016
In this issue
Effects of parental substance use
An updated clinical report distills information on how to guide
parents whose substance use affects their children. Page 42
Female athlete triad: Early
by Amanda K. Weiss Kelly, M.D., FAAP
The female athlete triad originally was considered an interrelationship of disordered eating,
amenorrhea and osteoporosis.
Our understanding has evolved to
recognize that each of the components — now defined as energy availability (EA), menstrual function and bone health — exists on a spectrum from
optimal health to disease. Athletes affected by the
triad also may have risk factors for cardiovascular
disease, and they may present with disease in one
or any combination of the components.
Updated guidance on diagnosis and treatment of the triad conditions can be found in
the new AAP clinical report The Female Athlete
Triad, available at http://dx.doi.org/10.1542/
peds.2016-0922. The report from the Council
on Sports Medicine and Fitness is published in
the August issue of Pediatrics.
Components of the triad
When exercise occurs without adequate compensation for exercise-related energy expenditure,
adverse effects on reproductive, bone and cardiovascular health may occur.
EA is defined as daily dietary energy intake minus daily exercise energy expenditure corrected for
fat-free mass (FFM). Optimal EA, where reproductive, bone and cardiovascular health are well-maintained, has been identified as 45 kilocalories per
kilogram (kcal/kg) FFM per day in adults but may
be higher in adolescents who are growing.
For many athletes affected by the triad, low EA
is unintentional, and pathological eating behaviors are not present. An EA of less than 30 kcal/kg
FFM per day has been associated with disruptions
in menstrual function and bone mineralization.
The spectrum of menstrual disturbances related
to the triad ranges from anovulation and luteal
dysfunction to oligomenorrhea and amenorrhea
(primary or secondary). As anovulation and luteal phase deficiency often are asymptomatic, they
See Expulsions, page 5
See Flu, page 4
Get to know the AAP candidates running for district office vacancies and hear the president-elect candidates’ thoughts on
the evolving medical home. AAP voting runs from Oct. 21 to
Nov. 21. Pages 25-29
With young children being expelled from preschool settings at an
alarming rate, the Academy — and 30 additional groups — signed
a statement supporting joint federal policy to severely reduce and
ultimately eliminate suspensions and expulsions.
by Henry H. Bernstein, D.O., M.H.C.M., FAAP, and
David W. Kimberlin, M.D., FAAP
The Academy supports the Centers for Disease
Control and Prevention’s (CDC’s) interim recommendation that quadrivalent live attenuated influenza
vaccine (LAIV4) not be used in any setting during
the 2016-’ 17 season.
Vaccination remains the best preventive measure
against influenza, so everyone 6 months and older
should receive any age-appropriate trivalent or quadrivalent (no preference) inactivated influenza vaccine
(IIV) as soon as available.
Why no intranasal LAIV4 this season?
This approach was taken in light of new observa-
tional data from the U.S. Flu Vaccine Effectiveness
Network that documented poor vaccine effectiveness
(VE) of LAIV4 during each of the past three influenza
seasons (see table on page 4), especially against 2009
influenza A (H1N1) and pandemic (H1N1pdm09)
viruses. During the most recent season, LAIV4 had
an overall adjusted VE of 3% against any influenza,
while IIV had an adjusted VE of 63% in children 2
through 17 years of age.
In all pediatric age groups for all three seasons,
LAIV did not have any statistically significant benefit
in preventing influenza (all 95% CI cross zero), while
IIV provided statistically significant protection, albeit
to differing degrees by season. Children who received
LAIV had more than 2. 5 times higher odds of developing influenza due to any virus type compared
with IIV vaccinated children. For H1N1pdm09 in
Intranasal FluMISSED its target
AAP joins groups calling for drastic
reduction in early childhood expulsions
See Triad, page 7