Is Oxygen More Toxic Than Currently Believed?

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COMMENTARIES

Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.

Is Oxygen More Toxic Than

Currently Believed?

ABBREVIATIONS. ROP, retinopathy of prematurity; CLD, chronic lung disease; CI, 95% confidence interval.

S

cheele and Priestly discovered oxygen

indepen-dently of each other in 1772 and 1774, respec-tively. It was quickly realized that this gas is not only life-giving but might be poisonous as well. However, what man has known for only 2 centuries nature itself has known for some 700 million years. One of the biggest leaps forward in evolution oc-curred when blue– grelike algae developed en-zymes that scavenge the superoxide radical enabling them to live in an oxygen-rich atmosphere.1

Shortly after its discovery, oxygen was used for medical purposes. In 1780 France’s Chaussier exper-imented giving oxygen to newborn infants who failed to establish normal breathing.2In 1928 Flagg

described a detailed procedure for intubation and intermittent positive pressure insufflation using a mixture of oxygen and carbon dioxide for resuscita-tion of asphyxiated newborns.2 Oxygen therapy for

newborn infants was introduced in the United States in the 1930s and 1940s although the Finnish pedia-trician Ylppo in 1917 had already recommended in-tragastric administration of oxygen, a practice that continued a surprisingly long time, into the mid-1950s.2 Not before the discovery of its relation to

retrolental fibroplasia (retinopathy of prematurity [ROP]) were questions raised concerning the use of oxygen.3The rest of the story is well-known: in the

1950s and 1960s the oxygen concentration was turned down in many incubators apparently resulting in a reduction in ROP but probably increased mortality.4

In the 1970s the transcutaneous electrodes were introduced—first the oxygen and subsequently the carbon dioxide electrode. Such electrodes should be a means to strict control of the oxygenation of the neonate, and it was thought that the problem related to ROP was solved. Or perhaps it was not? One problem was that the skin of the most immature infants often could not tolerate the heated electrodes. Further, it became clear that these electrodes, how-ever accurate and sensitive they are, in many cases give values that are too high or too low.5During the

1980s many centers reported an increasing incidence

of ROP, mainly attributable to the fact that more immature infants survived. However, it became clear that ROP is not only attributable to exposure of ox-ygen. Oxidative stress per se because of oxygen exposure and high oxygen content in the blood, in-creased oxidative stress mediated through inflamma-tions, or reduced antioxidant defense might be im-portant contributing factors.6

In the 1980s pulse oximeters were introduced in neonatal intensive care units. Now arterial oxygen saturation could be followed continuously without any dermal harm even in the tiniest infants. These devices are noninvasive, easy to use, do not require calibration or heating of the skin, and give almost immediate information regarding changes in arterial oxygenation. Several problems related to the use of pulse oximeters were, however, revealed. They have a relatively high rate of false alarms, often caused by motion artifacts. They are also light-sensitive. Differ-ent models use differDiffer-ent techniques. For instance, oximeters that display functional oxygen saturation show a somewhat (1.5%–3%) higher saturation than those recording so-called fractional saturations.7But

perhaps more importantly, if the saturations are too high, for instance⬎95%, the pulse oximeters do not give sufficient information about the oxygen tension, which could be very high.

Bronchopulmonary dysplasia or chronic lung dis-ease (CLD) has also been recognized as a disdis-ease related to oxidative stress. A high oxygen concentra-tion in inspired air therefore might be detrimental. Today we know that the truth is more complicated and that both barotrauma and volutrauma play roles. Still, oxidative stress seems to be an important factor triggering this condition.8

The other side of the coin is that too low satura-tions increase pulmonary resistance, increase airway resistance, limit somatic growth, and perhaps also increase the risks of sudden death in infants with CLD.9,10

Very recently at least 2 reports have explored whether a high saturation of oxygen may elevate the risks of lung and/or ophtalmologic injuries. The STOP-ROP trial tested whether a regime aiming at a high arterial oxygen saturation (96%–99% vs 89%– 94%) for at least 2 weeks reduced further develop-ment of ROP once pretreshold retinopathy had been detected. No reduction in progression of ROP in the high-saturation group was found but there was a tendency for pneumonia and/or exacerbation of CLD to occur in more infants in the high- rather than in the low-saturation group (13% vs 8%). The need for supplemental oxygen at 50 weeks postmenstrual age was also lower in the low-saturation group (37% vs 47%;P⫽.02).11In another study by Van Marter et

Received for publication Jul 12, 2001; accepted Jul 12, 2001.

Reprint requests to (O.D.S.) Department of Pediatric Research, Rikshospi-talet 0027, Oslo, Norway. E-mail: o.d.saugstad@klinmed.uio.no

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al a high concentration of inspired oxygen was found in infants developing CLD. A fraction of inspired oxygen of 1.0 the first day of life almost doubled the risk of CLD. In contrast, oxygen saturations were equivalent for those who developed and those who did not develop CLD.12

In a study by Tin et al13 the effect of 4 different

oxygenation policies were studied in infants born between 23 to 27 weeks of gestation in the Northern England in 1990 –1994. A total of 295 of these infants who survived infancy had been treated in 5 nurseries and monitored with pulse oximetry for at least 4 weeks of their life. The policy regarding oxygen sat-uration was ascertained retrospectively and it be-came clear that 4 different regimes could be identi-fied, namely supplemental oxygen given to maintain arterial oxygen saturations with alarm limits be-tween: 1) 70% to 90%; 2) 84% to 94%; 3) 85% to 95%; and 4) 88% to 98%. It seemed that the nursing staff aimed at the upper range of these levels. For in-stance, in the first group with the lowest limits sat-urations were typically kept between 80% and 90%. Saturation was monitored using the Critikon (Cri-tikon, Tampa, FL), Nellcor (Mallinckrodt Inc, Pleas-anton, CA), Ohmeda (Datex-Ohmeda, Tewksbury, MA), or Radiometer (Radiometer, Copenhagen, Den-mark) pulse oximeters throughout the time the in-fants were in supplemental oxygen, that is pulse oximeters depending on different techniques and therefore giving slightly different values. At 1 year of age there were no differences in either survival (44%–55%) or in incidence of cerebral palsy (15%– 17%) among the groups. However, among the 126 infants with oxygen saturation limits between 70% and 90% only 6% (95% confidence interval [CI]: 1.7%–15%) had threshold retinopathy versus 28% (95% CI: 17%– 40%) in infants aiming at oxygen sat-urations in the upper ranges, ie, 88% to 98%. In the 2 groups between 14% and 16% of infants developed threshold retinopathy, respectively. When infants with the lowest saturations were compared with those with the highest saturations they required sig-nificantly shorter duration of both supplemental ox-ygen (40 vs 96 days) as well as artificial ventilation (14 vs 31 days).

Birth weights 940 (855–1074) g vs 910 (810 –1018) g, gestational age 27.1 (26.2–27.3) weeks vs 26.4 (25.8 – 27.3) weeks and gender (46% vs 55% male) did not seem to differ between the low- and high-saturation groups. However, more infants in the highest than in the lowest saturation group had arterial lines in for ⬎1 week (49 vs 2 infants). The high saturation infants also received more blood transfusions. Weight cen-tiles fell more in the high than in the low-saturation group, and 45% of the former and 17% of the latter had a weight less than the third centile at discharge. The study by Tin et al has several obvious

short-comings that have been commented on by Marlow.14

First, it was not a randomized study. Although the patients were collected in a prospective collaborative observational study the different policies in the nurs-eries were assessed retrospectively. Different pulse oximeters were used in the different units and as mentioned above this could account for a 1.5% to 3%

difference in the saturations measured. It is also not clear from this report whether the saturations were monitored preductally or postductally. The exact ox-ygen levels were not given but in a later reply the authors state that Pao2ranged between 5 and 11 kpa

(38 – 83 mm Hg) in the low-saturation group.15 The

rate of retinopathy also seems to be extremely high in the highest oxygen saturation group compared with other centers in the United Kingdom.14 Could it be

that the differences in outcomes found between the high-saturation and low-saturation groups mainly reflect differences in disease severity? Thus, the sicker infants were maintained at a higher oxygen saturation, required more arterial lines for longer time periods, needed more blood transfusions, and also had a slower weight gain? Although this might not be likely this and other questions as mentioned above can only be sorted out fully in a prospective, randomized study. Still the data presented by Tin et al are thought-provoking.

It has been acknowledged for 5 decades that oxy-gen might be harmful to premature infants, is it still possible that toxic reactions of oxygen are underes-timated? Since we demonstrated that most newborn infants in need of resuscitation at birth can be resus-citated equally efficiently with room air as with 100% oxygen,162 more studies have shown that

resuscita-tion with pure oxygen might have detrimental ef-fects. Vento et al17were able to show that newborn

infants who were resuscitated with 100% oxygen have an increased oxidative stress for at least a month, in contrast to infants resuscitated with room air. Oxidative stress was assessed both by the ratio of reduced to oxidized glutathione in erythrocytes and oxidized mitochondrial DNA products in urine. Fur-ther, Temesvari and his colleagues found that 100% oxygen resuscitation of newborn piglets with pneu-mothorax had no advantage compared with room air. On the contrary, early neurologic outcome was significantly impaired in the oxygen resuscitated compared with room air resuscitated animals.18This

is in line with results from experiments with adult dogs with cardiac arrest where mortality was higher after resuscitation with 100% oxygen than with room air.19The reason for this is not clear but it is evident

that 100% oxygen resuscitation produces more oxy-gen-free radicals than room air resuscitation.20 –23

If oxygen is a toxic substance even beyond our concept up to now perhaps it was correct as sug-gested by Sjostedt and Rooth 35 years ago that

pre-mature infants could be nursed in ⬍21% oxygen?

These authors found that growth and development apparently are normal in infants nursed in as low as 15%–16% oxygen.24I don’t think this is the solution

although this study shows us that it is possible to nurse premature infants at oxygen saturations⬍21%. A more recent study by Parkins et al25showed that it

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room air which would develop hypoxemic episodes and which would not.

The study by Sjostedt and Rooth as well as the recent one by Tin et al have taught us that the opti-mal arterial oxygen saturation of extremely prema-ture infants the first weeks of life perhaps is not known. This is despite the fact that the normal oxy-gen saturation in both term and preterm infants dur-ing the first 24 hours of life has been studied exten-sively and found to be in median 98% with a range from 80% to 100%. During the first weeks of life both preterm and term infants seem to have a normal arterial oxygen saturation between 93% and 100%

with mean/median values from 97% to 99%.26 –29

The preterm infants in these studies ranged however between 30 and 36 weeks of gestation. In preterm infants with bronchopulmonary dysplasia Halliday et al have shown that a Pao2 should be preferably

⬎55 m Hg (7.3 kPa) to avoid pulmonary

hyperten-sion. The infants of that study were, however, not followed longitudinally.9

Do we know what the optimal arterial oxygen saturation of growing extremely premature infants is? Probably not. Although several recommendations exist, they are probably valid for the more mature premature infants only. These recommendations vary from keeping the saturation between 89% and 92% to values⬎92% in infants with CLD, and⬎94%

if the child is on oxygen therapy.10 Perhaps new

recommendations are needed for the most extreme premature infants with gestational ages between 23 and 27 weeks? Perhaps these infants should be nursed with lower oxygen saturations than used by mainstream nurseries up to now, at least the first few days of life? As mentioned above it seems that even a hyperoxic exposure during a few minutes after birth may increase the oxidative stress for weeks. Because oxidative stress influences apoptosis and cell growth, this may have long-term consequences on growth and development.30 If this is the case,

there is an urgent need for well-controlled, multi-center trials testing out the optimal arterial oxygen saturation at the different days postpartum in our most tiny patients. However, as commented by Mar-low as well,14an arm testing out oxygen saturations

climbing too high should be avoided and probably not accepted by ethical committees. Any such study needs long-term follow-up. If oxygen is toxic beyond present knowledge, we cannot wait with regard to getting these studies conducted.

Ola Didrik Saugstad, MD, PhD

Department of Pediatric Research Rikshospitalet 0027, Oslo, Norway

REFERENCES

1. Gilbert DL. Perspectives on the history of oxygen and life. In: Gilbert DL, ed.Oxygen and Living Processes.New York, NY: Springer-Verlag; 1985:1– 43

2. Howell, M, Ford P. The paradoxes of a small American disaster. In: Howell M, Ford P, eds.The Beetle of Aphrodite.New York, NY: Random House; 1985:210 –236

3. Silverman WA. Retinopathy of prematurity: oxygen dogma challenged.

Arch Dis Child.1982;57:731–733

4. Bolton DPG, Cross KW. Further observation on cost of preventing retrolental fibroplasia.Lancet. 1974;i:445– 448

5. Lubbers DW. Cutaneous and transcutaneous PO2and PCO2and their

measuring conditions.Birth Defects Orig Artic Ser. 1979;15:13–31 6. Saugstad OD. Oxygen toxicity in the neonatal period.Acta Paediatr

Scand. 1990;79:881– 892

7. Bohnhorst B, Peter CS, Poets CF. Pulse oximeter’s reliability in detecting hypoxemia and bradycardia: comparison between a conventional and two new generation oximeters. Crit Care Med. 2000;28:1565–1568 8. Saugstad OD. Chronic lung disease: oxygen dogma revisited. Acta

Paediatr. 2001;90:113–115

9. Halliday HL, Dumpiest FM, Brady JP. Effects of inspired oxygen on echocardiograph assessment of pulmonary vascular resistance and myocardial contractility in bronchopulmonary dysplasia. Pediatrics. 1980;65:536 –540

10. Poets CF. When do infants need additional inspired oxygen? A review of current literature.Pediatr Pulmonol. 1998;26:424 – 428

11. The STOP-ROP Multicenter Study Group. Supplemental therapeutic oxygen for prethreshold retinopathy of prematurity (STOP-ROP): a randomized, controlled, trial: primary outcomes.Pediatrics. 2000;105: 295–310

12. Van Marter LJ, Allred EN, Pagano M, et al. Do clinical markers of barotrauma and oxygen toxicity explain interhospital variation rates of chronic lung disease?Pediatrics.2000;105:1194 –1201

13. Tin W, Milligan WA, Pennefather P, Hey E. Pulse oximetry, severe retinopathy, and outcome at one year in babies of less than 28 weeks gestation.Arch Dis Child Fetal Neonatal Ed.2001;184:F106 –F110 14. Marlow N. High or low oxygen saturation for the preterm baby.Arch

Dis Child Fetal Neonatal Ed.2001;84:F149 –F150

15. Hey E. Two sacred cows of neonatal intensive care—author’s response.

Arch Dis Child Fetal Neonatal Ed.2001;85:F75–F76

16. Saugstad OD, Rootwelt T, Aalen O. Resuscitation of asphyxiated new-born infants with room air or oxygen: an international controlled trial: the Resair 2 study. Pediatrics. 1998;102(1). Available at: http:// www.pediatrics.org/cgi/content/full/102/1/e1

17. Vento M, Asensi M, Sastre J, Garcia-Sala F, Pallardo FV, Vina J. Resus-citation with room air instead of 100% oxygen prevents oxidative stress in moderately asphyxiated term neonates.Pediatrics. 2001;107:642– 647 18. Temesvari P, Karg E, Bodi I, et al. Impaired early neurologic outcome in newborn piglets reoxygenated with 100% oxygen compared with room air after pneumothorax-induced asphyxia.Pediatr Res.2001;49:812– 819 19. Zwemer CF, Whitesall SE, D’Alecy LG. Cardiopulmonary-cerebral re-suscitation with 100% oxygen exacerbates neurological dysfunction fol-lowing nine minutes of normothermic cardiac arrest in dogs. Resuscita-tion. 1994;27:159 –170

20. Armstead WM, Mirro R, Busija DW, Leffler CW. Postischemic genera-tion of superoxide anion by newborn pig brain.Am J Physiol. 1988;255: H401–H403

21. Bagenholm R, Nilsson UA, Gotborg CW, Kjellmer I. Free radicals are formed in the brain of fetal sheep during reperfusion after cerebral ischemia.Pediatr Res. 1998;43:271–275

22. Kondo M, Itoh S, Isobe K, et al. Chemiluminescence because of the production of reactive oxygen species in the lungs of newborn piglets during resuscitation periods after asphyxiation load.Pediatr Res. 2000; 47:524 –527

23. Kutzsche S, Ilves P, Kirkeby OJ, Saugstad OD. Hydrogen peroxide production in leukocytes during cerebral hypoxia and reoxygenation with 100% or 21% oxygen in newborn piglets.Pediatr Res. 2001;49: 834 – 842

24. Sjo¨stedt S, Rooth G. Low oxygen tension in the management of newborn infants.Arch Dis Child. 1957;32:397– 400

25. Parkins KJ, Poets CF, O’Brian LM, Stebbens VA, Southall DP. Effects of exposure to 15% oxygen on breathing patterns and oxygen saturation in infants: interventional study.Br Med J. 1998;316:887– 891

26. Richards D, Poets CF, Neale S, Stebbens VA, Alexander JR, Southall DP. Arterial oxygen saturation in preterm neonates without respiratory failure.J Pediatr. 1993;123:963–968

27. Ng A, Subhedar N, Primhak RA, Shawa NJ. Arterial oxygen saturation profiles in healthy preterm infants.Arch Dis Child Fetal Neonatal Ed.

1998;79:F64 –F66

28. Poets CF, Stebbens VA, Alexander JR, Arrowsmith WA, Salfield SAW, Southall DP. Arterial oxygen saturation in preterm infants: normal values at discharge from the hospital and 6 weeks later. J Pediatr. 1992;120:447– 454

29. O’Brien LM, Stebbens VA, Poets CF, Heycock EG, Southall DP. Oxygen saturation during the first 24 hours of life.Arch Dis Child Fetal Neonatal Ed.2000;83:F35–F38

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The New Morbidity: Where the

Rubber Hits the Road or the

Practitioner’s Guide to the New

Morbidity

ABBREVIATIONS. AAP, American Academy of Pediatrics; DSM-PC, Diagnostic and Statistical Manual for Primary Care.

T

he American Academy of Pediatrics (AAP)

policy statement entitled “The New Morbidity Revisited: A Renewed Commitment to the Psy-chosocial Aspects of Pediatric Care”1from the

Com-mittee on Psychosocial Aspects of Child and Family Health is found in this month’s issue of Pediatrics. Few experienced pediatric practitioners would dis-agree with this description of our life’s work. Most embrace this “renewed commitment” to relevant and comprehensive care for our children and families. It is not hard to look past the examination room and appreciate the struggles, tensions, and morbidities that this complex world presents our patients as they grow and develop. But what about the complex world of our practices? We are well-intended, but are we well-trained, and are we able to follow through on our “commitment”?

Mental health needs of children and adolescents are increasing while access to behavioral health, mental health, and substance abuse service is decreasing.”2

The rate of psychosocial problems identified by primary care physicians in the children they care for has increased from 7% to 18% in the past 20 years. Information accumulated by the Pediatric Research

in Office Settings (PROS) group3 confirmed what

practicing pediatricians already know: the children we see for earaches bring with them symptoms of their behavioral health. These children may have attentional difficulties, conduct issues, or significant problems of mood. They may suffer acute adjust-ment difficulties or evidence posttraumatic stress from physical, emotional, or sexual abuse, and may experience family poverty, family divorce, or a host of other intrinsic or situational problems that impact on their health and the ability of their family and caregivers to provide for their health.

We are seeing more problems and, lacking referral sources, often have to provide more care.

TRAINING FOR THE NEW MORBIDITIES

Skills needed to address the new morbidities are part of our training. Pediatrics has always been a science of development; now pediatric trainees have increased experience in child development, both nor-mal and abnornor-mal. Residency programs must pro-vide specific training in normal and abnormal behav-ior and child development from infancy through

young adulthood. “The program must educate their residents in the intrinsic and extrinsic factors that influence behavior to enable them to differentiate behavior that can and should be managed by the general pediatrician from behavior that warrants ferral to other specialists.” Components of this re-quired training can be found at the Accreditation Council for Graduate Medical Education Web site.4

Developmental pediatric skills among experi-enced, board-certified pediatricians varies. Although experience is an important teacher, quality measures in behavioral health care in primary care practices are lacking. Clinical guidelines are a recent develop-ment, and they are not widely known, consulted, or used. For example, the AAP’s guidelines for the di-agnosis of attention-deficit/hyperactivity disorder5

were published in the May 2000 issue of Pediatrics, and the companion treatment guideline appears in the October 2001 issue.6Will they be used? An AAP

working group has been convened to encourage adoption of and adherence to the new guidelines, seeking to impose a higher community standard of care. Clinical guidelines useful to pediatricians have not yet been developed for other behavioral health disorders, such as depression in childhood and ado-lescence, obsessive compulsive disorder, and the dis-orders of oppositionality and conduct.

Consistent with its “renewed commitment” to be-havioral and developmental morbidities, training in this area is a key and essential part of the AAP’s continuing education efforts. This reflects the AAP’s core values, but also responds to practicing pediatri-cians, who know they need these skills and desire to provide treatments that are sensitive to child and family needs and that have good outcome. And, in the near future, the American Board of Pediatrics will bestow subspecialty board status in Develop-mental and Behavioral Pediatrics to those pediatri-cians who complete a 2-year postresidency fellow-ship and demonstrate certain competencies.

We are trained, our training is improving, and opportunities for additional training are many. But will we be paid for our efforts, and will we have the help of consultants available to us?

REIMBURSEMENT

The pediatric office today should provide behav-ioral health screening and anticipatory guidance in the context of every well-child and sick visit. The pediatrician must be prepared to uncover and effec-tively address psychosocial issues at every encoun-ter: some earaches are complicated by parental di-vorce. Although a sick call visit does not usually include the necessary time to address the child’s and family’s adjustment to this or other significant psy-chosocial stressors, there is time for identification, perhaps brief patient education and anticipatory guidance, and certainly an opportunity to make ar-rangements for a meeting later on.

But, if primary care providers are not reimbursed for their services, behavioral health care will not find a home in primary care. Fee schedules for well-child care or sick care are not adequate to compensate time spent in training for, consulting on, or providing care Received for publication Sep 10, 2001; accepted Sep 10, 2001.

Address correspondence to Joseph F. Hagan, Jr, MD, 410 Shelburne Rd, Burlington, VT 05401-5039.

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for the behavioral and psychosocial problems uncov-ered in those visits.

CURRENT REIMBURSEMENT SYSTEMS

A significant minority of children’s mental health services are accessed only through state Medicaid systems. Nationally, almost 20% of children are in-sured by Medicaid, but the rate of coverage varies widely by state.

Primary care providers struggle with reimburse-ment for reimburse-mental health in the Medicaid system. State Medicaid programs vary in the services or codes they will allow primary care physicians to bill, limiting the provision of mental health services that will be reimbursable. Billing for primary care services, in-cluding mental health, requires both a diagnosis and a procedure code. Specific diagnosis is essential to patient care, and an improperly applied diagnosis could be considered fraudulent. State Medicaid of-fices often limit providers both in the diagnoses they might be allowed to care for and in the procedures that they will be allowed to provide.

For example, a pediatrician may always bill under

Current Procedural Terminology7 codes 99211 to

99215 for evaluation and management of a problem, but they might be restricted in using codes 90804 and 90806 for counseling services. Or although a diagno-sis code of 311.x indicating clinical depression might be allowed, services provided under the diagnosis of mood problem, v40.3, will be rejected. Yet, the prob-lem to child and family is significant to the family regardless of the diagnosis, and the services pro-vided are of value.

PRIVATE THIRD-PARTY SYSTEMS

Third-party coverage for health care and mental health care may take many forms, ranging from tra-ditional fee-for-service to varied levels of care man-agement. Managed care contracts vary in their re-strictions, from the lenient preferred provider contracts to the more stringent capitated systems. The system of reimbursement is essential in the con-sideration of providing mental health services in a primary care office.

With fee-for-service, services billed are paid at published rates. Limitations might exist on fees al-lowed or on allowable diagnoses based on provider credentials. Procedure codes might also be limited by provider type, as described previously. But fee-for-service provides reimbursement for specific work done for the individual patient.

Managed care contracts may use a modified fee-for-service reimbursement mechanism or rely on capitated reimbursement, where a practice receives a small monthly capitation to provide all primary care services for a patient over the length of the insurance contract. Practitioners receive the same amount per month for high service utilization as for nonutilizers. Consequently, there is no financial incentive to take the extra time to deliver mental health services; in-deed, there is a disincentive. Capitation inadver-tently rewards the practitioner who ignores psycho-social issues.

NEW SCHEMA FOR REIMBURSEMENT IN PRIMARY CARE

Recognizing the importance of behavioral health services in primary care, the American Psychiatric Association in collaboration with the American Academy of Pediatrics, the Society for Developmen-tal and Behavioral Pediatrics, the American ogy Association, the Society for Pediatric

Psychol-ogy, the American Academy of Child and

Adolescent Psychology, the National Institute for Mental Health, and the Maternal and Child Health Bureau of the US Department of Health and Human Services developed theDiagnostic and Statistical Man-ual for Primary Care (DSMC-PC).8 The DSM-PC

uti-lizes diagnoses consistent withDSM-IV9and the In-ternational Classification of Diseases, Ninth Revision10

and includes diagnostic descriptors. Each diagnostic category is considered from normal variant, through problem behaviors, to full diagnosis. In addition to diagnostic criteria, each category is described, exem-plified, and differential diagnoses and comorbidities are noted. TheDSM-PCis useful not just for coding, but also as a reference source.

TheDSM-PCnow provides primary care pediatri-cians with the diagnostic codes necessary to bill for the psychological services they provide in their prac-tices. Although insurers may continue to reject claims from primary care physicians for certain di-agnoses, types of services, or supplementary situa-tional morbidities, a schema for demonstrating the breadth of psychosocial service problems cared for and time spent in the provision of services is an important first step. Proper diagnostic coding allows the assessment of outcome and justification that ef-fective services were provided. It allows the primary care physician to more fully describe their interven-tions than could be accomplished with simply med-ical diagnoses. A new standard of care can be

estab-lished and documented. Now the insurance

companies may argue “pediatricians don’t do that.” If primary care pediatricians would simply tell in-surance companies what they do, the basis for reim-bursement is established. If it is consistently billed, a new standard is defined and reimbursement must follow.

An important contribution ofDSM-PCto primary

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What can be done in the meanwhile? In the fee-for-service system a number of special codes, which are poorly used, are allowed to primary care physi-cians (see Table 1). These specific codes reimburse for some of the medical minutia, but they are often forgotten.

In the managed care environment, primary care pediatricians who provide developmental and be-havioral services should be encouraged to negotiate special contracts for these services. Two options are proposed. The argument can be made that pediatri-cians with expertise in psychosocial problem man-agement could be seen as both primary care physi-cians and subspecialists. This is a familiar model that has been used by gynecologists who provide pri-mary care general medical services for women as well as specialty obstetric and gynecologic care. Al-though insurance companies will not welcome this proposal, properly credentialed and experienced pe-diatricians should draw attention to their special skills that make them different from all other pri-mary care providers who receive the same capitation or negotiated reimbursement, but do not provide the developmental and behavioral pediatric services.

An alternative (although not mutually exclusive) argument has to do with the cost of consultants. Experienced pediatricians might argue that it is less costly to the insurer for the experienced pediatrician to care for children with attention-deficit/hyperac-tivity disorder, family adjustment problems, or un-complicated depression than it would be to refer that child to a specialist. One argues that the long-term relationship with the child and family provides a more cost-effective opportunity for intervention.

In addition to contracting, pediatricians providing special services must be prepared to defend and challenge denied claims. An example of such a de-fense is found in Table 2.

CONSULTATIONS AND REFERRALS

Just as generalists may need to call on subspecial-ists for assistance with their patients’ medical prob-lems, generalists must have access to mental health professionals for assistance in management of behav-ioral and psychosocial problems. Although it is im-portant that general pediatricians take a more active role in these frequently occurring morbidities, they cannot be expected to provide this type of service without appropriate backup. Will consultants be available?

In recent years, primary care physicians have taken on an ever-increasing role in prescribing psy-chotropic medications. This is a complex and ever-expanding pharmacology, often with only subtle dif-ferences between agents but perhaps remarkable differences in appropriate use and outcomes. Noting our expanding understanding of brain function on the cellular and molecular levels, one managed care company medical director has noted, “In ten years all mental health will be pharmacology” (personal com-munication). Although few would agree with his assessment, the source and impact of this attitude are clear. Psychopharmacology will be a treatment stan-dard, and primary care physicians will be expected to expand their treatments with these agents.

Primary care doctors will need help. They will need to stay current with a new literature. They will need to assure themselves and their patients that they are providing up-to-date treatments of the high-est quality, so that primary care pediatrics does not become the second balcony of children’s psycho-pharmacology.

Difficult cases need be discussed with other pedi-atricians or with specific mental health consultants. Consultation might include discussion of the pedia-trician’s own management, with specific

recommen-TABLE 1. Behavioral/Attention-Deficit/Hyperactivity Disorder/Special Needs Codes

Description Time Spent Code

Care conference (with or without patient present) 30 min 60 min

99361 99362 E & M codes (existing patient codes) OV minimal

OV problem-focused OV expanded focus OV detailed OV highly complex

99211 99212 99213 99214 99215 Family psychotherapy—without patient (child) present

—with patient (child) present

Not time-related Not time-related

90846 90847 OV with physical (link to another diagnosis) Problem-focused

Expanded focus Detailed

99212-99225 99213-99225 99214-99225

Phone case management Brief call

Intermediate call Complex call

99371 99372 99373 Physician supervision (covers 30-d period) 15–29 min

30⫹min

99374 99375

Preventive counseling 15 min

30 min 45 min 60 min

99401 99402 99403 99404 Prolonged physician services (face-to-face) First 60 min

each additional 30 min

99354 99355 Prolonged physician services (without face-to-face) First 60 min 99358

Review testing; psychological/school Not time-related 90887

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dations and direction in the use of psychopharmaco-logical agents.

Select cases will need to be referred, and referral sources must be available. The American Academy of Child Psychiatry notes that 30 000 child psychiatrists are needed, but only 6300 are available. There is a maldistribution in child psychiatric services, and ru-ral areas as well as areas of low socioeconomic status have the least access. Traditional Medicaid pro-grams, that is, programs not enhanced by specific waiver, limit mental health providers to psychia-trists, psychologists, and other mental health provid-ers only when supervised on site by a psychiatrist. Thus, access to clinical social workers or other mas-ters level professionals, key providers for children, is limited. In this era of Medicaid expansion and the State Child Health Insurance Program, many states have included new provisions for mental health care access in their Medicaid expansion programs, in-creasing the availability of services.

Access to providers in the Medicaid system

con-tinues to be limited by reduced reimbursements, of-ten a fraction of the state’s already low Medicare rates. It is common for mental health providers to limit the number of Medicaid referrals they will ac-cept to preserve a mix of practice reimbursements.

Managed care Medicaid is found in some states. Although these programs are designed to improve access to medical services, mental health services may be handled differently, similar to the private insurance programs.

In other third-party contracts, the “carve out” of mental health coverage has resulted in limitations on services that are provided by a family’s health insur-ance, and often a reduction in provider reimburse-ment. The extra out-of-session and unreimbursed time spent talking with parents, teachers, and others in the child patient’s life is an additional disincentive to mental health providers for children. Managed care health insurance can complicate this process. Is the needed consultant in the same network as the primary care physician? If in a different network, can

TABLE 2. Challenge to Denied Third-Party Reimbursement

Any pediatrician Anytown, USA September 5, 2001 ATTN: Case Manager

RE: DOB:

INSURANCE #

To Whom It May Concern:

I saw on for .

This letter documents the components of the services billed under diagnosis code .

The following services were provided:

Parent conference, regarding the diagnosis, etiology, management, and medical treatments of . This conference lasted approximately minutes.

Face-to-face visit with for additional discussion and initiation of therapy; minutes.

Correspondence with the school attends.

Review of school records.

Phone consultation(s): minutes.

Other:

Should you have any additional questions or wish these services to be coded in a different way, please contact in my office.

Thank you for your consideration.

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the patient be referred to that consultant? Is the referral process uniform, and does it ensure ready access, or is it cumbersome with delays and restric-tions?

CONCLUSION

The Surgeon General’s report on children’s mental health11notes, “Mental health is a critical component

of children’s learning and general health.” Eight goals for addressing the mental health needs of all of America’s children are proposed. Although all 8 goals are in the purview of primary care pediatrics, goal 7 deserves special mention: “Train frontline pro-viders to recognize and manage mental health is-sues.”

The medical model of our training can and will work for us as we provide these broader services addressing the new morbidities of our patients’ be-havioral health needs. We must take thorough histo-ries and, to do so, enhance our interviewing skills. Pediatricians must become familiar with tested screening tools and checklists, assisting in develop-ing appropriate differential diagnoses, and assessdevelop-ing the presence of comorbidities. Additional effective primary care interventions are needed, and primary care pediatricians will learn to use them. Each gen-eralist must develop his or her own network for case discussion, consultation, and referral. New models for the collaborative practice of primary care and mental health practitioners working side by side must be developed that are community-based and not limited only to universities or training centers.

Commitment to confronting the new morbidities of psychosocial problems is intrinsic to our pediatric

identity, and the systemic changes necessary to allow this new standard of care are within our reach.

Joseph F. Hagan, Jr, MD

Burlington, VT 05401-5039

REFERENCES

1. American Academy of Pediatrics, Committee on Psychosocial Aspects of Child and Family Health. The new morbidity revisited: a renewed commitment to the psychosocial aspects of pediatric care.Pediatrics. 2001;108:1227–1230

2. American Academy of Pediatrics. Insurance coverage of mental health and substance abuse service of children and adolescents: a consensus statement.Pediatrics. 2000;106:860 – 862

3. Kelleher KJ, McInerny TK, Gardner WP, Childs GE, Wasserman RC. Increasing identification of psychosocial problems: 1979 –1996. Pediat-rics.2000;105:1313–1321

4. Accreditation Council for Graduate Medical Education. Program re-quirements/Pediatrics-competencies. Available at: http://www. acgme.org

5. American Academy of Pediatrics, Committee on Quality Improvement and Subcommittee on Attention-Deficit/Hyperactivity Disorder. Clini-cal practice guideline: diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder.Pediatrics. 2000;105:1158 –1170 6. American Academy of Pediatrics, Subcommittee on Attention-Deficit/ Hyperactivity Disorder and Committee on Quality Improvement. Clin-ical practice guideline: treatment of the school-aged child with attention-deficit/hyperactivity disorder.Pediatrics. 2001;108:1033–1044 7. American Medical Association. Current Procedural Terminology CPT

2001. Chicago, IL: American Medical Association; 2000

8. American Academy of Pediatrics.The Classification of Child and Adoles-cent Mental Diagnoses in Primary Care. Diagnostic and Statistical Manual for Primary Care (DSM-PC) Child and Adolescent Version. Wolraich ML, Felice ME, Drotar D, eds. Elk Grove Village, IL: American Academy of Pediatrics; 1996

9. American Psychiatric Association.Diagnostic Criteria from DSM-IV. First MB, ed. Washington, DC: American Psychiatric Association; 1994 10. American Medical Association. International Classification of Diseases

ICD-9-CM 2001. Chicago, IL: American Medical Association; 2000 11. US Public Health Service.Report of the Surgeon General’s Conference on

Children’s Mental Health: A National Agenda. Washington, DC: Depart-ment of Health and Human Services; 2000

COMPUTERS IN MAJORITY OF US HOMES

“More than half of the households in the United States had at least one computer last year, and more than 40% were connected to the Internet, a Census Bureau report (released September 6, 2001) said.

In addition, 65% of children ages 3 to 17 had access to a computer at home in 2000, up from about 55% in 1998. Of children in that age group, 30% logged onto the Internet, compared with 19% in 1998, the report found . . . ‘‘Years from now we will look back on this as a watershed year, when computers went from a special thing in a home to a common appliance.’ . . . Among households with incomes of $75,000 or more, 88% had a computer and 79% went online. In households with incomes below $25,000, 28% had a computer and 19% used the Internet.“

New York Times.September 7, 2001

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DOI: 10.1542/peds.108.5.1203

2001;108;1203

Pediatrics

Ola Didrik Saugstad

Is Oxygen More Toxic Than Currently Believed?

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2001;108;1203

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Ola Didrik Saugstad

Is Oxygen More Toxic Than Currently Believed?

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Figure

TABLE 1.Behavioral/Attention-Deficit/Hyperactivity Disorder/Special Needs Codes

TABLE 1.Behavioral/Attention-Deficit/Hyperactivity

Disorder/Special Needs Codes p.6

References