Pediatric bloom affliction is accomplished with the ambition of announcement the best interests of the child. Analysis about is rendered beneath a anticipation in favor of comestible life. However, in some circumstances, the antithesis of allowances and burdens to the adolescent leads to an appraisal that abnegating life-sustaining medical analysis (LSMT) is ethically acceptable or advisable. Parents are accustomed advanced breadth in controlling apropos end-of-life affliction for their accouchement in best situations. Collaborative controlling about LSMT is bigger by absolute advice amid all stakeholders, including medical staff, the family, and the patient, back possible, throughout the evolving beforehand of the patient’s illness. Clear advice of all-embracing goals of affliction is brash to beforehand agreed-on plans, including resuscitation status. Perceived altercation amid the aggregation of professionals may be demanding to families. At the aforementioned time, compassionate the ambit of able opinions abaft analysis recommendations is analytical to allegorical ancestors decision-making. Input from specialists in booze care, ethics, pastoral care, and added disciplines enhances abutment for families and medical agents back decisions to abandon LSMT are actuality considered. Compassionate specific annual of institutional, regional, state, and civic regulations accompanying to abnegating LSMT is important to convenance ethically aural absolute accustomed frameworks. This advice represents an amend of the 1994 annual from the American Academy of Pediatrics on abnegating LSMT.
Pediatric bloom affliction is accomplished with the ambition of announcement the best interests of the child. Analysis is about rendered beneath a anticipation in favor of comestible life. However, as medical and surgical technologies advance, pediatricians, parents, and added ancestors caregivers may charge to accede back it is ethically acceptable or adapted to use accessible interventions to sustain the activity of a adolescent who is acutely ill. In abandoned patients, they may achieve that connected analysis above maximizing abundance is no best in the best interests of the adolescent and instead alter analysis adjoin limitation or abandonment of interventions that are accounted added crushing than beneficial.
Many deaths in pediatric and neonatal analytical affliction units are preceded by decisions agreed on by the medical aggregation and ancestors to abstain or abjure life-sustaining medical analysis (LSMT).1–4 This annual provides advice for controlling and advice about denial and abandoning LSMT and directs physicians adjoin American Academy of Pediatrics’ (AAP) statements that beforehand optimal end-of-life affliction for children.5–7 This annual is presented in the ambience of bloom affliction in the United States today, in which continuing LSMT is affected to be the admiration of the accommodating or ancestors unless abnegating analysis is accurately discussed, agreed on, and ordered.
In this statement, LSMT refers to any analysis accustomed to extend adaptation or for which a able accord exists that it may. LSMT includes interventions such as assisted ventilation, medically administered diet and hydration, renal backup therapy, vasoactive infusions, or built-in cyberbanking instruments, such as cardiac defibrillators or ventricular abetment devices. In some instances, LSMT additionally refers to treatments such as transfusions, added oxygen, and medications such as antibiotics, insulin, and others.
A analysis that has been advised for a accommodating but not amorphous is said to accept been “withheld.” One that was started and again discontinued was “withdrawn.” The appellation “forgoing” refers to the activity of either denial or withdrawing.
The acceding “burden” and “burdensome” are acclimated in this advice to accredit to the adverse affection and adversity accomplished by the adolescent in affiliation with accurate medical and surgical interventions.
As accustomed by able organizations in North America and Europe, ethical controlling apropos accouterment or abnegating LSMT for accouchement is guided by the patient’s best interests.8–10 Acknowledging that the byword “best interests” is awful abstract and may be difficult to ascertain in any accustomed situation, it charcoal important to beforehand the axis of accommodating interests back developing goals of care.
Applying the best interests accustomed leads to benign interventions that are acceptable to accommodate greater annual than accountability for the adolescent and black the admission or assiduity of interventions that are acceptable to beforehand to greater accountability than benefit.11,12 The burdens to the adolescent of greatest appendage in this ambience are those that abide or recur admitting astute attempts at absolution and prevention. Such burdens may accommodate pain, exceptionable or diffuse restrictions on activity (by application pharmacological or concrete means), anxiety, fear, isolation, or added activity changes that annual ache to the child.
Some treatments absurd to annual patients in the abiding accept concise absolute furnishings that animate patients, physicians, and added caregivers to accommodate those interventions admitting a abridgement of close affirmation of adeptness over time. Whether such interventions should be advised “futile” or “nonbeneficial treatment”13 has been the accountable of debate.14 Some groups absorption adjoin “broadly anecdotic a analysis as ‘futile’ or ‘non-beneficial’”10 and acclaim instead that physicians analyze how anniversary analysis option, including decisions to abandon LSMT, may or may not beforehand accustomed goals of care.
Interventions that accept no adventitious of accomplishing the advised physiologic annual are advised “physiologically futile.” Some advisers accept argued that physicians should accommodate treatments that are physiologically abortive if awkward disagreements with families occur.15 Others acquisition the convenance ethically ambiguous in that it “adds accountability for the patient” and “may absorb a anatomy of deception, through ‘pretending’ that a analysis has abeyant for physiological annual back it does not.”10 According to a collective annual by 5 able organizations anxious with the affliction of those with analytical illness, physicians should not accommodate such interventions in the attenuate bearings in which they agree, afterwards a deliberative and across-the-board process, that the activity would be physiologically futile.16
One access to evaluating the benefit-burden antithesis of life-prolonging interventions is referred to as “provisional accelerated care.”12 In such situations, time-limited trials of LSMT are initiated, again aloof afterwards a prespecified aeon of time if they accept bootless to accord to beforehand in the patient’s cachet or are begin to appoint greater accountability than benefit. It may abide difficult for caregivers and physicians akin to abandon LSMT at the end of such a trial, alike back accord exists about abridgement of net annual of the intervention, decidedly if abandonment is associated with a faculty of claimed accountability for the patient’s death. Admitting the altered affecting and cerebral meanings that denial and abandoning LSMT may have, they are broadly advised to be ethically and about equivalent.6,8
Children in states of acutely analytical affliction associated with about no adventitious of accretion may be perceived by their families and/or physicians to be adversity significantly, admitting all-embracing attempts to abate affliction and added symptoms. In these circumstances, abnegating crushing LSMT may be advised ethically advisable. The AAP and added organizations8–10 abutment continuing booze measures advised to administer affliction or adversity in all instances.
The ethical duties of accuracy and allegiance alarm physicians to allotment “complete, honest and aloof advice with patients and their families on an advancing base and in means they acquisition advantageous and affirming.”17 Beneficent accomplishments additionally accommodate efforts to analyze individuals, groups, and added assets that can accommodate abutment to the accommodating and family. Back physicians appoint in partnerships characterized by aggregate controlling about goals of care, it can abate the about cutting accountability on families and adolescents advertent difficult analysis decisions, including those that absorb abnegating LSMT.18
Pediatricians may alum from training activity afflictive discussing end-of-life affliction or demography allotment in its planning.19–21 Accustomed the accent of advice abilities back discussing abnegating LSMT, pediatricians may ambition to beforehand these abilities through focused training, collaborative assignment with a ambit of pediatric medical subspecialists and pediatric surgical specialists, mentorship by colleagues whose advice abilities are awful valued, and assets offered by a ambit of able organizations.22 This is appropriately important for pediatric subspecialists, pediatric surgeons, providers of astute affliction and pediatricians in the medical home.23
Treating accouchement with life-limiting altitude may actualize cogent moral ache for associates of the affliction team. Physicians who, on moral grounds, abatement to participate in limitation or abandonment of LSMT should abide to accomplish the “duty of care”10 to the adolescent until they are able to align for affliction by accession physician. Advice can be begin in the 2009 AAP annual on claims of conscience.24
Children and families are accustomed as basal associates of the bloom affliction team, as participants in development of all aspects of the bloom affliction plan, and as aggregate owners of that plan.17 Parents and ancestors caregivers about are admired as best able to acknowledge the best interests of the child,9 which is the axial framework for ethical controlling apropos analysis options in pediatrics, including decisions to abandon LSMT, based on goals of care. Parents, guardians, and adolescents complex in developing the plan of affliction will annual from accepting advice and assets all-important to advice them advanced what decisions may lie ahead. Supports may accommodate explanations and images, updates about an evolving beforehand of illness, and a charge from providers to accept to families’ questions, needs, and values.
According to standards of convenance answer by the Civic Hospice and Booze Affliction Organization, every adolescent has a adapted to “open and honest” advice of “age-appropriate advice about his or her illness, as able-bodied as abeyant treatments and outcomes, aural the ambience of ancestors decisions”9 and to be “given the befalling to participate in decisions affecting his or her care, according to age, understanding, capacity, and affectionate support.”9 These recommendations, reflected in guidelines issued by added able organizations in North America and Europe,8,10 alarm for physicians to seek assent, and booty into application dissent, of earlier accouchement and adolescents who authenticate some bloom affliction controlling capacity, “while ensuring the child’s best interests abide at the amount of decisions.”9
The AAP recognizes that “some pediatric patients, abnormally earlier adolescents and those with medical acquaintance because of abiding illness, may acquire able capacity, cerebral ability, and acumen to appoint finer in the a accord or abnegation activity for proposed goals of care.”25 As Diekema has written, others may not “truly acquire acceptable adaptation to accomplish life-altering medical decisions,” such as crumbling LSMT.26
When attempted resuscitation is not acceptable clinically or adapted in inpatient settings, specific orders accounting in the medical almanac about booty the anatomy of “do not attack resuscitation” (DNAR) orders, additionally alleged “do not resuscitate” or “allow accustomed death” orders. Progress addendum that accompany these orders about announce cast and call the agreeable of discussions with the ancestors and the medical team, the bidding wishes of the accommodating and ancestors decision-makers, any issues that abide unresolved, and recommendations of the alleviative aggregation and consultants.8,10 This convenance promotes added boundless compassionate amid associates of the bloom affliction aggregation of the considerations allegorical decisions to abandon attempts at resuscitation.
Physicians who amusement accouchement charge to be acquainted of institutional policies, bounded and accompaniment bloom regulations, and federal legislation pertaining to abnegating LSMT. As 1 example, in some institutions, ancestors caregivers are asked to assurance orders to abandon LSMT, creating potentially demanding demands on ancestors caregivers who are already anticipating the afterlife of their child. In others, exact agreement, or artlessly acceptance the activity afterwards altercation with the analysis team, is sufficient.
The developing freedom of accouchement and adolescents to accurate preferences and wishes for affliction and afterthought about the end of activity may be accurate by the use of accoutrement such as “Voicing my Choices,”27 “Personal Resuscitation Plans,”28 and “Child and Ancestors Wishes,”29 originally acquired from adult-oriented beforehand affliction plans.
One of the decisions that may appear from these discussions with accouchement and families is for the physician to abode an out-of-hospital DNAR order. These orders are accurate in abounding but not all states.30,31 Back parents or guardians feel acerb about acknowledging the child’s DNAR status, accouterment affidavit to emergency medical responders in the acreage and hospital emergency departments will access the likelihood their wishes will be respected. Parents and accustomed guardians should be reassured they can aish out-of-hospital DNAR orders at any time or accomplish the adaptation not to present the forms to emergency responders.
Some accouchement with DNAR orders are candidates for interventions beneath abysmal balance or accustomed anesthesia, aspects of which would be advised resuscitative in added contexts. To best abutment goals of care, the AAP and added civic organizations endorse the abstraction of “required reconsideration” of DNAR orders in the activity of a accord for anaplasty or anesthesia32 and advance that continuing a DNAR adjustment intraoperatively and perioperatively may be ethically acceptable in some circumstances.
Family decision-makers may disagree with medical recommendations to abandon LSMT because of altered perceptions and expectations about the child’s accustomed and approaching affection of life, altered interpretations of the prognosis, or religious and culturally based behavior that access their faculty of what is in the child’s best interests. The AAP and added organizations abutment acclamation these considerations with the absolute absorption for families’ viewpoints, continuing a activity of admiring and honest advice administration as the patient’s action and the family’s compassionate advance over time.8–10,16,17 Differences amid ancestors caregivers or amid the affliction aggregation and adolescent and/or ancestors decision-makers can be approached by application basal attempt of acceding and battle resolution and abutment from pastoral affliction providers and consultants in booze affliction or ethics.8,9,16 If a ancestors agrees to cessation of LSMT but requests a adjournment to acquiesce others to appointment the child, reasonable accommodations, guided and bound by the interests of the patient, may acquiesce for closure.
Typically, physicians may access permission to accommodate LSMT from either allowable parent. In some states, however, permission to abjure or abstain LSMT charge be provided by both parents unless one has been appointed the sole accustomed guardian for bloom affliction decisions or the adolescent has accession accustomed guardian. Although accustomed requirements may alter from accompaniment to state, ethical considerations with absorption to abnegating LSMT are identical above accompaniment lines.
Physicians and the affliction aggregation may accede whether it is adapted to abandon LSMT admitting ancestors objections back the advancing allowances of LSMT are basal and the perceived accountability of adversity charcoal abundant alike afterwards all-embracing attempts accept been fabricated to abate affliction and added adverse symptoms. Although this may be ethically acceptable in attenuate affairs of acute accountability of analysis with no annual to the accommodating above cessation of death, accompaniment regulations may crave accord from guardians. At this point in time, it is accurately permissible in at atomic 1 accompaniment for physicians to abjure LSMT adjoin ancestors wishes.33 Some hospitals accept behavior and procedures acceptance physicians to abode unilateral DNAR orders. Strategies that institutions can apparatus to anticipate and abode such conflicts are proposed in a collective annual by 5 able organizations anxious with the affliction of those with analytical illness.16
The affliction of accouchement with medical complication involves contributions from assorted pediatric medical subspecialists and pediatric surgical specialists, pediatricians in the medical home,23 and bloom affliction professionals from abounding disciplines. All can accommodate advice and abutment to ancestors decision-makers back options to abandon LSMT are discussed.
Conversations with accouchement and families about analysis options over which the affliction aggregation is acerb disconnected can be demanding to ancestors decision-makers. At the aforementioned time, compassionate the ambit of able opinions abaft analysis recommendations is analytical to allegorical ancestors decision-makers (and children, in some cases), alike back these angle conflict. It can be arduous to administer the breeze of advice in means that are minimally ambagious and maximally admiring to families and able staff.22,34 Interdisciplinary affairs and appointment with booze affliction specialists can beforehand these goals. Belief appointment casework accommodate abutment for families and medical agents and are accessible aboriginal in the beforehand of affliction and as apropos and conflicts arise.35,36
Medically administered diet and hydration aggregate interventions that may be withheld or aloof for the aforementioned types of affidavit as added medical treatments. It is advised ethically acceptable to abandon medically administered diet and hydration back there is accord that they do not accommodate net annual to the adolescent and thereby abort to abutment the child’s best interests. As with the abnegating of added LSMT, parents and accustomed guardians should be absolutely complex in controlling and be reassured that their adolescent will abide to be provided with booze measures to ensure comfort.6,8
The ethical foundation of controlling apropos abnegating LSMT is the aforementioned for accouchement with adorning disabilities as for those advised about developing.8 The access to anecdotic goals of affliction and anticipation analysis affairs based on those goals, including considerations to abandon LSMT, is ashore in the application of anniversary child’s best interests. Some accouchement with adorning disabilities acquaintance associated altitude that accreditation palliation. A baby cardinal of accouchement accept axial afraid arrangement crime so abundant that questions appear as to their adaptation to acquaintance amusement or any annual from connected existence; these considerations amount into assessments of allowances and burdens of treatment.8
Decisions about abnegating LSMT may appear in the affliction of accouchement who are in the aegis of adolescent careful casework afterwards affectionate rights accept been concluded but afore acceptance has taken place. In these cases, the accompaniment and its agents, acting in loco parentis, may charge medical and ethical advice from associates of the affliction aggregation apropos issues with which they abridgement acquaintance or experience. In these situations, it is ethically acceptable to acquaint parents about end-of-life discussions, although they abridgement controlling authority.
For accouchement whose injuries are believed to be the aftereffect of adolescent abuse, the aforementioned medical and ethical controlling belief administer to abnegating LSMT as for added children, including altercation of abeyant bureau donation with guardians and the medical examiner. Conflicts may appear for bodies accused of accepting acquired the injuries or for those in an developed accord with bodies who are so accused if accustomed accuse will change depending on whether the adolescent survives or dies. Appointing a guardian ad litem in all cases in which such conflicts are doubtable promotes states’ interests in absorption accessible citizens. Advice from accustomed and belief consultants should be accustomed by providers who are anxious that such conflicts accession the abeyant that a child’s best interests are not actuality pursued.
In the affliction of neonates who were built-in acutely preterm, survived abstruse asphyxia, acquire assertive life-threatening complete anomalies, or accept assorted bureau arrangement failure, decisions to abandon LSMT may be awfully difficult because of the ambiguity about cast during the aboriginal hours or canicule of life. Uncertainties are abstract by the alteration banned of activity as the convenance of neonatology advances and because denial antecedent analysis may aggravate outcomes of some breed who accidentally survive. The AAP supports a activity of aggregate controlling with the ancestors in the access to resuscitation and accelerated affliction of breed built-in at acutely low gestational age (<25 weeks), for whom “the accident of permanent, astringent neurodevelopmental and added adapted bloom affliction needs affect both the baby and the ancestors and, for some parents, may outweigh the annual of adaptation alone.”37 In the affliction of added high-risk bairn breed whose “prognosis is ambiguous but acceptable to be actual poor and [for whom] adaptation may be associated with a beneath affection of activity for the child,” AAP action affirms that “parental desires should actuate the analysis approach”5 The AAP additionally asserts that a analysis should be advised “inappropriate” back it is “harmful, of no benefit, or abortive and abandoned assiduity dying.”5 As in all instances above the neonatal period, abundance affliction of bairn breed is adapted whenever a adaptation is fabricated to abandon resuscitation or accelerated care.37
In 1994, the US Congress adapted the Adolescent Corruption Blockage and Analysis Act of 1984 (Human Casework Amendments of 1994, Pub L No. 103–252) to crave accompaniment adolescent careful casework agencies to advance and apparatus mechanisms to address to a government bureau analysis withheld from breed on the base of disability, except in any of the afterward situations: (1) back an baby is chronically and irreversibly comatose; (2) back accouterment the analysis would abandoned prolong dying, would not be able in ameliorating or acclimation all of the infant’s life-threatening conditions, or would be abortive in acceding of the infant’s survival; or (3) back the analysis would be about abortive and inhumane.38 It is important to admit that this legislation pertains abandoned to infants, is advised to anticipate bigotry on the base of affliction alone, and may not consistently be constant with approaches that compassionately accede anniversary child’s evolving medical action and best interests.39,40 The Adolescent Corruption Blockage and Analysis Act is directed at states, not abandoned physicians, and it does not accommodate administration on what accomplishments accompaniment governments and agencies should again booty back a accessible corruption is reported. Compassionate specific annual of institutional, regional, state, and civic regulations accompanying to abnegating LSMT is important to convenance ethically aural absolute accustomed frameworks.
Recommended processes for the analysis of afterlife by neurologic belief in accouchement and breed accept been adapted over time. Physicians should use accustomed processes and be acquainted of accompaniment statutes and institutional behavior that may bind the assurance of afterlife by neurologic belief in assertive circumstances. They are encouraged to action the time and advice bare to advice families accept that already afterlife by neurologic belief has been determined, their adolescent has met accustomed belief for death.41 Families’ religious behavior and practices should be accustomed during the activity of free afterlife by neurologic criteria, and physicians should be a about accompaniment laws that may annual exemptions to this determination. The activity of alternate interventions that sustain oxygenation and tissue perfusion in a adolescent whose afterlife was bent by neurologic criteria, although fundamentally altered from abandoning LSMT, may be accomplished analogously by families and clinicians. In addition, it is important for pediatricians to be acquainted of regulations about advertisement approaching afterlife to organ-procurement agencies and the need, in some instances, to sustain bureau abutment until annual for bureau accretion has been established.
When decisions to abandon LSMT are actuality contemplated, compassionate affliction for accouchement who are acutely ill and their families is added by absorption to the afterward considerations:
Although there is a anticipation in favor of comestible activity in best circumstances, abnegating LSMT is ethically acceptable back the burdens of analysis outweigh the allowances to the child;
Understanding specific annual of institutional, regional, state, and civic regulations accompanying to abnegating LSMT, including the Adolescent Corruption Blockage and Analysis Act, is important to convenance ethically aural absolute accustomed frameworks;
Respectful, truthful, and absolute advice amid associates of the analysis team, the medical home, the patient, and ancestors decision-makers supports the activity of aggregate controlling above affliction environments and throughout the evolving beforehand of the child’s illness;
Perceived altercation amid the aggregation of professionals may be demanding to families. At the aforementioned time, able opinions abaft analysis recommendations are analytical to allegorical ancestors decision-makers, alike back these angle conflict;
Each adolescent is advantaged to “open and honest” advice of “age-appropriate advice about his or her illness, as able-bodied as abeyant treatments and outcomes, aural the ambience of ancestors decisions” and to be “given the befalling to participate in decisions affecting his or her care, according to age, understanding, capacity, and affectionate support.”9 The child’s accord can be added through the use of care-planning tools;
Ethics appointment may be advantageous to the bloom affliction aggregation and to families back ethical apropos about abnegating LSMT are aloft or crave clarification;
Ethical approaches to managing altercation amid the angle and wishes of ancestors caregivers and/or amid ancestors decision-makers and the bloom affliction aggregation can be approached by application basal attempt of acceding and battle resolution and addressed with abutment from airy affliction providers and consultants in booze affliction or ethics;
Reasonable adaptation for the timing of abnegating LSMT may be accustomed to families to acquiesce ancestors associates to gather, but the absolute affliction is acceptable to abstain assiduity adversity of the patient;
It may be ethically acceptable to abandon LSMT afterwards ancestors acceding in attenuate affairs of acute accountability of analysis with no annual to the accommodating above cessation of death;
Medically administered diet and hydration, like added LSMTs, aggregate interventions that may be withheld or aloof back there is accord that they do not accommodate net annual to the adolescent and thereby abort to abutment the child’s best interests;
The AAP endorses the abstraction of “required reconsideration” of DNAR orders in the activity of a accord for anaplasty or anesthesia. It may be ethically adapted to abide DNAR orders intraoperatively and perioperatively if this is constant with goals of care;
Physicians who abatement to participate in limitation or abandonment of LSMT on the base of their own moral, religious, or claimed behavior should abide to affliction for the adolescent until they are able to align for affliction by accession physician;
Ethical and medical controlling in assertive adapted situations, including the affliction of accouchement with adorning disabilities, accouchement who are in advance care, and accouchement whose injuries are believed to be the aftereffect of adolescent abuse, are guided by the aforementioned attempt as controlling for added children;
For some bairn breed who were built-in at acutely low gestational age (<25 weeks), survived abstruse asphyxia, acquire assertive life-threatening complete anomalies, or accept assorted bureau arrangement failure, the AAP recognizes that “prognosis is ambiguous but acceptable to be actual poor,”5 and adaptation may be accompanied by a aerial accident of “permanent, astringent neurodevelopmental and added adapted bloom affliction needs” and beneath affection of life.37 In such instances, it is ethically acceptable for decisions about abnegating LSMT, developed in a ambience of aggregate controlling with professionals involved, to be bent by affectionate preferences, except back requested treatments are advised to be of net harm, “of no benefit, or physiologically abortive and abandoned assiduity dying”5; and
Physicians should use accustomed processes for the analysis of afterlife by neurologic belief and be acquainted of pertinent accompaniment statutes and institutional policies.
Kathryn L. Weise, MD, MA, FAAP
Alexander L. Okun, MD, FAAP
Brian S. Carter, MD, FAAP
Cindy W. Christian, MD, FAAP
Aviva L. Katz, MD, FAAP, Chairperson
Naomi Tricot Laventhal, MD, FAAP
Robert Conover Macauley, MD, FAAP
Margaret Rusha Moon, MD, FAAP
Alexander L. Okun, MD, FAAP
Douglas J. Opel, MD, MPH, FAAP
Mindy B. Statter, MD, FAAP
Dawn Davies, MD, FRCPC, MA – Canadian Paediatric Society
Mary Lynn Dell, MD, DMin – American Academy of Adolescent and Adolescent Psychiatry
Douglas S. Diekema, MD, MPH, FAAP – American Board of Pediatrics
Sigal Klipstein, MD – American College of Obstetricians and Gynecologists
Nanette Elster, JD, MPH – Accustomed Consultant
Florence Rivera, MPH
Chris Feudtner, MD, PhD, FAAP, Chairperson
Renee Denise Boss, MD, FAAP
Julie Marie Hauer, MD, FAAP
Lisa Michelle Humphrey, MD, FAAP
Jeffrey Klick, MD, FAAP
Jennifer S. Linebarger, MD, MPH, FAAP
Stacy Parker – Ancestors Liaison
Blyth Lord, EdM – Ancestors Liaison
Sonia Imaizumi, MD, FAAP
Madra Guinn-Jones, MPH
Emalee G. Flaherty, MD, FAAP, Chairperson
CAPT Amy R. Gavril, MD, MSCI, FAAP
Sheila M. Idzerda, MD, FAAP
Antoinette Laskey, MD, MPH, MBA, FAAP
Lori A. Legano, MD, FAAP
John M. Leventhal, MD, FAAP
Beverly L. Fortson, PhD – Centers for Disease Control and Prevention
Harriet MacMillan, MD, MSc, FRCPC – American Academy of Adolescent and Adolescent Psychiatry
Elaine Stedt, MSW, ACSW – Administration for Children, Youth and Families, Office on Adolescent Corruption and Neglect
This certificate is copyrighted and is acreage of the American Academy of Pediatrics and its Board of Directors. All authors accept filed battle of absorption statements with the American Academy of Pediatrics. Any conflicts accept been bound through a activity accustomed by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accustomed any bartering captivation in the development of the agreeable of this publication.
Policy statements from the American Academy of Pediatrics annual from ability and assets of liaisons and centralized (AAP) and alien reviewers. However, action statements from the American Academy of Pediatrics may not reflect the angle of the liaisons or the organizations or government agencies that they represent.
The advice in this annual does not announce an absolute beforehand of analysis or serve as a accustomed of medical care. Variations, demography into annual abandoned circumstances, may be appropriate.
All action statements from the American Academy of Pediatrics automatically expire 5 years afterwards advertisement unless reaffirmed, revised, or retired at or afore that time.
FINANCIAL DISCLOSURE: The authors accept adumbrated they accept no banking relationships accordant to this commodity to disclose.
FUNDING: No alien funding.
POTENTIAL CONFLICT OF INTEREST: Dr Christian provides medical-legal able assignment in adolescent corruption cases; and Drs Weise, Okun, and Carter accept adumbrated they accept no abeyant conflicts of absorption to disclose.
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