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American Academy of Pediatrics (AAP): 2016 National Conference and Exhibition
Preventing EMR problems means foreseeing them first
SAN FRANCISCO – Are electronic medical records wreaking havoc for you? Herschel R. Lessin, MD, vice president of the Children’s Medical Group in Poughkeepsie, N.Y., had some EMR recommendations.
In his presentation entitled “Help! My EMR Threw Me Under the Bus!” at the annual meeting of the American Academy of Pediatrics, Dr. Lessin offered the following recommendations for troubleshooting or preventing EMR problems, starting with customizing your EMR right away to reduce alert fatigue.
• Document the specifics of a particular condition, treatment, history, or other note when checking boxes.
• Document your thinking in terms of differential diagnoses.
• Document a follow-up plan beyond just checking the box of a patient’s return date.
• Be wary of cutting and pasting too quickly or relying on the template as a standard of care instead of thoughtful application of the evidence.
• Learn the entry fields for diagnosis codes and for medications and their route of administration.
• Double check that you’re clicking the correct patient, medication, and date of service.
• To prevent data breaches, including HIPAA violations, set up different levels of employee access to EMRs and never share your password.
• Narrative notes should be customized and included, even if the records ask many yes/no questions.
• Keep consistent records. Inconsistency in record keeping is one of the fastest ways to end up in litigation, Dr. Lessin warned. Separation of staff duties in filling out different parts of the EMR, failure to review templates, and “hybrid” charts for which the paper and electronic records don’t match are among the biggest risks for inconsistencies.
• Devise a method for tracking and following up with nonresponsive specialists and with patients, checking on their compliance and unique health care needs. “If a patient with diabetes comes in three times between October and February and you don’t give them a flu shot, then when they get the flu, whose fault is that?” he said. “You need some way to track high-risk patients who need immunizations.”
• Enter notes in a timely fashion – knowing that audits will show time and date of entries – and only use addenda to modify notes.
“If you’re going to make any changes in the medical record, you need to do it as an addendum,” Dr. Lessin said. And, of course, never try to erase a record. Even accidental alterations of records that aren’t following the rules can look very bad, he said.
Dr. Lessin is a principal with Physician Integration Consultants in Atlanta.
SAN FRANCISCO – Are electronic medical records wreaking havoc for you? Herschel R. Lessin, MD, vice president of the Children’s Medical Group in Poughkeepsie, N.Y., had some EMR recommendations.
In his presentation entitled “Help! My EMR Threw Me Under the Bus!” at the annual meeting of the American Academy of Pediatrics, Dr. Lessin offered the following recommendations for troubleshooting or preventing EMR problems, starting with customizing your EMR right away to reduce alert fatigue.
• Document the specifics of a particular condition, treatment, history, or other note when checking boxes.
• Document your thinking in terms of differential diagnoses.
• Document a follow-up plan beyond just checking the box of a patient’s return date.
• Be wary of cutting and pasting too quickly or relying on the template as a standard of care instead of thoughtful application of the evidence.
• Learn the entry fields for diagnosis codes and for medications and their route of administration.
• Double check that you’re clicking the correct patient, medication, and date of service.
• To prevent data breaches, including HIPAA violations, set up different levels of employee access to EMRs and never share your password.
• Narrative notes should be customized and included, even if the records ask many yes/no questions.
• Keep consistent records. Inconsistency in record keeping is one of the fastest ways to end up in litigation, Dr. Lessin warned. Separation of staff duties in filling out different parts of the EMR, failure to review templates, and “hybrid” charts for which the paper and electronic records don’t match are among the biggest risks for inconsistencies.
• Devise a method for tracking and following up with nonresponsive specialists and with patients, checking on their compliance and unique health care needs. “If a patient with diabetes comes in three times between October and February and you don’t give them a flu shot, then when they get the flu, whose fault is that?” he said. “You need some way to track high-risk patients who need immunizations.”
• Enter notes in a timely fashion – knowing that audits will show time and date of entries – and only use addenda to modify notes.
“If you’re going to make any changes in the medical record, you need to do it as an addendum,” Dr. Lessin said. And, of course, never try to erase a record. Even accidental alterations of records that aren’t following the rules can look very bad, he said.
Dr. Lessin is a principal with Physician Integration Consultants in Atlanta.
SAN FRANCISCO – Are electronic medical records wreaking havoc for you? Herschel R. Lessin, MD, vice president of the Children’s Medical Group in Poughkeepsie, N.Y., had some EMR recommendations.
In his presentation entitled “Help! My EMR Threw Me Under the Bus!” at the annual meeting of the American Academy of Pediatrics, Dr. Lessin offered the following recommendations for troubleshooting or preventing EMR problems, starting with customizing your EMR right away to reduce alert fatigue.
• Document the specifics of a particular condition, treatment, history, or other note when checking boxes.
• Document your thinking in terms of differential diagnoses.
• Document a follow-up plan beyond just checking the box of a patient’s return date.
• Be wary of cutting and pasting too quickly or relying on the template as a standard of care instead of thoughtful application of the evidence.
• Learn the entry fields for diagnosis codes and for medications and their route of administration.
• Double check that you’re clicking the correct patient, medication, and date of service.
• To prevent data breaches, including HIPAA violations, set up different levels of employee access to EMRs and never share your password.
• Narrative notes should be customized and included, even if the records ask many yes/no questions.
• Keep consistent records. Inconsistency in record keeping is one of the fastest ways to end up in litigation, Dr. Lessin warned. Separation of staff duties in filling out different parts of the EMR, failure to review templates, and “hybrid” charts for which the paper and electronic records don’t match are among the biggest risks for inconsistencies.
• Devise a method for tracking and following up with nonresponsive specialists and with patients, checking on their compliance and unique health care needs. “If a patient with diabetes comes in three times between October and February and you don’t give them a flu shot, then when they get the flu, whose fault is that?” he said. “You need some way to track high-risk patients who need immunizations.”
• Enter notes in a timely fashion – knowing that audits will show time and date of entries – and only use addenda to modify notes.
“If you’re going to make any changes in the medical record, you need to do it as an addendum,” Dr. Lessin said. And, of course, never try to erase a record. Even accidental alterations of records that aren’t following the rules can look very bad, he said.
Dr. Lessin is a principal with Physician Integration Consultants in Atlanta.
AT AAP 16
Resources and technologies are making teen drivers safer
SAN FRANCISCO – Clinicians and parents should capitalize on a variety of resources and new technologies that help keep teen drivers safe behind the wheel, according to Dr. Joseph O’Neil, a pediatrician at the Riley Hospital for Children in Indianapolis.
“As I like to share with parents, this is the one developmental milestone that parents really want their kids to have that is potentially lethal. This could really kill them,” he said at the annual meeting of the American Academy of Pediatrics. “Believe me, that’s a conversation stopper; they sort of look at you funny. But it’s true.”
“But there is some good news. We have been paying attention,” Dr. O’Neil said. Concerted safety efforts and campaigns led to a halving of young driver fatalities between 2005 and 2014, although a recent analysis suggesting a reversal of that trend has generated some concern.
Risk factors
Numerous factors increase the risk of crashes and deaths for teen drivers, beginning with their developmental stage, according to Dr. O’Neil. Youth are characterized by their striving for autonomy, impulsivity, risk taking, and greater susceptibility to peer influences, compounded by poor judgment of hazards.
“We know that their executive function is still improving, still maturing, They really don’t start getting to adult levels, if they ever do, until about 25,” he commented humorously.
Other risk factors include speeding, drinking and substance use, sleep deprivation, and distractions that range from cell phones, to eating and grooming, to all the gizmos on the dashboard today. Not wearing seat belts also plays a role, as teens are the age group least likely to buckle up, and risk rises with the number of young passengers in the vehicle.
The rate of fatal crashes among young drivers is more than twice as high at night, compared with during the day, with the hours of 9 p.m. to midnight being most hazardous. And the riskiest meteorologic conditions are, not surprisingly, snow and ice – something that parents should take into account in their typical rush to get driver’s education out of the way in the summer months, he said.
“Most of the evidence points to inexperience as probably the single most important risk factor because with inexperience, you’re going to use cell phones, you’re going to be distracted, you’re not going to be paying attention because you don’t have the experience to know that you should,” Dr. O’Neil said.
Graduated driver’s licenses
A key resource in addressing teen drivers’ inexperience and the fact that their crash rate is highest in their first year of driving are graduated driver licenses (GDLs). These licenses start with a learner’s permit mandating supervision and having many restrictions on conditions such as times when driving is permitted and number of passengers, and if there are no infractions, slowly lift these restrictions as the teen gains more driving experience, until he or she receives a full driver’s license.
Use of GDLs over the past 20 years or so been credited with a reduction of 10%-30% in the rate of motor vehicle fatalities among young teen drivers.
“The problem is that teens have smartened up; they are waiting until later, age 18, to start driving because they don’t want to go through the rigmarole of a GDL,” he said. “We know that that’s a problem because we have right shifted that curve, so we are not seeing as many 15- and 16-year-olds dying behind the wheel; we are seeing more of the 18- and 19-year-olds up to 25-year-olds.”
Clinicians should familiarize themselves with their state’s GDL, Dr. O’Neil recommended. As most states’ GDL laws end at age 18, legislators are now looking at options such as establishing a GDL requirement for all new drivers, regardless of age.
High-tech tools
Clinicians also should also be aware of a host of new high-tech tools designed to make teen drivers safer, often by extending parents’ supervisory role, Dr. O’Neil advised. “Your parents in your practices are going to ask you about these,” he said.
So-called black boxes on vehicles collect a wealth of data about driving and conditions inside the vehicle that can be made available to parents. If black boxes are used correctly, they can enable parents to give feedback to the young driver and reduce overall crash risk, he said.
New GPS monitors will track a vehicle’s speed and range, with an optional feature called geofencing whereby parents can prespecify geographic limits on where their teen driver can go. If the teen ventures outside those limits, the monitor sends a notification.
Video monitoring systems now on the market will record footage both inside and outside of the car. Some record continuously, whereas others capture only events. Parents can obtain a summary report, generally through a monthly subscription, delivered by telephone or email to see how their teen is driving when solo.
Other in-vehicle monitoring technologies include direct-feedback systems, such as the tones that sound when the driver fails to fasten his or her seat belt, changes lanes, or gets too close to another car. Some systems can be configured to send a text or email when these alerts are engaged.
Parents who want to be more proactive can, for certain vehicles, invest in smart keys that are programmed to control vehicle parameters, such as the vehicle speed or the volume on the radio, according to Dr. O’Neil.
Finally, downloadable apps for cell phones will block the user’s ability to call (except in an emergency), text, surf, and take selfies while driving. “This doesn’t mean the child won’t be able to use someone else’s phone, but it does do a nice job for that particular installation,” he commented.
Parent-teen driving agreements
“We’ve talked about a lot of neat things that are out there, but what it all boils down to in the end are the parents – mom and dad. Parents truly are the gatekeepers of the keys,” Dr. O’Neil asserted. “We know that they can have an influence on their teens’ behavior. Parents can set restrictions and regulations on driving, and make sure [teens] follow all the traffic laws and set limits on high-risk driving situations.”
However, parents often underestimate the risks that their teens take behind the wheel. “Everyone always thinks that it’s the other kid who’s going to be driving wildly,” he said. “It’s okay for us to say, ‘I know he’s a great kid, but it’s not the bad kids who get into crashes. All kids get into crashes,’” he said. “It’s important to remind parents that all kids are at risk.
“One of the most valuable things that we can do as physicians to help parents navigate these crazy waters is talk about parent-teen driving agreements or contracts,” Dr. O’Neil said. “This has been shown time and time again to have a positive effect on driving behavior.”
These agreements list rules and expectations, and consequences for breaking the rules. “Both mom and dad, and the teen sign it. You put your name on the line, and that’s important because that really means something. This is probably the first contract this kid will ever sign, and it’s probably the most important one that [the teen] will ever sign.” He recommended that a paper version of the agreement be placed in a prominent location, such as on the refrigerator door, for maximal effectiveness.
A variety of parent-teen driving agreements are available online through initiatives such as the Checkpoints Program, Parents Are the Key to Safe Teen Drivers, I Drive Safely, and the AAP’s Parent-Teen Driving Agreement. Overall, their use has been shown to reduce the risks of traffic violations and crashes by 40%-50%.
Of note, these contracts complement rather than replace GDLs. Additionally, “the law of the land doesn’t trump the law of reality and the law of physics,” Dr. O’Neil pointed out. “We know that the laws in our states are not really always best practice, so as we advocate for best practice laws, what we can do is let the parents set better limits on the teen’s driving.”
Anticipatory guidance
“I usually start talking [with families] about driving when the child is 12 or 13,” Dr. O’Neil said. “Anticipatory guidance does work. We know that for a lot of other things that we do, but parents often need help in trying to figure out what to do.”
He recommended the AAP’s Healthy Children website as a source of good information and resources, including a Young Driver Tool for parents. “This has been vetted through the PROS [Pediatric Research in Office Settings] network, and it has been shown that parents do use it, parents do like it,” he noted. “And really it makes your job easier, because it takes time to talk about all these risk factors, and you can say, ‘Hey, I want you to go look at this website for teen driving. This will help.’ ”
Clinicians should generally cover with families the various risk factors, limit setting, use of GDLs, and parent-teen driving agreements. “Talk to parents about all these things. Talk to the teen; the teen will listen to you; you are an authority figure,” and “use interventional motivational techniques,” he said.
As parents control the vehicle their child drives, they should be counseled to give their teen the family’s safest car, preferably a newer, mid- to full-size vehicle with a small engine and modern safety features, according to Dr. O’Neil. “And we really do try to discourage teens buying their own cars because that sort of limits the parents’ leverage over them when they are starting to drive.”
Clinicians also should familiarize themselves with the driver’s education and similar resources in their community, including safe-driving initiatives spearheaded by groups such as Mothers Against Drunk Driving (MADD). They also should work with schools and the police to support “risky driving” prevention efforts.
Special anticipatory guidance is warranted when the new teen driver has a relevant condition such as attention-deficit/hyperactivity disorder. These youth are two to four times more likely to have a motor vehicle accident than typical teen drivers.
They may benefit from extended-release ADHD medication or a booster dose of their medication to keep them covered while driving, according to Dr. O’Neil.
“You may want to talk to them about holding off. Maybe their brain hasn’t matured enough yet, and you want to delay their driving. You may want to do a longer period of supervised driving or consider other things we’ve talked about – electronic resources or using a bigger, safer vehicle,” he suggested. “And always, always, always encourage limiting of distractions while driving.”
Dr. O’Neil said he had no relevant conflicts of interest.
SAN FRANCISCO – Clinicians and parents should capitalize on a variety of resources and new technologies that help keep teen drivers safe behind the wheel, according to Dr. Joseph O’Neil, a pediatrician at the Riley Hospital for Children in Indianapolis.
“As I like to share with parents, this is the one developmental milestone that parents really want their kids to have that is potentially lethal. This could really kill them,” he said at the annual meeting of the American Academy of Pediatrics. “Believe me, that’s a conversation stopper; they sort of look at you funny. But it’s true.”
“But there is some good news. We have been paying attention,” Dr. O’Neil said. Concerted safety efforts and campaigns led to a halving of young driver fatalities between 2005 and 2014, although a recent analysis suggesting a reversal of that trend has generated some concern.
Risk factors
Numerous factors increase the risk of crashes and deaths for teen drivers, beginning with their developmental stage, according to Dr. O’Neil. Youth are characterized by their striving for autonomy, impulsivity, risk taking, and greater susceptibility to peer influences, compounded by poor judgment of hazards.
“We know that their executive function is still improving, still maturing, They really don’t start getting to adult levels, if they ever do, until about 25,” he commented humorously.
Other risk factors include speeding, drinking and substance use, sleep deprivation, and distractions that range from cell phones, to eating and grooming, to all the gizmos on the dashboard today. Not wearing seat belts also plays a role, as teens are the age group least likely to buckle up, and risk rises with the number of young passengers in the vehicle.
The rate of fatal crashes among young drivers is more than twice as high at night, compared with during the day, with the hours of 9 p.m. to midnight being most hazardous. And the riskiest meteorologic conditions are, not surprisingly, snow and ice – something that parents should take into account in their typical rush to get driver’s education out of the way in the summer months, he said.
“Most of the evidence points to inexperience as probably the single most important risk factor because with inexperience, you’re going to use cell phones, you’re going to be distracted, you’re not going to be paying attention because you don’t have the experience to know that you should,” Dr. O’Neil said.
Graduated driver’s licenses
A key resource in addressing teen drivers’ inexperience and the fact that their crash rate is highest in their first year of driving are graduated driver licenses (GDLs). These licenses start with a learner’s permit mandating supervision and having many restrictions on conditions such as times when driving is permitted and number of passengers, and if there are no infractions, slowly lift these restrictions as the teen gains more driving experience, until he or she receives a full driver’s license.
Use of GDLs over the past 20 years or so been credited with a reduction of 10%-30% in the rate of motor vehicle fatalities among young teen drivers.
“The problem is that teens have smartened up; they are waiting until later, age 18, to start driving because they don’t want to go through the rigmarole of a GDL,” he said. “We know that that’s a problem because we have right shifted that curve, so we are not seeing as many 15- and 16-year-olds dying behind the wheel; we are seeing more of the 18- and 19-year-olds up to 25-year-olds.”
Clinicians should familiarize themselves with their state’s GDL, Dr. O’Neil recommended. As most states’ GDL laws end at age 18, legislators are now looking at options such as establishing a GDL requirement for all new drivers, regardless of age.
High-tech tools
Clinicians also should also be aware of a host of new high-tech tools designed to make teen drivers safer, often by extending parents’ supervisory role, Dr. O’Neil advised. “Your parents in your practices are going to ask you about these,” he said.
So-called black boxes on vehicles collect a wealth of data about driving and conditions inside the vehicle that can be made available to parents. If black boxes are used correctly, they can enable parents to give feedback to the young driver and reduce overall crash risk, he said.
New GPS monitors will track a vehicle’s speed and range, with an optional feature called geofencing whereby parents can prespecify geographic limits on where their teen driver can go. If the teen ventures outside those limits, the monitor sends a notification.
Video monitoring systems now on the market will record footage both inside and outside of the car. Some record continuously, whereas others capture only events. Parents can obtain a summary report, generally through a monthly subscription, delivered by telephone or email to see how their teen is driving when solo.
Other in-vehicle monitoring technologies include direct-feedback systems, such as the tones that sound when the driver fails to fasten his or her seat belt, changes lanes, or gets too close to another car. Some systems can be configured to send a text or email when these alerts are engaged.
Parents who want to be more proactive can, for certain vehicles, invest in smart keys that are programmed to control vehicle parameters, such as the vehicle speed or the volume on the radio, according to Dr. O’Neil.
Finally, downloadable apps for cell phones will block the user’s ability to call (except in an emergency), text, surf, and take selfies while driving. “This doesn’t mean the child won’t be able to use someone else’s phone, but it does do a nice job for that particular installation,” he commented.
Parent-teen driving agreements
“We’ve talked about a lot of neat things that are out there, but what it all boils down to in the end are the parents – mom and dad. Parents truly are the gatekeepers of the keys,” Dr. O’Neil asserted. “We know that they can have an influence on their teens’ behavior. Parents can set restrictions and regulations on driving, and make sure [teens] follow all the traffic laws and set limits on high-risk driving situations.”
However, parents often underestimate the risks that their teens take behind the wheel. “Everyone always thinks that it’s the other kid who’s going to be driving wildly,” he said. “It’s okay for us to say, ‘I know he’s a great kid, but it’s not the bad kids who get into crashes. All kids get into crashes,’” he said. “It’s important to remind parents that all kids are at risk.
“One of the most valuable things that we can do as physicians to help parents navigate these crazy waters is talk about parent-teen driving agreements or contracts,” Dr. O’Neil said. “This has been shown time and time again to have a positive effect on driving behavior.”
These agreements list rules and expectations, and consequences for breaking the rules. “Both mom and dad, and the teen sign it. You put your name on the line, and that’s important because that really means something. This is probably the first contract this kid will ever sign, and it’s probably the most important one that [the teen] will ever sign.” He recommended that a paper version of the agreement be placed in a prominent location, such as on the refrigerator door, for maximal effectiveness.
A variety of parent-teen driving agreements are available online through initiatives such as the Checkpoints Program, Parents Are the Key to Safe Teen Drivers, I Drive Safely, and the AAP’s Parent-Teen Driving Agreement. Overall, their use has been shown to reduce the risks of traffic violations and crashes by 40%-50%.
Of note, these contracts complement rather than replace GDLs. Additionally, “the law of the land doesn’t trump the law of reality and the law of physics,” Dr. O’Neil pointed out. “We know that the laws in our states are not really always best practice, so as we advocate for best practice laws, what we can do is let the parents set better limits on the teen’s driving.”
Anticipatory guidance
“I usually start talking [with families] about driving when the child is 12 or 13,” Dr. O’Neil said. “Anticipatory guidance does work. We know that for a lot of other things that we do, but parents often need help in trying to figure out what to do.”
He recommended the AAP’s Healthy Children website as a source of good information and resources, including a Young Driver Tool for parents. “This has been vetted through the PROS [Pediatric Research in Office Settings] network, and it has been shown that parents do use it, parents do like it,” he noted. “And really it makes your job easier, because it takes time to talk about all these risk factors, and you can say, ‘Hey, I want you to go look at this website for teen driving. This will help.’ ”
Clinicians should generally cover with families the various risk factors, limit setting, use of GDLs, and parent-teen driving agreements. “Talk to parents about all these things. Talk to the teen; the teen will listen to you; you are an authority figure,” and “use interventional motivational techniques,” he said.
As parents control the vehicle their child drives, they should be counseled to give their teen the family’s safest car, preferably a newer, mid- to full-size vehicle with a small engine and modern safety features, according to Dr. O’Neil. “And we really do try to discourage teens buying their own cars because that sort of limits the parents’ leverage over them when they are starting to drive.”
Clinicians also should familiarize themselves with the driver’s education and similar resources in their community, including safe-driving initiatives spearheaded by groups such as Mothers Against Drunk Driving (MADD). They also should work with schools and the police to support “risky driving” prevention efforts.
Special anticipatory guidance is warranted when the new teen driver has a relevant condition such as attention-deficit/hyperactivity disorder. These youth are two to four times more likely to have a motor vehicle accident than typical teen drivers.
They may benefit from extended-release ADHD medication or a booster dose of their medication to keep them covered while driving, according to Dr. O’Neil.
“You may want to talk to them about holding off. Maybe their brain hasn’t matured enough yet, and you want to delay their driving. You may want to do a longer period of supervised driving or consider other things we’ve talked about – electronic resources or using a bigger, safer vehicle,” he suggested. “And always, always, always encourage limiting of distractions while driving.”
Dr. O’Neil said he had no relevant conflicts of interest.
SAN FRANCISCO – Clinicians and parents should capitalize on a variety of resources and new technologies that help keep teen drivers safe behind the wheel, according to Dr. Joseph O’Neil, a pediatrician at the Riley Hospital for Children in Indianapolis.
“As I like to share with parents, this is the one developmental milestone that parents really want their kids to have that is potentially lethal. This could really kill them,” he said at the annual meeting of the American Academy of Pediatrics. “Believe me, that’s a conversation stopper; they sort of look at you funny. But it’s true.”
“But there is some good news. We have been paying attention,” Dr. O’Neil said. Concerted safety efforts and campaigns led to a halving of young driver fatalities between 2005 and 2014, although a recent analysis suggesting a reversal of that trend has generated some concern.
Risk factors
Numerous factors increase the risk of crashes and deaths for teen drivers, beginning with their developmental stage, according to Dr. O’Neil. Youth are characterized by their striving for autonomy, impulsivity, risk taking, and greater susceptibility to peer influences, compounded by poor judgment of hazards.
“We know that their executive function is still improving, still maturing, They really don’t start getting to adult levels, if they ever do, until about 25,” he commented humorously.
Other risk factors include speeding, drinking and substance use, sleep deprivation, and distractions that range from cell phones, to eating and grooming, to all the gizmos on the dashboard today. Not wearing seat belts also plays a role, as teens are the age group least likely to buckle up, and risk rises with the number of young passengers in the vehicle.
The rate of fatal crashes among young drivers is more than twice as high at night, compared with during the day, with the hours of 9 p.m. to midnight being most hazardous. And the riskiest meteorologic conditions are, not surprisingly, snow and ice – something that parents should take into account in their typical rush to get driver’s education out of the way in the summer months, he said.
“Most of the evidence points to inexperience as probably the single most important risk factor because with inexperience, you’re going to use cell phones, you’re going to be distracted, you’re not going to be paying attention because you don’t have the experience to know that you should,” Dr. O’Neil said.
Graduated driver’s licenses
A key resource in addressing teen drivers’ inexperience and the fact that their crash rate is highest in their first year of driving are graduated driver licenses (GDLs). These licenses start with a learner’s permit mandating supervision and having many restrictions on conditions such as times when driving is permitted and number of passengers, and if there are no infractions, slowly lift these restrictions as the teen gains more driving experience, until he or she receives a full driver’s license.
Use of GDLs over the past 20 years or so been credited with a reduction of 10%-30% in the rate of motor vehicle fatalities among young teen drivers.
“The problem is that teens have smartened up; they are waiting until later, age 18, to start driving because they don’t want to go through the rigmarole of a GDL,” he said. “We know that that’s a problem because we have right shifted that curve, so we are not seeing as many 15- and 16-year-olds dying behind the wheel; we are seeing more of the 18- and 19-year-olds up to 25-year-olds.”
Clinicians should familiarize themselves with their state’s GDL, Dr. O’Neil recommended. As most states’ GDL laws end at age 18, legislators are now looking at options such as establishing a GDL requirement for all new drivers, regardless of age.
High-tech tools
Clinicians also should also be aware of a host of new high-tech tools designed to make teen drivers safer, often by extending parents’ supervisory role, Dr. O’Neil advised. “Your parents in your practices are going to ask you about these,” he said.
So-called black boxes on vehicles collect a wealth of data about driving and conditions inside the vehicle that can be made available to parents. If black boxes are used correctly, they can enable parents to give feedback to the young driver and reduce overall crash risk, he said.
New GPS monitors will track a vehicle’s speed and range, with an optional feature called geofencing whereby parents can prespecify geographic limits on where their teen driver can go. If the teen ventures outside those limits, the monitor sends a notification.
Video monitoring systems now on the market will record footage both inside and outside of the car. Some record continuously, whereas others capture only events. Parents can obtain a summary report, generally through a monthly subscription, delivered by telephone or email to see how their teen is driving when solo.
Other in-vehicle monitoring technologies include direct-feedback systems, such as the tones that sound when the driver fails to fasten his or her seat belt, changes lanes, or gets too close to another car. Some systems can be configured to send a text or email when these alerts are engaged.
Parents who want to be more proactive can, for certain vehicles, invest in smart keys that are programmed to control vehicle parameters, such as the vehicle speed or the volume on the radio, according to Dr. O’Neil.
Finally, downloadable apps for cell phones will block the user’s ability to call (except in an emergency), text, surf, and take selfies while driving. “This doesn’t mean the child won’t be able to use someone else’s phone, but it does do a nice job for that particular installation,” he commented.
Parent-teen driving agreements
“We’ve talked about a lot of neat things that are out there, but what it all boils down to in the end are the parents – mom and dad. Parents truly are the gatekeepers of the keys,” Dr. O’Neil asserted. “We know that they can have an influence on their teens’ behavior. Parents can set restrictions and regulations on driving, and make sure [teens] follow all the traffic laws and set limits on high-risk driving situations.”
However, parents often underestimate the risks that their teens take behind the wheel. “Everyone always thinks that it’s the other kid who’s going to be driving wildly,” he said. “It’s okay for us to say, ‘I know he’s a great kid, but it’s not the bad kids who get into crashes. All kids get into crashes,’” he said. “It’s important to remind parents that all kids are at risk.
“One of the most valuable things that we can do as physicians to help parents navigate these crazy waters is talk about parent-teen driving agreements or contracts,” Dr. O’Neil said. “This has been shown time and time again to have a positive effect on driving behavior.”
These agreements list rules and expectations, and consequences for breaking the rules. “Both mom and dad, and the teen sign it. You put your name on the line, and that’s important because that really means something. This is probably the first contract this kid will ever sign, and it’s probably the most important one that [the teen] will ever sign.” He recommended that a paper version of the agreement be placed in a prominent location, such as on the refrigerator door, for maximal effectiveness.
A variety of parent-teen driving agreements are available online through initiatives such as the Checkpoints Program, Parents Are the Key to Safe Teen Drivers, I Drive Safely, and the AAP’s Parent-Teen Driving Agreement. Overall, their use has been shown to reduce the risks of traffic violations and crashes by 40%-50%.
Of note, these contracts complement rather than replace GDLs. Additionally, “the law of the land doesn’t trump the law of reality and the law of physics,” Dr. O’Neil pointed out. “We know that the laws in our states are not really always best practice, so as we advocate for best practice laws, what we can do is let the parents set better limits on the teen’s driving.”
Anticipatory guidance
“I usually start talking [with families] about driving when the child is 12 or 13,” Dr. O’Neil said. “Anticipatory guidance does work. We know that for a lot of other things that we do, but parents often need help in trying to figure out what to do.”
He recommended the AAP’s Healthy Children website as a source of good information and resources, including a Young Driver Tool for parents. “This has been vetted through the PROS [Pediatric Research in Office Settings] network, and it has been shown that parents do use it, parents do like it,” he noted. “And really it makes your job easier, because it takes time to talk about all these risk factors, and you can say, ‘Hey, I want you to go look at this website for teen driving. This will help.’ ”
Clinicians should generally cover with families the various risk factors, limit setting, use of GDLs, and parent-teen driving agreements. “Talk to parents about all these things. Talk to the teen; the teen will listen to you; you are an authority figure,” and “use interventional motivational techniques,” he said.
As parents control the vehicle their child drives, they should be counseled to give their teen the family’s safest car, preferably a newer, mid- to full-size vehicle with a small engine and modern safety features, according to Dr. O’Neil. “And we really do try to discourage teens buying their own cars because that sort of limits the parents’ leverage over them when they are starting to drive.”
Clinicians also should familiarize themselves with the driver’s education and similar resources in their community, including safe-driving initiatives spearheaded by groups such as Mothers Against Drunk Driving (MADD). They also should work with schools and the police to support “risky driving” prevention efforts.
Special anticipatory guidance is warranted when the new teen driver has a relevant condition such as attention-deficit/hyperactivity disorder. These youth are two to four times more likely to have a motor vehicle accident than typical teen drivers.
They may benefit from extended-release ADHD medication or a booster dose of their medication to keep them covered while driving, according to Dr. O’Neil.
“You may want to talk to them about holding off. Maybe their brain hasn’t matured enough yet, and you want to delay their driving. You may want to do a longer period of supervised driving or consider other things we’ve talked about – electronic resources or using a bigger, safer vehicle,” he suggested. “And always, always, always encourage limiting of distractions while driving.”
Dr. O’Neil said he had no relevant conflicts of interest.
Vitamin D supplementation recommended in all children, teens
SAN FRANCISCO – Vitamin D deficiency is common among children and adolescents, particularly those with chronic disease, Catherine Gordon, MD, said at the annual meeting of the American Academy of Pediatrics.
Yet the precise definition of vitamin D deficiency and the healthy threshold for vitamin D levels lack universally agreed-upon standards. Generally speaking, levels of at least 30 ng/mL (75 nmol/L) appear safe and reasonable for children with chronic disease, and additional research is confirming whether this range is appropriate for other pediatric groups as well. Although too much vitamin D can lead to hypercalcemia, vitamin D intoxication is very rare, said Dr. Gordon, director of the division of adolescents and transition medicine at the University of Cincinnati.
Severe vitamin D deficiency can lead to rickets, when bones have insufficient calcium and phosphorus levels, resulting in bone softening and weakening before growth plates close. If not treated with vitamin D and calcium supplementation, rickets becomes osteomalacia after the growth plates close.
Vitamin D deficiency rates vary by population
It’s difficult to pin down rates of vitamin D deficiency. One 2004 study of just over 300 children found nearly a quarter of them (24%) were deficient based on a threshold of levels below 15 ng/mL, and another 42% had insufficient levels, defined as 20 ng/mL or lower, but all were asymptomatic. Another 2008 study using different cut-offs found that 12% of healthy 8- to 24-month-olds were deficient, defined as levels below 20 ng/mL. Forty percent of the children had suboptimal levels below 30 ng/mL. Overall, a third of the children showed demineralization on their x-rays. While the season of the year and race/ethnicity did not emerge as predictors of vitamin D insufficiency, breastfeeding without supplementation and lack of milk consumption did.
Because the vitamin D content in human breast milk is low, breastfed infants typically develop low vitamin D levels unless they receive supplementation or plenty of exposure to sunlight. A maternal dose of 6,400 IU of vitamin D is needed for breastfed infants to reach normal vitamin D levels, Dr. Gordon said. Babies born to mothers with vitamin D deficiency have the highest risk of becoming deficient themselves, although formula-fed babies usually receive plenty through the vitamin D fortification in infant formula.
Among adolescents, obesity remains a common risk factor, and those with obesity require higher doses to correct deficiency or insufficiency. A study in the Journal of Pediatrics this year found that adult-sized teens need at least 5,000 IU of vitamin D3 a day for 8 weeks to correct deficiency. Similarly, a small 2012 study of 61 children and adolescents with inflammatory bowel disease found that supplementation of 2,000 IU of vitamin D3 daily or 50,000 IU of D2 weekly, for 6 weeks, more effectively corrected vitamin D deficiency than 2,000 IU daily of vitamin D2 without any changes to parathyroid hormone suppression.
How much to supplement
Much debate and uncertainty surround how much (if at all) healthy infants, children, and adolescents should be supplemented with vitamin D. The American Academy of Pediatrics recommends daily supplementation of 400 IU of vitamin D from birth through adolescence for all children and teens, although that’s far below the safe upper limit of vitamin D intake, Dr. Gordon said.
The health and sciences division (formerly the Institute of Medicine) of the National Academies of Sciences, Engineering, and Medicine, by contrast, recommends a daily intake of 400 IU of vitamin D for the first year of life and then 600 IU for age 1 through old age. The safe upper limits set by the health and sciences division include 1,000 IU for infants up to 6 months old, 1,500 IU for infants aged 6 months to 1 year, 2,500 IU for toddlers up to 3 years, 3,000 IU for children aged 4-8 years, and 4,000 IU for those 9 years and older.
Yet the Endocrine Society recommends a greater amount of supplementation for children at risk for vitamin D deficiency or low bone density mass: from 400 to 1,000 IU for children 1 year and younger, and 600-1,000 IU for all older children, adolescents, and adults. The Endocrine Society also cites a higher safe upper limit of 2,000 IU for infants up to 12 months and 4,000 IU for those aged 1 year and up.
Part of the discordance in these recommendations lies in what populations they are aimed at, Dr. Gordon explained. While the health and sciences division recommendations were written for healthy children and adolescents, the Endocrine Society is specifically addressing those in risk groups, such as transplant recipients, those with chronic conditions that can cause malabsorption, and those taking anticonvulsants or receiving other treatments that can threaten bone health. Among older children and adolescents, anorexia nervosa is also a risk factor for inadequate vitamin D levels.
Dr. Gordon recommended 600 IU of vitamin D daily for all healthy children and teens while noting that those in risk groups may require 1,000-2,000 IU to prevent vitamin D deficiency.
Additional concerns with inadequate vitamin D
Aside from bone mineral density and levels of 25(OH)D (25-hydroxy vitamin D) and parathyroid hormone, vitamin D insufficiency may be suspected based on several other biomarkers, including fractures or falls, intestinal calcium absorption, dental health, insulin sensitivity, beta-cell or immune functioning, respiratory disease such as wheezing or tuberculosis, and possibly hypertension.
Researchers have developed new interest in exploring whether factors during childhood and adolescence – critical years for bone acquisition – such as vitamin D levels might influence the risk for osteoporosis later in life, Dr. Gordon said.
Both males and females reach their peak bone mass and skeletal strength in their early to mid-20s and maintain these through about their mid-40s. While individuals have no control over intrinsic factors that help determine their bone mass, such as sex, family history, and ethnicity, other extrinsic factors are also bone mass determinants, including diet, body mass, a particular individual’s hormonal mix, illnesses and their treatments, physical activity level, and lifestyle choices.
Therefore, health providers should encourage patients to regularly exercise, maintain a healthy weight, eat healthfully, and take daily supplements, Dr. Gordon said. She only recommended testing 25(OH)D levels in those at risk for deficiency and/or low bone mass.
Dr. Gordon reported no relevant financial disclosures.
SAN FRANCISCO – Vitamin D deficiency is common among children and adolescents, particularly those with chronic disease, Catherine Gordon, MD, said at the annual meeting of the American Academy of Pediatrics.
Yet the precise definition of vitamin D deficiency and the healthy threshold for vitamin D levels lack universally agreed-upon standards. Generally speaking, levels of at least 30 ng/mL (75 nmol/L) appear safe and reasonable for children with chronic disease, and additional research is confirming whether this range is appropriate for other pediatric groups as well. Although too much vitamin D can lead to hypercalcemia, vitamin D intoxication is very rare, said Dr. Gordon, director of the division of adolescents and transition medicine at the University of Cincinnati.
Severe vitamin D deficiency can lead to rickets, when bones have insufficient calcium and phosphorus levels, resulting in bone softening and weakening before growth plates close. If not treated with vitamin D and calcium supplementation, rickets becomes osteomalacia after the growth plates close.
Vitamin D deficiency rates vary by population
It’s difficult to pin down rates of vitamin D deficiency. One 2004 study of just over 300 children found nearly a quarter of them (24%) were deficient based on a threshold of levels below 15 ng/mL, and another 42% had insufficient levels, defined as 20 ng/mL or lower, but all were asymptomatic. Another 2008 study using different cut-offs found that 12% of healthy 8- to 24-month-olds were deficient, defined as levels below 20 ng/mL. Forty percent of the children had suboptimal levels below 30 ng/mL. Overall, a third of the children showed demineralization on their x-rays. While the season of the year and race/ethnicity did not emerge as predictors of vitamin D insufficiency, breastfeeding without supplementation and lack of milk consumption did.
Because the vitamin D content in human breast milk is low, breastfed infants typically develop low vitamin D levels unless they receive supplementation or plenty of exposure to sunlight. A maternal dose of 6,400 IU of vitamin D is needed for breastfed infants to reach normal vitamin D levels, Dr. Gordon said. Babies born to mothers with vitamin D deficiency have the highest risk of becoming deficient themselves, although formula-fed babies usually receive plenty through the vitamin D fortification in infant formula.
Among adolescents, obesity remains a common risk factor, and those with obesity require higher doses to correct deficiency or insufficiency. A study in the Journal of Pediatrics this year found that adult-sized teens need at least 5,000 IU of vitamin D3 a day for 8 weeks to correct deficiency. Similarly, a small 2012 study of 61 children and adolescents with inflammatory bowel disease found that supplementation of 2,000 IU of vitamin D3 daily or 50,000 IU of D2 weekly, for 6 weeks, more effectively corrected vitamin D deficiency than 2,000 IU daily of vitamin D2 without any changes to parathyroid hormone suppression.
How much to supplement
Much debate and uncertainty surround how much (if at all) healthy infants, children, and adolescents should be supplemented with vitamin D. The American Academy of Pediatrics recommends daily supplementation of 400 IU of vitamin D from birth through adolescence for all children and teens, although that’s far below the safe upper limit of vitamin D intake, Dr. Gordon said.
The health and sciences division (formerly the Institute of Medicine) of the National Academies of Sciences, Engineering, and Medicine, by contrast, recommends a daily intake of 400 IU of vitamin D for the first year of life and then 600 IU for age 1 through old age. The safe upper limits set by the health and sciences division include 1,000 IU for infants up to 6 months old, 1,500 IU for infants aged 6 months to 1 year, 2,500 IU for toddlers up to 3 years, 3,000 IU for children aged 4-8 years, and 4,000 IU for those 9 years and older.
Yet the Endocrine Society recommends a greater amount of supplementation for children at risk for vitamin D deficiency or low bone density mass: from 400 to 1,000 IU for children 1 year and younger, and 600-1,000 IU for all older children, adolescents, and adults. The Endocrine Society also cites a higher safe upper limit of 2,000 IU for infants up to 12 months and 4,000 IU for those aged 1 year and up.
Part of the discordance in these recommendations lies in what populations they are aimed at, Dr. Gordon explained. While the health and sciences division recommendations were written for healthy children and adolescents, the Endocrine Society is specifically addressing those in risk groups, such as transplant recipients, those with chronic conditions that can cause malabsorption, and those taking anticonvulsants or receiving other treatments that can threaten bone health. Among older children and adolescents, anorexia nervosa is also a risk factor for inadequate vitamin D levels.
Dr. Gordon recommended 600 IU of vitamin D daily for all healthy children and teens while noting that those in risk groups may require 1,000-2,000 IU to prevent vitamin D deficiency.
Additional concerns with inadequate vitamin D
Aside from bone mineral density and levels of 25(OH)D (25-hydroxy vitamin D) and parathyroid hormone, vitamin D insufficiency may be suspected based on several other biomarkers, including fractures or falls, intestinal calcium absorption, dental health, insulin sensitivity, beta-cell or immune functioning, respiratory disease such as wheezing or tuberculosis, and possibly hypertension.
Researchers have developed new interest in exploring whether factors during childhood and adolescence – critical years for bone acquisition – such as vitamin D levels might influence the risk for osteoporosis later in life, Dr. Gordon said.
Both males and females reach their peak bone mass and skeletal strength in their early to mid-20s and maintain these through about their mid-40s. While individuals have no control over intrinsic factors that help determine their bone mass, such as sex, family history, and ethnicity, other extrinsic factors are also bone mass determinants, including diet, body mass, a particular individual’s hormonal mix, illnesses and their treatments, physical activity level, and lifestyle choices.
Therefore, health providers should encourage patients to regularly exercise, maintain a healthy weight, eat healthfully, and take daily supplements, Dr. Gordon said. She only recommended testing 25(OH)D levels in those at risk for deficiency and/or low bone mass.
Dr. Gordon reported no relevant financial disclosures.
SAN FRANCISCO – Vitamin D deficiency is common among children and adolescents, particularly those with chronic disease, Catherine Gordon, MD, said at the annual meeting of the American Academy of Pediatrics.
Yet the precise definition of vitamin D deficiency and the healthy threshold for vitamin D levels lack universally agreed-upon standards. Generally speaking, levels of at least 30 ng/mL (75 nmol/L) appear safe and reasonable for children with chronic disease, and additional research is confirming whether this range is appropriate for other pediatric groups as well. Although too much vitamin D can lead to hypercalcemia, vitamin D intoxication is very rare, said Dr. Gordon, director of the division of adolescents and transition medicine at the University of Cincinnati.
Severe vitamin D deficiency can lead to rickets, when bones have insufficient calcium and phosphorus levels, resulting in bone softening and weakening before growth plates close. If not treated with vitamin D and calcium supplementation, rickets becomes osteomalacia after the growth plates close.
Vitamin D deficiency rates vary by population
It’s difficult to pin down rates of vitamin D deficiency. One 2004 study of just over 300 children found nearly a quarter of them (24%) were deficient based on a threshold of levels below 15 ng/mL, and another 42% had insufficient levels, defined as 20 ng/mL or lower, but all were asymptomatic. Another 2008 study using different cut-offs found that 12% of healthy 8- to 24-month-olds were deficient, defined as levels below 20 ng/mL. Forty percent of the children had suboptimal levels below 30 ng/mL. Overall, a third of the children showed demineralization on their x-rays. While the season of the year and race/ethnicity did not emerge as predictors of vitamin D insufficiency, breastfeeding without supplementation and lack of milk consumption did.
Because the vitamin D content in human breast milk is low, breastfed infants typically develop low vitamin D levels unless they receive supplementation or plenty of exposure to sunlight. A maternal dose of 6,400 IU of vitamin D is needed for breastfed infants to reach normal vitamin D levels, Dr. Gordon said. Babies born to mothers with vitamin D deficiency have the highest risk of becoming deficient themselves, although formula-fed babies usually receive plenty through the vitamin D fortification in infant formula.
Among adolescents, obesity remains a common risk factor, and those with obesity require higher doses to correct deficiency or insufficiency. A study in the Journal of Pediatrics this year found that adult-sized teens need at least 5,000 IU of vitamin D3 a day for 8 weeks to correct deficiency. Similarly, a small 2012 study of 61 children and adolescents with inflammatory bowel disease found that supplementation of 2,000 IU of vitamin D3 daily or 50,000 IU of D2 weekly, for 6 weeks, more effectively corrected vitamin D deficiency than 2,000 IU daily of vitamin D2 without any changes to parathyroid hormone suppression.
How much to supplement
Much debate and uncertainty surround how much (if at all) healthy infants, children, and adolescents should be supplemented with vitamin D. The American Academy of Pediatrics recommends daily supplementation of 400 IU of vitamin D from birth through adolescence for all children and teens, although that’s far below the safe upper limit of vitamin D intake, Dr. Gordon said.
The health and sciences division (formerly the Institute of Medicine) of the National Academies of Sciences, Engineering, and Medicine, by contrast, recommends a daily intake of 400 IU of vitamin D for the first year of life and then 600 IU for age 1 through old age. The safe upper limits set by the health and sciences division include 1,000 IU for infants up to 6 months old, 1,500 IU for infants aged 6 months to 1 year, 2,500 IU for toddlers up to 3 years, 3,000 IU for children aged 4-8 years, and 4,000 IU for those 9 years and older.
Yet the Endocrine Society recommends a greater amount of supplementation for children at risk for vitamin D deficiency or low bone density mass: from 400 to 1,000 IU for children 1 year and younger, and 600-1,000 IU for all older children, adolescents, and adults. The Endocrine Society also cites a higher safe upper limit of 2,000 IU for infants up to 12 months and 4,000 IU for those aged 1 year and up.
Part of the discordance in these recommendations lies in what populations they are aimed at, Dr. Gordon explained. While the health and sciences division recommendations were written for healthy children and adolescents, the Endocrine Society is specifically addressing those in risk groups, such as transplant recipients, those with chronic conditions that can cause malabsorption, and those taking anticonvulsants or receiving other treatments that can threaten bone health. Among older children and adolescents, anorexia nervosa is also a risk factor for inadequate vitamin D levels.
Dr. Gordon recommended 600 IU of vitamin D daily for all healthy children and teens while noting that those in risk groups may require 1,000-2,000 IU to prevent vitamin D deficiency.
Additional concerns with inadequate vitamin D
Aside from bone mineral density and levels of 25(OH)D (25-hydroxy vitamin D) and parathyroid hormone, vitamin D insufficiency may be suspected based on several other biomarkers, including fractures or falls, intestinal calcium absorption, dental health, insulin sensitivity, beta-cell or immune functioning, respiratory disease such as wheezing or tuberculosis, and possibly hypertension.
Researchers have developed new interest in exploring whether factors during childhood and adolescence – critical years for bone acquisition – such as vitamin D levels might influence the risk for osteoporosis later in life, Dr. Gordon said.
Both males and females reach their peak bone mass and skeletal strength in their early to mid-20s and maintain these through about their mid-40s. While individuals have no control over intrinsic factors that help determine their bone mass, such as sex, family history, and ethnicity, other extrinsic factors are also bone mass determinants, including diet, body mass, a particular individual’s hormonal mix, illnesses and their treatments, physical activity level, and lifestyle choices.
Therefore, health providers should encourage patients to regularly exercise, maintain a healthy weight, eat healthfully, and take daily supplements, Dr. Gordon said. She only recommended testing 25(OH)D levels in those at risk for deficiency and/or low bone mass.
Dr. Gordon reported no relevant financial disclosures.
EXPERT ANALYSIS FROM AAP 16
Restrict gluten if necessary, but confirm condition first
SAN FRANCISCO – Elimination diet crazes have been around for centuries, and one of today’s biggest targets is gluten, contributing to an industry of gluten-free products with revenue in the billions of dollars.
But does taking gluten off your child’s plate actually improve their health? It will if they have a condition in which gluten actually causes symptoms, explained Michelle M. Pietzak, MD, a pediatrician at the University of Southern California, Los Angeles.
Gluten is a mixture of proteins found in wheat, rye, barley, oats, corn, and rice that gives food its elasticity and helps dough rise. Only the gluten in wheat, rye, and barley causes gluten-related symptoms, but it is found in a variety of derivative products, such as spelt, kamut, triticale, couscous, bulgar, faro, matzo flour, and other grains as well. Oats are also considered cross-contaminated with gluten because they are milled with wheat, and other foods containing gluten may be difficult to identify due to food labeling and preparation practices in the United States.
For those with celiac disease, wheat allergy, irritable bowel syndrome (IBS), or nonceliac gluten sensitivity or intolerance, a gluten-free diet can reduce or eliminate the symptoms causing problems. For others, however, the symptoms likely come from somewhere besides gluten or may be a nocebo effect, where a patient who expects negative symptoms becomes more likely to have them.
Lactose intolerance is one example that can cause symptoms similar to those that respond to restricting gluten. Another is sensitivity to fructans, a wheat carbohydrate and one of the fermentable oligo-di-monosaccharides and polyols (FODMAPs) that can improve IBS when restricted. Imbalance in a person’s gut bacteria, called dysbiosis, also may cause similar symptoms and results from excess yeast, parasites, or an overgrowth of bad bacteria in the absence of beneficial ones.
Understanding celiac disease
This immune-mediated disease causes primarily gastrointestinal symptoms when someone ingests proteins called prolamines, which those with celiac disease are genetically predisposed to have difficulty digesting. Common symptoms include diarrhea, nausea, vomiting, abdominal pain, constipation, appetite changes, and, in unusual cases, excess fat in the feces (steatorrhea).
But celiac disease also may contribute to a short stature, osteoporosis, dermatitis herpetiformis, delayed onset of puberty, infertility, anemia (from iron and/or folic acid deficits), epilepsy, and behavioral changes. Although those with celiac disease are at a higher risk for arthritis, osteoporosis, osteopenia, osteomalacia, and rickets, a gluten-free diet can improve children’s low bone mineral density.
Screening for celiac disease includes testing for antigliadin (AGA) IgG and IgA, antiendomysial IgA, anti-tissue transglutaminase (tTG) IgA, total serum IgA, and genetic testing related to HLA-DQ2 and HLA-DQ8 genes.
Wheat allergy
A wheat allergy, among the eight most common food allergies, involves an IgE-mediated reaction to water- and salt-insoluble gliadins, especially omega-5 gliadin, which can cause anaphylaxis in a wheat-allergic person who exercises after ingesting wheat. Symptoms of wheat allergy include hives; swelling, itching or irritation of the mouth, throat, eyes, and nose; difficulty breathing; and cramps, nausea, vomiting, and diarrhea. Wheat allergy most commonly occurs in infants or toddlers, and typically co-occurs with other food allergies, but children usually outgrow the allergy by ages 3-5 years.
Nonceliac gluten sensitivity or intolerance
Physicians only should consider gluten insensitivity or intolerance after ruling out celiac disease and wheat allergy. Less understood and more controversial, gluten sensitivity or intolerance may be an immune-mediated condition – or instead an intestinal malfunction. Some patients may simply have an intolerance to high fiber foods in general. Patients with this sensitivity or intolerance will have a normal intestinal biopsy, but AGA IgG and/or IgA testing and genetic HLA-DQ2 testing may be positive. The clinical diagnosis is ultimately one of exclusion determined when a gluten-free diet alleviates symptoms.
Although gas, diarrhea, weight loss, and abdominal pain are the most common symptoms, other transient symptoms may include dyspepsia, nausea, vomiting, bloating, constipation, intestinal rumbling, joint or bone pain, muscle cramps or pain, fatigue, numbness, cramps, headaches, rashes, tongue inflammation, anemia, leg numbness, osteoporosis, or unexplained anemia.
Another potential effect of gluten sensitivity is dermatitis herpetiformis, a skin inflammation involving blisters, hives, or other types of erythematous or urticarial papules, usually symmetrically distributed, with severe itching. Although 90% of individuals with dermatitis herpetiformis lack any gastrointestinal symptoms, about 75% have villous atrophy, Dr. Pietzak said.
Even less understood are neurologic symptoms of gluten sensitivity and their potential mechanisms. Reported neurologic findings of gluten sensitivity include ataxia, peripheral neuropathy, depression, schizophrenia, epilepsy, and intracranial calcifications.
Irritable bowel syndrome
The similarity of symptoms between IBS and celiac disease has meant many with celiac disease were misdiagnosed with IBS, particularly women, Dr. Pietzak said. To confuse matters more, restricting gluten has shown improvement in IBS symptoms for some patients: in one study, 60% of those with diarrhea returned to having normal stools after 6 months of a gluten-free diet. Again, AGA IgG and tTG IgG testing was more likely to be positive among these patients. IBS and celiac disease can co-occur in patients, but it’s necessary to rule out celiac disease before diagnosing a patient with IBS.
Importance of differential diagnosis
It’s important to know the difference between celiac disease and other conditions because patients may face different risks even if their treatment is similar. Those with celiac disease, for example, have a greater risk of nutritional deficiencies leading to conditions such as iron-deficiency anemia and osteoporosis, and are more likely to develop gastrointestinal cancers or other autoimmune conditions, such as thyroid disease, type 1 diabetes, joint diseases, and liver diseases.
Those with food allergies and intolerances do not share those increased risks, and their symptoms resolve without long-term organ damage when they remove the gluten or wheat from their diet. Further, only those with celiac disease must restrict all foods with gluten. Those with a wheat allergy may be able to eat rye, barley, and oats, for example, and restricting gluten may improve IBS symptoms for only a subset of patients.
Dr. Pietzak has consulted for Nestle Nutrition and is on the speaker’s bureau for Prometheus Labs, a lab which does business in testing for celiac disease.
SAN FRANCISCO – Elimination diet crazes have been around for centuries, and one of today’s biggest targets is gluten, contributing to an industry of gluten-free products with revenue in the billions of dollars.
But does taking gluten off your child’s plate actually improve their health? It will if they have a condition in which gluten actually causes symptoms, explained Michelle M. Pietzak, MD, a pediatrician at the University of Southern California, Los Angeles.
Gluten is a mixture of proteins found in wheat, rye, barley, oats, corn, and rice that gives food its elasticity and helps dough rise. Only the gluten in wheat, rye, and barley causes gluten-related symptoms, but it is found in a variety of derivative products, such as spelt, kamut, triticale, couscous, bulgar, faro, matzo flour, and other grains as well. Oats are also considered cross-contaminated with gluten because they are milled with wheat, and other foods containing gluten may be difficult to identify due to food labeling and preparation practices in the United States.
For those with celiac disease, wheat allergy, irritable bowel syndrome (IBS), or nonceliac gluten sensitivity or intolerance, a gluten-free diet can reduce or eliminate the symptoms causing problems. For others, however, the symptoms likely come from somewhere besides gluten or may be a nocebo effect, where a patient who expects negative symptoms becomes more likely to have them.
Lactose intolerance is one example that can cause symptoms similar to those that respond to restricting gluten. Another is sensitivity to fructans, a wheat carbohydrate and one of the fermentable oligo-di-monosaccharides and polyols (FODMAPs) that can improve IBS when restricted. Imbalance in a person’s gut bacteria, called dysbiosis, also may cause similar symptoms and results from excess yeast, parasites, or an overgrowth of bad bacteria in the absence of beneficial ones.
Understanding celiac disease
This immune-mediated disease causes primarily gastrointestinal symptoms when someone ingests proteins called prolamines, which those with celiac disease are genetically predisposed to have difficulty digesting. Common symptoms include diarrhea, nausea, vomiting, abdominal pain, constipation, appetite changes, and, in unusual cases, excess fat in the feces (steatorrhea).
But celiac disease also may contribute to a short stature, osteoporosis, dermatitis herpetiformis, delayed onset of puberty, infertility, anemia (from iron and/or folic acid deficits), epilepsy, and behavioral changes. Although those with celiac disease are at a higher risk for arthritis, osteoporosis, osteopenia, osteomalacia, and rickets, a gluten-free diet can improve children’s low bone mineral density.
Screening for celiac disease includes testing for antigliadin (AGA) IgG and IgA, antiendomysial IgA, anti-tissue transglutaminase (tTG) IgA, total serum IgA, and genetic testing related to HLA-DQ2 and HLA-DQ8 genes.
Wheat allergy
A wheat allergy, among the eight most common food allergies, involves an IgE-mediated reaction to water- and salt-insoluble gliadins, especially omega-5 gliadin, which can cause anaphylaxis in a wheat-allergic person who exercises after ingesting wheat. Symptoms of wheat allergy include hives; swelling, itching or irritation of the mouth, throat, eyes, and nose; difficulty breathing; and cramps, nausea, vomiting, and diarrhea. Wheat allergy most commonly occurs in infants or toddlers, and typically co-occurs with other food allergies, but children usually outgrow the allergy by ages 3-5 years.
Nonceliac gluten sensitivity or intolerance
Physicians only should consider gluten insensitivity or intolerance after ruling out celiac disease and wheat allergy. Less understood and more controversial, gluten sensitivity or intolerance may be an immune-mediated condition – or instead an intestinal malfunction. Some patients may simply have an intolerance to high fiber foods in general. Patients with this sensitivity or intolerance will have a normal intestinal biopsy, but AGA IgG and/or IgA testing and genetic HLA-DQ2 testing may be positive. The clinical diagnosis is ultimately one of exclusion determined when a gluten-free diet alleviates symptoms.
Although gas, diarrhea, weight loss, and abdominal pain are the most common symptoms, other transient symptoms may include dyspepsia, nausea, vomiting, bloating, constipation, intestinal rumbling, joint or bone pain, muscle cramps or pain, fatigue, numbness, cramps, headaches, rashes, tongue inflammation, anemia, leg numbness, osteoporosis, or unexplained anemia.
Another potential effect of gluten sensitivity is dermatitis herpetiformis, a skin inflammation involving blisters, hives, or other types of erythematous or urticarial papules, usually symmetrically distributed, with severe itching. Although 90% of individuals with dermatitis herpetiformis lack any gastrointestinal symptoms, about 75% have villous atrophy, Dr. Pietzak said.
Even less understood are neurologic symptoms of gluten sensitivity and their potential mechanisms. Reported neurologic findings of gluten sensitivity include ataxia, peripheral neuropathy, depression, schizophrenia, epilepsy, and intracranial calcifications.
Irritable bowel syndrome
The similarity of symptoms between IBS and celiac disease has meant many with celiac disease were misdiagnosed with IBS, particularly women, Dr. Pietzak said. To confuse matters more, restricting gluten has shown improvement in IBS symptoms for some patients: in one study, 60% of those with diarrhea returned to having normal stools after 6 months of a gluten-free diet. Again, AGA IgG and tTG IgG testing was more likely to be positive among these patients. IBS and celiac disease can co-occur in patients, but it’s necessary to rule out celiac disease before diagnosing a patient with IBS.
Importance of differential diagnosis
It’s important to know the difference between celiac disease and other conditions because patients may face different risks even if their treatment is similar. Those with celiac disease, for example, have a greater risk of nutritional deficiencies leading to conditions such as iron-deficiency anemia and osteoporosis, and are more likely to develop gastrointestinal cancers or other autoimmune conditions, such as thyroid disease, type 1 diabetes, joint diseases, and liver diseases.
Those with food allergies and intolerances do not share those increased risks, and their symptoms resolve without long-term organ damage when they remove the gluten or wheat from their diet. Further, only those with celiac disease must restrict all foods with gluten. Those with a wheat allergy may be able to eat rye, barley, and oats, for example, and restricting gluten may improve IBS symptoms for only a subset of patients.
Dr. Pietzak has consulted for Nestle Nutrition and is on the speaker’s bureau for Prometheus Labs, a lab which does business in testing for celiac disease.
SAN FRANCISCO – Elimination diet crazes have been around for centuries, and one of today’s biggest targets is gluten, contributing to an industry of gluten-free products with revenue in the billions of dollars.
But does taking gluten off your child’s plate actually improve their health? It will if they have a condition in which gluten actually causes symptoms, explained Michelle M. Pietzak, MD, a pediatrician at the University of Southern California, Los Angeles.
Gluten is a mixture of proteins found in wheat, rye, barley, oats, corn, and rice that gives food its elasticity and helps dough rise. Only the gluten in wheat, rye, and barley causes gluten-related symptoms, but it is found in a variety of derivative products, such as spelt, kamut, triticale, couscous, bulgar, faro, matzo flour, and other grains as well. Oats are also considered cross-contaminated with gluten because they are milled with wheat, and other foods containing gluten may be difficult to identify due to food labeling and preparation practices in the United States.
For those with celiac disease, wheat allergy, irritable bowel syndrome (IBS), or nonceliac gluten sensitivity or intolerance, a gluten-free diet can reduce or eliminate the symptoms causing problems. For others, however, the symptoms likely come from somewhere besides gluten or may be a nocebo effect, where a patient who expects negative symptoms becomes more likely to have them.
Lactose intolerance is one example that can cause symptoms similar to those that respond to restricting gluten. Another is sensitivity to fructans, a wheat carbohydrate and one of the fermentable oligo-di-monosaccharides and polyols (FODMAPs) that can improve IBS when restricted. Imbalance in a person’s gut bacteria, called dysbiosis, also may cause similar symptoms and results from excess yeast, parasites, or an overgrowth of bad bacteria in the absence of beneficial ones.
Understanding celiac disease
This immune-mediated disease causes primarily gastrointestinal symptoms when someone ingests proteins called prolamines, which those with celiac disease are genetically predisposed to have difficulty digesting. Common symptoms include diarrhea, nausea, vomiting, abdominal pain, constipation, appetite changes, and, in unusual cases, excess fat in the feces (steatorrhea).
But celiac disease also may contribute to a short stature, osteoporosis, dermatitis herpetiformis, delayed onset of puberty, infertility, anemia (from iron and/or folic acid deficits), epilepsy, and behavioral changes. Although those with celiac disease are at a higher risk for arthritis, osteoporosis, osteopenia, osteomalacia, and rickets, a gluten-free diet can improve children’s low bone mineral density.
Screening for celiac disease includes testing for antigliadin (AGA) IgG and IgA, antiendomysial IgA, anti-tissue transglutaminase (tTG) IgA, total serum IgA, and genetic testing related to HLA-DQ2 and HLA-DQ8 genes.
Wheat allergy
A wheat allergy, among the eight most common food allergies, involves an IgE-mediated reaction to water- and salt-insoluble gliadins, especially omega-5 gliadin, which can cause anaphylaxis in a wheat-allergic person who exercises after ingesting wheat. Symptoms of wheat allergy include hives; swelling, itching or irritation of the mouth, throat, eyes, and nose; difficulty breathing; and cramps, nausea, vomiting, and diarrhea. Wheat allergy most commonly occurs in infants or toddlers, and typically co-occurs with other food allergies, but children usually outgrow the allergy by ages 3-5 years.
Nonceliac gluten sensitivity or intolerance
Physicians only should consider gluten insensitivity or intolerance after ruling out celiac disease and wheat allergy. Less understood and more controversial, gluten sensitivity or intolerance may be an immune-mediated condition – or instead an intestinal malfunction. Some patients may simply have an intolerance to high fiber foods in general. Patients with this sensitivity or intolerance will have a normal intestinal biopsy, but AGA IgG and/or IgA testing and genetic HLA-DQ2 testing may be positive. The clinical diagnosis is ultimately one of exclusion determined when a gluten-free diet alleviates symptoms.
Although gas, diarrhea, weight loss, and abdominal pain are the most common symptoms, other transient symptoms may include dyspepsia, nausea, vomiting, bloating, constipation, intestinal rumbling, joint or bone pain, muscle cramps or pain, fatigue, numbness, cramps, headaches, rashes, tongue inflammation, anemia, leg numbness, osteoporosis, or unexplained anemia.
Another potential effect of gluten sensitivity is dermatitis herpetiformis, a skin inflammation involving blisters, hives, or other types of erythematous or urticarial papules, usually symmetrically distributed, with severe itching. Although 90% of individuals with dermatitis herpetiformis lack any gastrointestinal symptoms, about 75% have villous atrophy, Dr. Pietzak said.
Even less understood are neurologic symptoms of gluten sensitivity and their potential mechanisms. Reported neurologic findings of gluten sensitivity include ataxia, peripheral neuropathy, depression, schizophrenia, epilepsy, and intracranial calcifications.
Irritable bowel syndrome
The similarity of symptoms between IBS and celiac disease has meant many with celiac disease were misdiagnosed with IBS, particularly women, Dr. Pietzak said. To confuse matters more, restricting gluten has shown improvement in IBS symptoms for some patients: in one study, 60% of those with diarrhea returned to having normal stools after 6 months of a gluten-free diet. Again, AGA IgG and tTG IgG testing was more likely to be positive among these patients. IBS and celiac disease can co-occur in patients, but it’s necessary to rule out celiac disease before diagnosing a patient with IBS.
Importance of differential diagnosis
It’s important to know the difference between celiac disease and other conditions because patients may face different risks even if their treatment is similar. Those with celiac disease, for example, have a greater risk of nutritional deficiencies leading to conditions such as iron-deficiency anemia and osteoporosis, and are more likely to develop gastrointestinal cancers or other autoimmune conditions, such as thyroid disease, type 1 diabetes, joint diseases, and liver diseases.
Those with food allergies and intolerances do not share those increased risks, and their symptoms resolve without long-term organ damage when they remove the gluten or wheat from their diet. Further, only those with celiac disease must restrict all foods with gluten. Those with a wheat allergy may be able to eat rye, barley, and oats, for example, and restricting gluten may improve IBS symptoms for only a subset of patients.
Dr. Pietzak has consulted for Nestle Nutrition and is on the speaker’s bureau for Prometheus Labs, a lab which does business in testing for celiac disease.
EXPERT ANALYSIS FROM AAP 16
Targeted interventions aid in HPV vaccination uptake
ATLANTA – Holly Groom, MPH, of the Center for Health Research at Kaiser Permanente Northwest, described the intervention to improve HPV vaccination rates within the Kaiser Permanente NW health care system involving two hospitals and 31 medical offices, which serves 44,000 adolescents aged 11-17 years. About a quarter of patients reside in Washington, with the remainder in Oregon.
In addition to two in-person provider education and feedback sessions, the intervention included quarterly vaccine coverage, missed vaccination opportunity assessment reports, and a mailed parent survey. The staff education sessions covered six different cancers caused by HPV – cervical, anal, oropharyngeal, penile, vaginal, and vulvar – and their annual incidence, such as an estimated 10,000 oropharyngeal cancer cases in males and more than 11,000 cervical cancer cases in females each year.
One of the tip sheets distributed during provider and staff education offered specific language that providers could use to recommend the vaccine to parents and educate them about what HPV disease is and what cancers it can cause. For parents who are confused or concerned about why the vaccine is recommended at ages 11-12 years, for example, providers can respond, “We’re vaccinating today so your child will have the best protection possible long before the start of any kind of sexual activity. We vaccinate people well before they are exposed to an infection, as is the case with measles and the other recommended childhood vaccines.”
For those providers uneasy about mentioning sexual activity, Ms. Groom said, they can stick with telling parents the vaccine should be administered “long before the risk of infection” without mentioning the mechanism of infection.
Ms. Groom provided three other recommended statements as well:
• “I strongly believe in the importance of this cancer-preventing vaccine.”
• “I have given HPV vaccine to my son/daughter (or grandchild/niece/nephew/friend’s children).”
• “Experts, such as the American Academy of Pediatrics, cancer doctors, and the Centers for Disease Control and Prevention, also agree that getting the HPV vaccine is very important for your child.”
Feedback from the training sessions was “overwhelmingly positive,” with 87% of the respondents stating that they planned to implement the strategies and tools discussed and an additional 12% said they were already using those strategies and tools.
The parental survey, although it had only a 12% response rate, initially revealed that just over a third (36%) of parents weren’t sure if they were going to vaccinate their child when they went in for a well visit, but more than 90% of these parents did vaccinate their children.
Ms. Groom reported no disclosures. No external funding was reported.
Communication strategies to improve HPV immunization
Several communication strategies have been developed by the Centers for Disease Control and Prevention to help providers overcome barriers to improving HPV immunization coverage, Yvonne Garcia said at the National Immunization Conference.
Among providers’ barriers are hesitancy to make a recommendation for the HPV vaccine, and the need to understand the burden of the disease and the need for the vaccine, said Ms. Garcia, a health communications specialist for the CDC.
“Also, they overestimate parents’ concerns about the vaccine when what we have learned from parents is that they value the HPV vaccine, but they’re not hearing their child’s doctor recommend it,” she said.
Overcoming these barriers requires patient outreach and awareness of HPV coverage rates at the city and state levels, as well as their individual and practice rates. Providers should bundle their recommendation with the other vaccines recommended by the CDC at the ages of 11 and 12 years: “Your child is due for three vaccines today that offer protection against meningitis, HPV cancers, and whooping cough,” is one example of language to use, Ms. Garcia said.
“Effective patient outreach for HPV vaccination includes the reminder/recall system, scheduling remaining doses at the time of receiving the first doses, and creating parental expectation that HPV vaccination is a very normal part of the immunization process, and that it occurs at ages 11 and 12,” she said.
She also reviewed the barriers among parents for HPV vaccination that providers can address. To respond to parents’ lack of knowledge about the vaccine or the need for it, providers “need to stress that it’s needed for cancer prevention,” Ms. Garcia said.
Providers also can reassure parents with concerns about safety and side effects that extensive safety research exists regarding HPV immunization from the past 10 years.
For those worried that HPV vaccination gives “permission for sexual activity” or that kids are too young, providers can reassure parents that the shot is not linked with increased sexual activity, and that it’s recommended at ages 11 and 12 years because the vaccine induces a better immune response at those ages than later on, she said.
Ms. Garcia reported no disclosures. No external funding was reported.
This article was updated Dec. 2, 2016.
ATLANTA – Holly Groom, MPH, of the Center for Health Research at Kaiser Permanente Northwest, described the intervention to improve HPV vaccination rates within the Kaiser Permanente NW health care system involving two hospitals and 31 medical offices, which serves 44,000 adolescents aged 11-17 years. About a quarter of patients reside in Washington, with the remainder in Oregon.
In addition to two in-person provider education and feedback sessions, the intervention included quarterly vaccine coverage, missed vaccination opportunity assessment reports, and a mailed parent survey. The staff education sessions covered six different cancers caused by HPV – cervical, anal, oropharyngeal, penile, vaginal, and vulvar – and their annual incidence, such as an estimated 10,000 oropharyngeal cancer cases in males and more than 11,000 cervical cancer cases in females each year.
One of the tip sheets distributed during provider and staff education offered specific language that providers could use to recommend the vaccine to parents and educate them about what HPV disease is and what cancers it can cause. For parents who are confused or concerned about why the vaccine is recommended at ages 11-12 years, for example, providers can respond, “We’re vaccinating today so your child will have the best protection possible long before the start of any kind of sexual activity. We vaccinate people well before they are exposed to an infection, as is the case with measles and the other recommended childhood vaccines.”
For those providers uneasy about mentioning sexual activity, Ms. Groom said, they can stick with telling parents the vaccine should be administered “long before the risk of infection” without mentioning the mechanism of infection.
Ms. Groom provided three other recommended statements as well:
• “I strongly believe in the importance of this cancer-preventing vaccine.”
• “I have given HPV vaccine to my son/daughter (or grandchild/niece/nephew/friend’s children).”
• “Experts, such as the American Academy of Pediatrics, cancer doctors, and the Centers for Disease Control and Prevention, also agree that getting the HPV vaccine is very important for your child.”
Feedback from the training sessions was “overwhelmingly positive,” with 87% of the respondents stating that they planned to implement the strategies and tools discussed and an additional 12% said they were already using those strategies and tools.
The parental survey, although it had only a 12% response rate, initially revealed that just over a third (36%) of parents weren’t sure if they were going to vaccinate their child when they went in for a well visit, but more than 90% of these parents did vaccinate their children.
Ms. Groom reported no disclosures. No external funding was reported.
Communication strategies to improve HPV immunization
Several communication strategies have been developed by the Centers for Disease Control and Prevention to help providers overcome barriers to improving HPV immunization coverage, Yvonne Garcia said at the National Immunization Conference.
Among providers’ barriers are hesitancy to make a recommendation for the HPV vaccine, and the need to understand the burden of the disease and the need for the vaccine, said Ms. Garcia, a health communications specialist for the CDC.
“Also, they overestimate parents’ concerns about the vaccine when what we have learned from parents is that they value the HPV vaccine, but they’re not hearing their child’s doctor recommend it,” she said.
Overcoming these barriers requires patient outreach and awareness of HPV coverage rates at the city and state levels, as well as their individual and practice rates. Providers should bundle their recommendation with the other vaccines recommended by the CDC at the ages of 11 and 12 years: “Your child is due for three vaccines today that offer protection against meningitis, HPV cancers, and whooping cough,” is one example of language to use, Ms. Garcia said.
“Effective patient outreach for HPV vaccination includes the reminder/recall system, scheduling remaining doses at the time of receiving the first doses, and creating parental expectation that HPV vaccination is a very normal part of the immunization process, and that it occurs at ages 11 and 12,” she said.
She also reviewed the barriers among parents for HPV vaccination that providers can address. To respond to parents’ lack of knowledge about the vaccine or the need for it, providers “need to stress that it’s needed for cancer prevention,” Ms. Garcia said.
Providers also can reassure parents with concerns about safety and side effects that extensive safety research exists regarding HPV immunization from the past 10 years.
For those worried that HPV vaccination gives “permission for sexual activity” or that kids are too young, providers can reassure parents that the shot is not linked with increased sexual activity, and that it’s recommended at ages 11 and 12 years because the vaccine induces a better immune response at those ages than later on, she said.
Ms. Garcia reported no disclosures. No external funding was reported.
This article was updated Dec. 2, 2016.
ATLANTA – Holly Groom, MPH, of the Center for Health Research at Kaiser Permanente Northwest, described the intervention to improve HPV vaccination rates within the Kaiser Permanente NW health care system involving two hospitals and 31 medical offices, which serves 44,000 adolescents aged 11-17 years. About a quarter of patients reside in Washington, with the remainder in Oregon.
In addition to two in-person provider education and feedback sessions, the intervention included quarterly vaccine coverage, missed vaccination opportunity assessment reports, and a mailed parent survey. The staff education sessions covered six different cancers caused by HPV – cervical, anal, oropharyngeal, penile, vaginal, and vulvar – and their annual incidence, such as an estimated 10,000 oropharyngeal cancer cases in males and more than 11,000 cervical cancer cases in females each year.
One of the tip sheets distributed during provider and staff education offered specific language that providers could use to recommend the vaccine to parents and educate them about what HPV disease is and what cancers it can cause. For parents who are confused or concerned about why the vaccine is recommended at ages 11-12 years, for example, providers can respond, “We’re vaccinating today so your child will have the best protection possible long before the start of any kind of sexual activity. We vaccinate people well before they are exposed to an infection, as is the case with measles and the other recommended childhood vaccines.”
For those providers uneasy about mentioning sexual activity, Ms. Groom said, they can stick with telling parents the vaccine should be administered “long before the risk of infection” without mentioning the mechanism of infection.
Ms. Groom provided three other recommended statements as well:
• “I strongly believe in the importance of this cancer-preventing vaccine.”
• “I have given HPV vaccine to my son/daughter (or grandchild/niece/nephew/friend’s children).”
• “Experts, such as the American Academy of Pediatrics, cancer doctors, and the Centers for Disease Control and Prevention, also agree that getting the HPV vaccine is very important for your child.”
Feedback from the training sessions was “overwhelmingly positive,” with 87% of the respondents stating that they planned to implement the strategies and tools discussed and an additional 12% said they were already using those strategies and tools.
The parental survey, although it had only a 12% response rate, initially revealed that just over a third (36%) of parents weren’t sure if they were going to vaccinate their child when they went in for a well visit, but more than 90% of these parents did vaccinate their children.
Ms. Groom reported no disclosures. No external funding was reported.
Communication strategies to improve HPV immunization
Several communication strategies have been developed by the Centers for Disease Control and Prevention to help providers overcome barriers to improving HPV immunization coverage, Yvonne Garcia said at the National Immunization Conference.
Among providers’ barriers are hesitancy to make a recommendation for the HPV vaccine, and the need to understand the burden of the disease and the need for the vaccine, said Ms. Garcia, a health communications specialist for the CDC.
“Also, they overestimate parents’ concerns about the vaccine when what we have learned from parents is that they value the HPV vaccine, but they’re not hearing their child’s doctor recommend it,” she said.
Overcoming these barriers requires patient outreach and awareness of HPV coverage rates at the city and state levels, as well as their individual and practice rates. Providers should bundle their recommendation with the other vaccines recommended by the CDC at the ages of 11 and 12 years: “Your child is due for three vaccines today that offer protection against meningitis, HPV cancers, and whooping cough,” is one example of language to use, Ms. Garcia said.
“Effective patient outreach for HPV vaccination includes the reminder/recall system, scheduling remaining doses at the time of receiving the first doses, and creating parental expectation that HPV vaccination is a very normal part of the immunization process, and that it occurs at ages 11 and 12,” she said.
She also reviewed the barriers among parents for HPV vaccination that providers can address. To respond to parents’ lack of knowledge about the vaccine or the need for it, providers “need to stress that it’s needed for cancer prevention,” Ms. Garcia said.
Providers also can reassure parents with concerns about safety and side effects that extensive safety research exists regarding HPV immunization from the past 10 years.
For those worried that HPV vaccination gives “permission for sexual activity” or that kids are too young, providers can reassure parents that the shot is not linked with increased sexual activity, and that it’s recommended at ages 11 and 12 years because the vaccine induces a better immune response at those ages than later on, she said.
Ms. Garcia reported no disclosures. No external funding was reported.
This article was updated Dec. 2, 2016.
AT THE NATIONAL IMMUNIZATION CONFERENCE
Key clinical point: Targeted interventions to improve HPV vaccination can be effective.
Major finding: In one health care system’s intervention, 87% of providers found the tools and strategies for increasing HPV vaccination uptake helpful and worth using.
Data source: A study within the Kaiser Permanente NW health care system involving two hospitals and 31 medical offices, which serves 44,000 adolescents aged 11-17 years.
Disclosures: Dr. Groom reported no disclosures. No external funding was reported.
Parental online sharing involves balancing risks, benefits
SAN FRANCISCO – More than two-thirds of parents worry about their children’s privacy online and/or that photos of their children might be reshared on the wider Web, according to a survey conducted by C.S. Mott Children’s Hospital.
Those fears are not baseless, and they need to be considered more often by parents themselves in posting about their children online, presenters agreed at a symposium on the media at the annual meeting of the American Academy of Pediatrics.
“The first children of social media are just now entering adulthood, entering the job market,” said Stacey Steinberg, JD, a legal skills professor at the University of Florida Levin College of Law, Gainesville. She is also with the law school’s center on children and families.
She and Bahareh Keith, DO, a pediatrician at the University of Florida, discussed the challenges and risks of “sharenting” – parents’ sharing information and photos of their children online – and pediatricians’ role in advising parents and looking out for children’s best interests.
“The dearth of discussion on this topic leaves even the most well-intentioned parents without enough information to thoroughly analyze this,” Ms. Steinberg said. “We’re not sitting here saying we know what the answers are. But we’re saying this is an important issue that affects families, and these children require a voice in this discussion.”
The way social media and blogging have changed the landscape for children coming of age today means that they often have a digital footprint shaped by their parents long before they create their own first account. This reality means it’s necessary to consider how to balance children’s right to privacy with parents’ right to free speech and expression.
The 2015 C.S. Mott survey asked 569 parents of children aged 4 years and younger about how they use social media as parents, and reported that more than half of mothers (56%) and a third of fathers (34%) discuss parenting and child health topics on Facebook, Twitter, blogs, online forums, and other online platforms.
The risks of this sharenting can range from embarrassment of the child to significantly more sinister repercussions. Just over half of the parents (52%) in the Mott survey reported that they are concerned their child might feel embarrassed when they grow older and discover what their parents shared online. But that embarrassment also can lead to bullying or determent of psychosocial development, Ms. Steinberg and Dr. Keith explained.
More serious, if less common, risks include the possibility that data brokers could access and use information about the children or that online child pornographers could repurpose the photos inappropriately. One worst case scenario of the former is digital kidnapping, a disturbing practice in which a stranger uses baby photos and information that is not their own to pass off the child as their own or to invite others to “invent” identities for the child. The Children’s Online Privacy Protection Rule of the Federal Trade Commission addresses only online use by those under age 13 years, not others’ use of those images.
Regarding the latter, Ms. Steinberg and Dr. Keith showed an example of a bare-bottomed baby standing in front of a bathtub that had been reshared hundreds of times, but other images that have been shared on child pornography sites depict children in everyday situations such as playing on a playground, running at the beach, or doing gymnastics.
“These are images that many of us would think are innocent, but pornographers would categorize these into folders,” Dr. Keith said. “It’s not even naked or half-naked pictures.”
A study conducted by an e-safety commission in Australia, for example, found that half of the thousands of photos shared on a sample of child pornography sites had originated from parental sharing.
But Ms. Steinberg and Dr. Keith pointed out that benefits of parents’ online sharing exist as well, as the Mott survey found. In that survey, 72% of parents who discuss parenting and/or their children on social media reported that doing so helps them feel less alone. Similarly, 70% said they learn what not to do through those experiences, 67% said they receive advice from more experienced parents, and 62% said they consequently worry less. Common topics they discussed included sleep, nutrition, discipline, day care, and behavior management.
Other benefits, Ms. Steinberg pointed out, are that families geographically spread apart can stay connected, and communities can grow stronger with shared communal experiences of parents meeting others online.
“For some parents, it gives them an opportunity for advocacy work and raises awareness for important social issues,” Ms. Steinberg said, although she added, “If you’re going to share your children’s behavioral problems, consider sharing anonymously.”
Neither Ms. Steinberg and Dr. Keith said they had simple solutions to these challenges. Rather, they recommended using the public health model of raising awareness and encouraging open dialogue among pediatricians, parents, and their children to look for ways to balance competing interests.
“Social media offers many positive benefits, and we don’t want to silence the many voices of parents who take part in online sharing,” Ms. Steinberg explained. But she and Ms. Keith said it’s also worth considering children’s potential interest in controlling what their digital footprint is as they become adults.
For example, one study they cited found that, among 249 pairs of parents and their children, three times more children than parents wanted the parents to have and follow rules regarding what they could share on social media about their children.
Although guidance for parents on monitoring children’s social media use is a part of the AAP policy statement on media, only one recommendation obliquely addresses how parents should or shouldn’t use social media by advising them to model appropriate use for their children.
“It’s just like any medical decision: What is the benefit, and what is the risk, and does the benefit outweigh the risk?” said Wendy Sue Swanson, MD, executive director of digital health at Seattle Children’s Hospital. She recommended that parents ask their child for permission before posting a story or photo if their kids are aged 6 or older.
Ms. Steinberg and Dr. Keith recommended that pediatricians broach this subject with parents to help them think about risks they simply might not have considered before.
“When we looked at what sorts of best practices could be encouraged or doctors could talk to parents about – the tangible harms, such as whether data brokers or people interested in child pornography could access the information – we didn’t want to create any unnecessary panic,” Ms. Steinberg said. “But we did find some concerns that were troublesome, and we thought that parents or at least physicians [should] be aware of those potential risks.”
Ms. Steinberg and Dr. Keith reported that they had no relevant financial disclosures.
SAN FRANCISCO – More than two-thirds of parents worry about their children’s privacy online and/or that photos of their children might be reshared on the wider Web, according to a survey conducted by C.S. Mott Children’s Hospital.
Those fears are not baseless, and they need to be considered more often by parents themselves in posting about their children online, presenters agreed at a symposium on the media at the annual meeting of the American Academy of Pediatrics.
“The first children of social media are just now entering adulthood, entering the job market,” said Stacey Steinberg, JD, a legal skills professor at the University of Florida Levin College of Law, Gainesville. She is also with the law school’s center on children and families.
She and Bahareh Keith, DO, a pediatrician at the University of Florida, discussed the challenges and risks of “sharenting” – parents’ sharing information and photos of their children online – and pediatricians’ role in advising parents and looking out for children’s best interests.
“The dearth of discussion on this topic leaves even the most well-intentioned parents without enough information to thoroughly analyze this,” Ms. Steinberg said. “We’re not sitting here saying we know what the answers are. But we’re saying this is an important issue that affects families, and these children require a voice in this discussion.”
The way social media and blogging have changed the landscape for children coming of age today means that they often have a digital footprint shaped by their parents long before they create their own first account. This reality means it’s necessary to consider how to balance children’s right to privacy with parents’ right to free speech and expression.
The 2015 C.S. Mott survey asked 569 parents of children aged 4 years and younger about how they use social media as parents, and reported that more than half of mothers (56%) and a third of fathers (34%) discuss parenting and child health topics on Facebook, Twitter, blogs, online forums, and other online platforms.
The risks of this sharenting can range from embarrassment of the child to significantly more sinister repercussions. Just over half of the parents (52%) in the Mott survey reported that they are concerned their child might feel embarrassed when they grow older and discover what their parents shared online. But that embarrassment also can lead to bullying or determent of psychosocial development, Ms. Steinberg and Dr. Keith explained.
More serious, if less common, risks include the possibility that data brokers could access and use information about the children or that online child pornographers could repurpose the photos inappropriately. One worst case scenario of the former is digital kidnapping, a disturbing practice in which a stranger uses baby photos and information that is not their own to pass off the child as their own or to invite others to “invent” identities for the child. The Children’s Online Privacy Protection Rule of the Federal Trade Commission addresses only online use by those under age 13 years, not others’ use of those images.
Regarding the latter, Ms. Steinberg and Dr. Keith showed an example of a bare-bottomed baby standing in front of a bathtub that had been reshared hundreds of times, but other images that have been shared on child pornography sites depict children in everyday situations such as playing on a playground, running at the beach, or doing gymnastics.
“These are images that many of us would think are innocent, but pornographers would categorize these into folders,” Dr. Keith said. “It’s not even naked or half-naked pictures.”
A study conducted by an e-safety commission in Australia, for example, found that half of the thousands of photos shared on a sample of child pornography sites had originated from parental sharing.
But Ms. Steinberg and Dr. Keith pointed out that benefits of parents’ online sharing exist as well, as the Mott survey found. In that survey, 72% of parents who discuss parenting and/or their children on social media reported that doing so helps them feel less alone. Similarly, 70% said they learn what not to do through those experiences, 67% said they receive advice from more experienced parents, and 62% said they consequently worry less. Common topics they discussed included sleep, nutrition, discipline, day care, and behavior management.
Other benefits, Ms. Steinberg pointed out, are that families geographically spread apart can stay connected, and communities can grow stronger with shared communal experiences of parents meeting others online.
“For some parents, it gives them an opportunity for advocacy work and raises awareness for important social issues,” Ms. Steinberg said, although she added, “If you’re going to share your children’s behavioral problems, consider sharing anonymously.”
Neither Ms. Steinberg and Dr. Keith said they had simple solutions to these challenges. Rather, they recommended using the public health model of raising awareness and encouraging open dialogue among pediatricians, parents, and their children to look for ways to balance competing interests.
“Social media offers many positive benefits, and we don’t want to silence the many voices of parents who take part in online sharing,” Ms. Steinberg explained. But she and Ms. Keith said it’s also worth considering children’s potential interest in controlling what their digital footprint is as they become adults.
For example, one study they cited found that, among 249 pairs of parents and their children, three times more children than parents wanted the parents to have and follow rules regarding what they could share on social media about their children.
Although guidance for parents on monitoring children’s social media use is a part of the AAP policy statement on media, only one recommendation obliquely addresses how parents should or shouldn’t use social media by advising them to model appropriate use for their children.
“It’s just like any medical decision: What is the benefit, and what is the risk, and does the benefit outweigh the risk?” said Wendy Sue Swanson, MD, executive director of digital health at Seattle Children’s Hospital. She recommended that parents ask their child for permission before posting a story or photo if their kids are aged 6 or older.
Ms. Steinberg and Dr. Keith recommended that pediatricians broach this subject with parents to help them think about risks they simply might not have considered before.
“When we looked at what sorts of best practices could be encouraged or doctors could talk to parents about – the tangible harms, such as whether data brokers or people interested in child pornography could access the information – we didn’t want to create any unnecessary panic,” Ms. Steinberg said. “But we did find some concerns that were troublesome, and we thought that parents or at least physicians [should] be aware of those potential risks.”
Ms. Steinberg and Dr. Keith reported that they had no relevant financial disclosures.
SAN FRANCISCO – More than two-thirds of parents worry about their children’s privacy online and/or that photos of their children might be reshared on the wider Web, according to a survey conducted by C.S. Mott Children’s Hospital.
Those fears are not baseless, and they need to be considered more often by parents themselves in posting about their children online, presenters agreed at a symposium on the media at the annual meeting of the American Academy of Pediatrics.
“The first children of social media are just now entering adulthood, entering the job market,” said Stacey Steinberg, JD, a legal skills professor at the University of Florida Levin College of Law, Gainesville. She is also with the law school’s center on children and families.
She and Bahareh Keith, DO, a pediatrician at the University of Florida, discussed the challenges and risks of “sharenting” – parents’ sharing information and photos of their children online – and pediatricians’ role in advising parents and looking out for children’s best interests.
“The dearth of discussion on this topic leaves even the most well-intentioned parents without enough information to thoroughly analyze this,” Ms. Steinberg said. “We’re not sitting here saying we know what the answers are. But we’re saying this is an important issue that affects families, and these children require a voice in this discussion.”
The way social media and blogging have changed the landscape for children coming of age today means that they often have a digital footprint shaped by their parents long before they create their own first account. This reality means it’s necessary to consider how to balance children’s right to privacy with parents’ right to free speech and expression.
The 2015 C.S. Mott survey asked 569 parents of children aged 4 years and younger about how they use social media as parents, and reported that more than half of mothers (56%) and a third of fathers (34%) discuss parenting and child health topics on Facebook, Twitter, blogs, online forums, and other online platforms.
The risks of this sharenting can range from embarrassment of the child to significantly more sinister repercussions. Just over half of the parents (52%) in the Mott survey reported that they are concerned their child might feel embarrassed when they grow older and discover what their parents shared online. But that embarrassment also can lead to bullying or determent of psychosocial development, Ms. Steinberg and Dr. Keith explained.
More serious, if less common, risks include the possibility that data brokers could access and use information about the children or that online child pornographers could repurpose the photos inappropriately. One worst case scenario of the former is digital kidnapping, a disturbing practice in which a stranger uses baby photos and information that is not their own to pass off the child as their own or to invite others to “invent” identities for the child. The Children’s Online Privacy Protection Rule of the Federal Trade Commission addresses only online use by those under age 13 years, not others’ use of those images.
Regarding the latter, Ms. Steinberg and Dr. Keith showed an example of a bare-bottomed baby standing in front of a bathtub that had been reshared hundreds of times, but other images that have been shared on child pornography sites depict children in everyday situations such as playing on a playground, running at the beach, or doing gymnastics.
“These are images that many of us would think are innocent, but pornographers would categorize these into folders,” Dr. Keith said. “It’s not even naked or half-naked pictures.”
A study conducted by an e-safety commission in Australia, for example, found that half of the thousands of photos shared on a sample of child pornography sites had originated from parental sharing.
But Ms. Steinberg and Dr. Keith pointed out that benefits of parents’ online sharing exist as well, as the Mott survey found. In that survey, 72% of parents who discuss parenting and/or their children on social media reported that doing so helps them feel less alone. Similarly, 70% said they learn what not to do through those experiences, 67% said they receive advice from more experienced parents, and 62% said they consequently worry less. Common topics they discussed included sleep, nutrition, discipline, day care, and behavior management.
Other benefits, Ms. Steinberg pointed out, are that families geographically spread apart can stay connected, and communities can grow stronger with shared communal experiences of parents meeting others online.
“For some parents, it gives them an opportunity for advocacy work and raises awareness for important social issues,” Ms. Steinberg said, although she added, “If you’re going to share your children’s behavioral problems, consider sharing anonymously.”
Neither Ms. Steinberg and Dr. Keith said they had simple solutions to these challenges. Rather, they recommended using the public health model of raising awareness and encouraging open dialogue among pediatricians, parents, and their children to look for ways to balance competing interests.
“Social media offers many positive benefits, and we don’t want to silence the many voices of parents who take part in online sharing,” Ms. Steinberg explained. But she and Ms. Keith said it’s also worth considering children’s potential interest in controlling what their digital footprint is as they become adults.
For example, one study they cited found that, among 249 pairs of parents and their children, three times more children than parents wanted the parents to have and follow rules regarding what they could share on social media about their children.
Although guidance for parents on monitoring children’s social media use is a part of the AAP policy statement on media, only one recommendation obliquely addresses how parents should or shouldn’t use social media by advising them to model appropriate use for their children.
“It’s just like any medical decision: What is the benefit, and what is the risk, and does the benefit outweigh the risk?” said Wendy Sue Swanson, MD, executive director of digital health at Seattle Children’s Hospital. She recommended that parents ask their child for permission before posting a story or photo if their kids are aged 6 or older.
Ms. Steinberg and Dr. Keith recommended that pediatricians broach this subject with parents to help them think about risks they simply might not have considered before.
“When we looked at what sorts of best practices could be encouraged or doctors could talk to parents about – the tangible harms, such as whether data brokers or people interested in child pornography could access the information – we didn’t want to create any unnecessary panic,” Ms. Steinberg said. “But we did find some concerns that were troublesome, and we thought that parents or at least physicians [should] be aware of those potential risks.”
Ms. Steinberg and Dr. Keith reported that they had no relevant financial disclosures.
AT AAP 2016
Managing stress in children, parents can reduce obesity risk
SAN FRANCISCO – Obesity is a multifactorial problem, influenced by factors ranging from genetics to lifestyle to the environment. Yet stress can play an outsize role in obesity as well, Elizabeth Prout Parks, MD, said at the annual meeting of the American Academy of Pediatrics.
Although the calorie-in/calorie-out model of energy balance has driven much of the thought about obesity, it’s not that simple, suggested Dr. Parks, the medical director of the Healthy Weight Adolescent Bariatrics Program at the Children’s Hospital of Philadelphia. Physical activity accounts for an estimated 15%-30% of energy expenditure, and thermogenesis accounts for an estimated 10%. But the energy expenditure required for basal metabolism can range from 60% to 75%, a sufficiently wide range for significant variation across different individuals.
The psychosocial effects can lead to anxiety, depression, disordered eating behaviors such as emotional eating, a sedentary lifestyle, poor sleep, and low maintenance with self-care activities. Further, poor sleep on its own is additionally associated with childhood obesity. The combination of these physiologic and psychosocial effects can increase the risk of metabolic syndrome, type 2 diabetes, and cardiovascular disease or events. While acute stress and chronic stress follow similar pathways in the brain, it’s chronic stress that carries the greater risk of behavioral and physical conditions.
Measuring and understanding child and parental stress
Several clinical assessments can measure stress in children, including the Daily Hassles Scale, which looks at everyday interactions in the environment and factors such as children’s school, family, neighborhood, peers, and lack of resources. The Multidimensional Life Events Rating Questionnaire and Adolescent Stress Questionnaire both are more appropriate for middle school and older adolescents.
In children, the primary biologic indicators of stress are cortisol levels, heart rate, and blood pressure, but it is perceived stress that has been most clearly linked to emotional eating and other disordered eating behaviors, Dr. Parks said. One 2008 study found perceived stress to be associated with emotional eating among middle school students both with and without obesity. A high level of perceived stress in adolescents was associated with a greater waist circumference and body mass index in a 2009 study.
The findings are somewhat more mixed, however, when it comes to parental stress and child weight. A 2012 study identified a link between parents’ perception of their stress and increased fast food consumption in their children, and a 2008 study identified a link between parenting stress and both overweight and underweight children. Yet a different study in 2008 found no association between child obesity and parenting stress. Research in 2011 found a relationship between children’s consumption of fruits and vegetables and their family’s overall functioning, as well as parental psychological stress and child behavior. Within a family, stress can come from financial strain (such as poverty or changes in employment or insurance), the family’s structure, and changes in physical or mental health of one or more family members.
Addressing the effects of stress on diet
Clinicians can help families manage the ways stress can lead to obesity by helping them with ideas for increasing fruit and vegetable intake, and planning ahead for on-the-go eating. For example, to ensure children get in their recommended five servings of fruit and vegetables each day, parents can serve fruit with breakfast every day and offer vegetables and/or fruit as a snack. Including side salads and a frozen vegetable with dinner will add two more servings, and children can munch on chopped veggies while parents prepare dinner. Offering fruit as a dessert provides another opportunity to bump up kids’ fruit and veggie intake, Dr. Parks said.
To manage the risk of unhealthy eating when out and about, Dr. Parks recommends planning ahead by packing a snack such as yogurt, fruit and vegetables, a sandwich or wrap, and water.
She described the “apple test” for determining whether someone is eating because of boredom or stress or because of actual hunger.“The next time you are thinking about a mini meal or second helpings at a meal, ask yourself, ‘Would I eat an apple instead?’ ” Dr. Parks said. “If the answer is no, then you probably are not really hungry and just need to get away from food.”
Other things people can consider when about to eat something are whether they are actually hungry and whether a distraction such as the television is contributing to distracted eating. “People may eat when they’re happy, sad, or bored,” Dr. Parks said, noting that outside messages such as commercials, advertisements, and passing restaurants may make someone feel like eating even if they don’t need sustenance at that moment. “Consider whether you really are hungry before you eat,” she said.
Avoiding emotional eating and using mindfulness
Additionally, parents and children can avoid emotional eating by skipping the food when they feel angry, tired, nervous, bored, or sad, instead choosing activities such as journaling, taking a walk, listening to music, reading a book, or taking deep breaths while thinking pleasant thoughts. It’s only time to eat if you physically feel hungry, your stomach is rumbling, you are not craving some specific sweet or salty food, or it’s a meal or snack time (or at least 2.5-4 hours since the last time you ate).
Dr. Parks also reviewed ways that mindfulness may help reduce the risk of obesity by reducing stress, enhancing a person’s ability to regulate their everyday behaviors, and teaching individuals to accept discomfort. Another stress reduction strategy is repeated use of “4-7-8 breathing,” which begins with exhalation while the mouth is closed. Then, inhale through the nose for 4 seconds, hold the breath for 7 seconds and slowly exhale out the mouth for 8 seconds.
Reducing the risk of obesity from stress comes from learning to manage stress. Clinicians can play a role in helping both parents and children learn strategies to manage and cope with stress in the short term while developing resilience over the longer term and reducing the likelihood of poor eating and emotional eating.
Dr. Parks reported no disclosures.
SAN FRANCISCO – Obesity is a multifactorial problem, influenced by factors ranging from genetics to lifestyle to the environment. Yet stress can play an outsize role in obesity as well, Elizabeth Prout Parks, MD, said at the annual meeting of the American Academy of Pediatrics.
Although the calorie-in/calorie-out model of energy balance has driven much of the thought about obesity, it’s not that simple, suggested Dr. Parks, the medical director of the Healthy Weight Adolescent Bariatrics Program at the Children’s Hospital of Philadelphia. Physical activity accounts for an estimated 15%-30% of energy expenditure, and thermogenesis accounts for an estimated 10%. But the energy expenditure required for basal metabolism can range from 60% to 75%, a sufficiently wide range for significant variation across different individuals.
The psychosocial effects can lead to anxiety, depression, disordered eating behaviors such as emotional eating, a sedentary lifestyle, poor sleep, and low maintenance with self-care activities. Further, poor sleep on its own is additionally associated with childhood obesity. The combination of these physiologic and psychosocial effects can increase the risk of metabolic syndrome, type 2 diabetes, and cardiovascular disease or events. While acute stress and chronic stress follow similar pathways in the brain, it’s chronic stress that carries the greater risk of behavioral and physical conditions.
Measuring and understanding child and parental stress
Several clinical assessments can measure stress in children, including the Daily Hassles Scale, which looks at everyday interactions in the environment and factors such as children’s school, family, neighborhood, peers, and lack of resources. The Multidimensional Life Events Rating Questionnaire and Adolescent Stress Questionnaire both are more appropriate for middle school and older adolescents.
In children, the primary biologic indicators of stress are cortisol levels, heart rate, and blood pressure, but it is perceived stress that has been most clearly linked to emotional eating and other disordered eating behaviors, Dr. Parks said. One 2008 study found perceived stress to be associated with emotional eating among middle school students both with and without obesity. A high level of perceived stress in adolescents was associated with a greater waist circumference and body mass index in a 2009 study.
The findings are somewhat more mixed, however, when it comes to parental stress and child weight. A 2012 study identified a link between parents’ perception of their stress and increased fast food consumption in their children, and a 2008 study identified a link between parenting stress and both overweight and underweight children. Yet a different study in 2008 found no association between child obesity and parenting stress. Research in 2011 found a relationship between children’s consumption of fruits and vegetables and their family’s overall functioning, as well as parental psychological stress and child behavior. Within a family, stress can come from financial strain (such as poverty or changes in employment or insurance), the family’s structure, and changes in physical or mental health of one or more family members.
Addressing the effects of stress on diet
Clinicians can help families manage the ways stress can lead to obesity by helping them with ideas for increasing fruit and vegetable intake, and planning ahead for on-the-go eating. For example, to ensure children get in their recommended five servings of fruit and vegetables each day, parents can serve fruit with breakfast every day and offer vegetables and/or fruit as a snack. Including side salads and a frozen vegetable with dinner will add two more servings, and children can munch on chopped veggies while parents prepare dinner. Offering fruit as a dessert provides another opportunity to bump up kids’ fruit and veggie intake, Dr. Parks said.
To manage the risk of unhealthy eating when out and about, Dr. Parks recommends planning ahead by packing a snack such as yogurt, fruit and vegetables, a sandwich or wrap, and water.
She described the “apple test” for determining whether someone is eating because of boredom or stress or because of actual hunger.“The next time you are thinking about a mini meal or second helpings at a meal, ask yourself, ‘Would I eat an apple instead?’ ” Dr. Parks said. “If the answer is no, then you probably are not really hungry and just need to get away from food.”
Other things people can consider when about to eat something are whether they are actually hungry and whether a distraction such as the television is contributing to distracted eating. “People may eat when they’re happy, sad, or bored,” Dr. Parks said, noting that outside messages such as commercials, advertisements, and passing restaurants may make someone feel like eating even if they don’t need sustenance at that moment. “Consider whether you really are hungry before you eat,” she said.
Avoiding emotional eating and using mindfulness
Additionally, parents and children can avoid emotional eating by skipping the food when they feel angry, tired, nervous, bored, or sad, instead choosing activities such as journaling, taking a walk, listening to music, reading a book, or taking deep breaths while thinking pleasant thoughts. It’s only time to eat if you physically feel hungry, your stomach is rumbling, you are not craving some specific sweet or salty food, or it’s a meal or snack time (or at least 2.5-4 hours since the last time you ate).
Dr. Parks also reviewed ways that mindfulness may help reduce the risk of obesity by reducing stress, enhancing a person’s ability to regulate their everyday behaviors, and teaching individuals to accept discomfort. Another stress reduction strategy is repeated use of “4-7-8 breathing,” which begins with exhalation while the mouth is closed. Then, inhale through the nose for 4 seconds, hold the breath for 7 seconds and slowly exhale out the mouth for 8 seconds.
Reducing the risk of obesity from stress comes from learning to manage stress. Clinicians can play a role in helping both parents and children learn strategies to manage and cope with stress in the short term while developing resilience over the longer term and reducing the likelihood of poor eating and emotional eating.
Dr. Parks reported no disclosures.
SAN FRANCISCO – Obesity is a multifactorial problem, influenced by factors ranging from genetics to lifestyle to the environment. Yet stress can play an outsize role in obesity as well, Elizabeth Prout Parks, MD, said at the annual meeting of the American Academy of Pediatrics.
Although the calorie-in/calorie-out model of energy balance has driven much of the thought about obesity, it’s not that simple, suggested Dr. Parks, the medical director of the Healthy Weight Adolescent Bariatrics Program at the Children’s Hospital of Philadelphia. Physical activity accounts for an estimated 15%-30% of energy expenditure, and thermogenesis accounts for an estimated 10%. But the energy expenditure required for basal metabolism can range from 60% to 75%, a sufficiently wide range for significant variation across different individuals.
The psychosocial effects can lead to anxiety, depression, disordered eating behaviors such as emotional eating, a sedentary lifestyle, poor sleep, and low maintenance with self-care activities. Further, poor sleep on its own is additionally associated with childhood obesity. The combination of these physiologic and psychosocial effects can increase the risk of metabolic syndrome, type 2 diabetes, and cardiovascular disease or events. While acute stress and chronic stress follow similar pathways in the brain, it’s chronic stress that carries the greater risk of behavioral and physical conditions.
Measuring and understanding child and parental stress
Several clinical assessments can measure stress in children, including the Daily Hassles Scale, which looks at everyday interactions in the environment and factors such as children’s school, family, neighborhood, peers, and lack of resources. The Multidimensional Life Events Rating Questionnaire and Adolescent Stress Questionnaire both are more appropriate for middle school and older adolescents.
In children, the primary biologic indicators of stress are cortisol levels, heart rate, and blood pressure, but it is perceived stress that has been most clearly linked to emotional eating and other disordered eating behaviors, Dr. Parks said. One 2008 study found perceived stress to be associated with emotional eating among middle school students both with and without obesity. A high level of perceived stress in adolescents was associated with a greater waist circumference and body mass index in a 2009 study.
The findings are somewhat more mixed, however, when it comes to parental stress and child weight. A 2012 study identified a link between parents’ perception of their stress and increased fast food consumption in their children, and a 2008 study identified a link between parenting stress and both overweight and underweight children. Yet a different study in 2008 found no association between child obesity and parenting stress. Research in 2011 found a relationship between children’s consumption of fruits and vegetables and their family’s overall functioning, as well as parental psychological stress and child behavior. Within a family, stress can come from financial strain (such as poverty or changes in employment or insurance), the family’s structure, and changes in physical or mental health of one or more family members.
Addressing the effects of stress on diet
Clinicians can help families manage the ways stress can lead to obesity by helping them with ideas for increasing fruit and vegetable intake, and planning ahead for on-the-go eating. For example, to ensure children get in their recommended five servings of fruit and vegetables each day, parents can serve fruit with breakfast every day and offer vegetables and/or fruit as a snack. Including side salads and a frozen vegetable with dinner will add two more servings, and children can munch on chopped veggies while parents prepare dinner. Offering fruit as a dessert provides another opportunity to bump up kids’ fruit and veggie intake, Dr. Parks said.
To manage the risk of unhealthy eating when out and about, Dr. Parks recommends planning ahead by packing a snack such as yogurt, fruit and vegetables, a sandwich or wrap, and water.
She described the “apple test” for determining whether someone is eating because of boredom or stress or because of actual hunger.“The next time you are thinking about a mini meal or second helpings at a meal, ask yourself, ‘Would I eat an apple instead?’ ” Dr. Parks said. “If the answer is no, then you probably are not really hungry and just need to get away from food.”
Other things people can consider when about to eat something are whether they are actually hungry and whether a distraction such as the television is contributing to distracted eating. “People may eat when they’re happy, sad, or bored,” Dr. Parks said, noting that outside messages such as commercials, advertisements, and passing restaurants may make someone feel like eating even if they don’t need sustenance at that moment. “Consider whether you really are hungry before you eat,” she said.
Avoiding emotional eating and using mindfulness
Additionally, parents and children can avoid emotional eating by skipping the food when they feel angry, tired, nervous, bored, or sad, instead choosing activities such as journaling, taking a walk, listening to music, reading a book, or taking deep breaths while thinking pleasant thoughts. It’s only time to eat if you physically feel hungry, your stomach is rumbling, you are not craving some specific sweet or salty food, or it’s a meal or snack time (or at least 2.5-4 hours since the last time you ate).
Dr. Parks also reviewed ways that mindfulness may help reduce the risk of obesity by reducing stress, enhancing a person’s ability to regulate their everyday behaviors, and teaching individuals to accept discomfort. Another stress reduction strategy is repeated use of “4-7-8 breathing,” which begins with exhalation while the mouth is closed. Then, inhale through the nose for 4 seconds, hold the breath for 7 seconds and slowly exhale out the mouth for 8 seconds.
Reducing the risk of obesity from stress comes from learning to manage stress. Clinicians can play a role in helping both parents and children learn strategies to manage and cope with stress in the short term while developing resilience over the longer term and reducing the likelihood of poor eating and emotional eating.
Dr. Parks reported no disclosures.
Recognizing, addressing giftedness can be challenging
SAN FRANCISCO – Gifted children are far too commonly misunderstood, mislabeled, and misdiagnosed, leading to a mismatch between their needs and others’ perceptions of their needs, Dan Peters, PhD, a licensed psychologist and executive director of the Summit Center in the greater San Francisco and Los Angeles areas, explained at the annual meeting of the American Academy of Pediatrics.
Too often, one or more of these children’s health, developmental, social-emotional or learning needs are overlooked, or they receive an inappropriate mental health, developmental and/or learning disorder diagnosis. In fact, many of the risk factors for giftedness resemble those of other conditions: underachievement, difficulties with peers, social isolation, power struggles, perfectionism, anxiety, and depression.
Further, those who are culturally or linguistically diverse may not be recognized if a non-English first language obscures their performance ability or their socioeconomic status or lack of resources and enrichment opportunities leads them to be overlooked. It’s therefore important that practitioners understand what giftedness actually is and the characteristics gifted children might exhibit.
Understanding giftedness
A simple definition of giftedness is demonstrating a performance or the capacity for performance that significantly exceeds age or grade-level expectations, according to one school district’s gifted and talented education program.
A more involved description provided by the Columbus Group in 1991 defines giftedness as an “asynchronous development in which advanced cognitive abilities and heightened intensity combine to create inner experiences and awareness that are qualitatively different from the norm.” This asynchrony increases with higher intellectual capacity, they wrote. “The uniqueness of the gifted renders them vulnerable and requires modifications in parenting, teaching, and counseling in order for them to develop optimally.”
The level of a child’s giftedness makes a difference in their needs as well; these levels include advanced learners (IQ of 120-129), moderately gifted (130-144), highly gifted (145-159), exceptionally gifted (160-179), and profoundly gifted (180 and greater). Different spheres of giftedness can include intellectual ability, creative or productive thinking, leadership ability, and visual or performing arts. Consider the list of common characteristics of gifted children that Dr. Peters provided:
- Rapid learners.
- Strong memory.
- Large vocabulary.
- Advanced comprehension of nuances.
- Largely self-taught.
- Unusual emotional depth.
- Abstract/complex/logical/insightful thinking.
- Idealism and a sense of justice.
- Intense feelings and reactions.
- Highly sensitive.
- Long attention span and persistence.
- Preoccupied with own thoughts.
- Impatient with self and others’ inabilities and slowness.
- Asks probing questions (able to go beyond what is taught).
- Wide range of interests.
- Highly developed curiosity.
- Interest in experimenting and doing things differently.
- Divergent thinking.
- Keen and unusual sense of humor.
Dr. Peters cited Kazimierz Dabrowski, MD, PhD, a Polish psychiatrist of the mid-20th century, as explaining the sensitivity and intensity experienced by many gifted individuals in terms of overexcitabilities – a “greater capacity to be stimulated by and respond to external and internal stimuli.”
“Overexcitability permeates a gifted person’s existence and gives energy to their intelligence, talents, and personality,” Dr. Peters explained of Dabrowski’s ideas. This enhancement manifests in psychomotor terms as a strong drive, a lot of energy or movement, or extended bouts of activity. Intellectually, gifted children have an “insatiable curiosity, and voracious appetite and capacity for intellectual effort and stimulation,” Dr. Peters said. They may have heightened sensual experience in seeing, smelling, tasting, touching, or hearing, and they have an active imaginary and fantasy life. They also exhibit a capacity for great emotional depth and empathy – they deeply feel their own and others’ emotions.
How giftedness can be misdiagnosed
It is the combination of these very characteristics that can lead gifted children to receive an inappropriate mental or developmental diagnosis instead of being recognized as gifted.
“By current estimates, at any given time, approximately 11%-20% of children in the United States have a behavioral or emotional disorder as defined in the DSM-5,” Dr. Peters cited. Further, one study found that diagnoses of attention-deficit/hyperactivity disorder have increased 66% between 2000 and 2010, with 90% of those children taking psychostimulant medications – yet a study in the Journal of Health Economics estimated that one in five children diagnosed with ADHD are probably misdiagnosed and are receiving those medications.
Other incorrect diagnoses besides ADHD that gifted youth may commonly receive include anger diagnoses, ideational or anxiety disorders, developmental and personality disorders, mood disorders, and learning disorders.
Twice exceptionalism (2e)
Even more challenging are twice exceptional children, or 2e, those who are both gifted and have a learning or emotional disability or challenge. Common dual diagnoses in gifted children include anxiety disorders, depression (or existential depression), sleep disorders (such as nightmares, night terrors, or sleep walking), allergies, asthma, ADHD, oppositional-defiant disorder, obsessive-compulsive personality disorder, autism spectrum disorder, nonverbal learning disability, social/pragmatic communication disorder, and learning disorders such as dyslexia, dyscalculia, central auditory processing disorder, or sensory-motor integration disorder.
“It’s very complex. What happens is, a lot of people think you’re either gifted or not,” Dr. Peters said. “In the classroom, sometimes the advanced ability overshadows the weakness and so we get a lot of readers with an IQ of 130-150 and reading at the 50% percentile, and everyone says they’re fine, but they’re dyslexic.”
Other times, the weakness overshadows the strength, and sometimes they’re right in the middle where neither their giftedness nor their disability is recognized or addressed, Peters said. 2e children are very difficult to diagnose but also at higher risk for difficulties if one or both (or more) of their diagnoses are missed.
Maximizing gifted children’s developmental potential
Pediatricians have an opportunity to support gifted children by recognizing and accepting them for who they are, while also acknowledging that they want to feel “normal,” and therefore need extra reassurance and support from adults. Pediatricians should seek information about giftedness and 2e children from state and national gifted organizations, and, in the office, frame conversations with families and children’s differential diagnoses in terms of a child’s giftedness. If a pediatrician is themself gifted, they may be “a supportive and kindred spirit” to the child, Dr. Peters said.
In daily life, as well, gifted children need to be accepted for who they are, provided opportunities to be with their intellectual and academic peers, and provided challenges in their areas of strength, interests, or passions. Parents and teachers should follow their lead in learning: Keep up the pace for those who want to learn fast, and go deeper for those who want slower, more in-depth learning. Adults also need to understand their intensities and sensitivities and lead with their strengths in discussions.
Dr. Peters reported no disclosures.
SAN FRANCISCO – Gifted children are far too commonly misunderstood, mislabeled, and misdiagnosed, leading to a mismatch between their needs and others’ perceptions of their needs, Dan Peters, PhD, a licensed psychologist and executive director of the Summit Center in the greater San Francisco and Los Angeles areas, explained at the annual meeting of the American Academy of Pediatrics.
Too often, one or more of these children’s health, developmental, social-emotional or learning needs are overlooked, or they receive an inappropriate mental health, developmental and/or learning disorder diagnosis. In fact, many of the risk factors for giftedness resemble those of other conditions: underachievement, difficulties with peers, social isolation, power struggles, perfectionism, anxiety, and depression.
Further, those who are culturally or linguistically diverse may not be recognized if a non-English first language obscures their performance ability or their socioeconomic status or lack of resources and enrichment opportunities leads them to be overlooked. It’s therefore important that practitioners understand what giftedness actually is and the characteristics gifted children might exhibit.
Understanding giftedness
A simple definition of giftedness is demonstrating a performance or the capacity for performance that significantly exceeds age or grade-level expectations, according to one school district’s gifted and talented education program.
A more involved description provided by the Columbus Group in 1991 defines giftedness as an “asynchronous development in which advanced cognitive abilities and heightened intensity combine to create inner experiences and awareness that are qualitatively different from the norm.” This asynchrony increases with higher intellectual capacity, they wrote. “The uniqueness of the gifted renders them vulnerable and requires modifications in parenting, teaching, and counseling in order for them to develop optimally.”
The level of a child’s giftedness makes a difference in their needs as well; these levels include advanced learners (IQ of 120-129), moderately gifted (130-144), highly gifted (145-159), exceptionally gifted (160-179), and profoundly gifted (180 and greater). Different spheres of giftedness can include intellectual ability, creative or productive thinking, leadership ability, and visual or performing arts. Consider the list of common characteristics of gifted children that Dr. Peters provided:
- Rapid learners.
- Strong memory.
- Large vocabulary.
- Advanced comprehension of nuances.
- Largely self-taught.
- Unusual emotional depth.
- Abstract/complex/logical/insightful thinking.
- Idealism and a sense of justice.
- Intense feelings and reactions.
- Highly sensitive.
- Long attention span and persistence.
- Preoccupied with own thoughts.
- Impatient with self and others’ inabilities and slowness.
- Asks probing questions (able to go beyond what is taught).
- Wide range of interests.
- Highly developed curiosity.
- Interest in experimenting and doing things differently.
- Divergent thinking.
- Keen and unusual sense of humor.
Dr. Peters cited Kazimierz Dabrowski, MD, PhD, a Polish psychiatrist of the mid-20th century, as explaining the sensitivity and intensity experienced by many gifted individuals in terms of overexcitabilities – a “greater capacity to be stimulated by and respond to external and internal stimuli.”
“Overexcitability permeates a gifted person’s existence and gives energy to their intelligence, talents, and personality,” Dr. Peters explained of Dabrowski’s ideas. This enhancement manifests in psychomotor terms as a strong drive, a lot of energy or movement, or extended bouts of activity. Intellectually, gifted children have an “insatiable curiosity, and voracious appetite and capacity for intellectual effort and stimulation,” Dr. Peters said. They may have heightened sensual experience in seeing, smelling, tasting, touching, or hearing, and they have an active imaginary and fantasy life. They also exhibit a capacity for great emotional depth and empathy – they deeply feel their own and others’ emotions.
How giftedness can be misdiagnosed
It is the combination of these very characteristics that can lead gifted children to receive an inappropriate mental or developmental diagnosis instead of being recognized as gifted.
“By current estimates, at any given time, approximately 11%-20% of children in the United States have a behavioral or emotional disorder as defined in the DSM-5,” Dr. Peters cited. Further, one study found that diagnoses of attention-deficit/hyperactivity disorder have increased 66% between 2000 and 2010, with 90% of those children taking psychostimulant medications – yet a study in the Journal of Health Economics estimated that one in five children diagnosed with ADHD are probably misdiagnosed and are receiving those medications.
Other incorrect diagnoses besides ADHD that gifted youth may commonly receive include anger diagnoses, ideational or anxiety disorders, developmental and personality disorders, mood disorders, and learning disorders.
Twice exceptionalism (2e)
Even more challenging are twice exceptional children, or 2e, those who are both gifted and have a learning or emotional disability or challenge. Common dual diagnoses in gifted children include anxiety disorders, depression (or existential depression), sleep disorders (such as nightmares, night terrors, or sleep walking), allergies, asthma, ADHD, oppositional-defiant disorder, obsessive-compulsive personality disorder, autism spectrum disorder, nonverbal learning disability, social/pragmatic communication disorder, and learning disorders such as dyslexia, dyscalculia, central auditory processing disorder, or sensory-motor integration disorder.
“It’s very complex. What happens is, a lot of people think you’re either gifted or not,” Dr. Peters said. “In the classroom, sometimes the advanced ability overshadows the weakness and so we get a lot of readers with an IQ of 130-150 and reading at the 50% percentile, and everyone says they’re fine, but they’re dyslexic.”
Other times, the weakness overshadows the strength, and sometimes they’re right in the middle where neither their giftedness nor their disability is recognized or addressed, Peters said. 2e children are very difficult to diagnose but also at higher risk for difficulties if one or both (or more) of their diagnoses are missed.
Maximizing gifted children’s developmental potential
Pediatricians have an opportunity to support gifted children by recognizing and accepting them for who they are, while also acknowledging that they want to feel “normal,” and therefore need extra reassurance and support from adults. Pediatricians should seek information about giftedness and 2e children from state and national gifted organizations, and, in the office, frame conversations with families and children’s differential diagnoses in terms of a child’s giftedness. If a pediatrician is themself gifted, they may be “a supportive and kindred spirit” to the child, Dr. Peters said.
In daily life, as well, gifted children need to be accepted for who they are, provided opportunities to be with their intellectual and academic peers, and provided challenges in their areas of strength, interests, or passions. Parents and teachers should follow their lead in learning: Keep up the pace for those who want to learn fast, and go deeper for those who want slower, more in-depth learning. Adults also need to understand their intensities and sensitivities and lead with their strengths in discussions.
Dr. Peters reported no disclosures.
SAN FRANCISCO – Gifted children are far too commonly misunderstood, mislabeled, and misdiagnosed, leading to a mismatch between their needs and others’ perceptions of their needs, Dan Peters, PhD, a licensed psychologist and executive director of the Summit Center in the greater San Francisco and Los Angeles areas, explained at the annual meeting of the American Academy of Pediatrics.
Too often, one or more of these children’s health, developmental, social-emotional or learning needs are overlooked, or they receive an inappropriate mental health, developmental and/or learning disorder diagnosis. In fact, many of the risk factors for giftedness resemble those of other conditions: underachievement, difficulties with peers, social isolation, power struggles, perfectionism, anxiety, and depression.
Further, those who are culturally or linguistically diverse may not be recognized if a non-English first language obscures their performance ability or their socioeconomic status or lack of resources and enrichment opportunities leads them to be overlooked. It’s therefore important that practitioners understand what giftedness actually is and the characteristics gifted children might exhibit.
Understanding giftedness
A simple definition of giftedness is demonstrating a performance or the capacity for performance that significantly exceeds age or grade-level expectations, according to one school district’s gifted and talented education program.
A more involved description provided by the Columbus Group in 1991 defines giftedness as an “asynchronous development in which advanced cognitive abilities and heightened intensity combine to create inner experiences and awareness that are qualitatively different from the norm.” This asynchrony increases with higher intellectual capacity, they wrote. “The uniqueness of the gifted renders them vulnerable and requires modifications in parenting, teaching, and counseling in order for them to develop optimally.”
The level of a child’s giftedness makes a difference in their needs as well; these levels include advanced learners (IQ of 120-129), moderately gifted (130-144), highly gifted (145-159), exceptionally gifted (160-179), and profoundly gifted (180 and greater). Different spheres of giftedness can include intellectual ability, creative or productive thinking, leadership ability, and visual or performing arts. Consider the list of common characteristics of gifted children that Dr. Peters provided:
- Rapid learners.
- Strong memory.
- Large vocabulary.
- Advanced comprehension of nuances.
- Largely self-taught.
- Unusual emotional depth.
- Abstract/complex/logical/insightful thinking.
- Idealism and a sense of justice.
- Intense feelings and reactions.
- Highly sensitive.
- Long attention span and persistence.
- Preoccupied with own thoughts.
- Impatient with self and others’ inabilities and slowness.
- Asks probing questions (able to go beyond what is taught).
- Wide range of interests.
- Highly developed curiosity.
- Interest in experimenting and doing things differently.
- Divergent thinking.
- Keen and unusual sense of humor.
Dr. Peters cited Kazimierz Dabrowski, MD, PhD, a Polish psychiatrist of the mid-20th century, as explaining the sensitivity and intensity experienced by many gifted individuals in terms of overexcitabilities – a “greater capacity to be stimulated by and respond to external and internal stimuli.”
“Overexcitability permeates a gifted person’s existence and gives energy to their intelligence, talents, and personality,” Dr. Peters explained of Dabrowski’s ideas. This enhancement manifests in psychomotor terms as a strong drive, a lot of energy or movement, or extended bouts of activity. Intellectually, gifted children have an “insatiable curiosity, and voracious appetite and capacity for intellectual effort and stimulation,” Dr. Peters said. They may have heightened sensual experience in seeing, smelling, tasting, touching, or hearing, and they have an active imaginary and fantasy life. They also exhibit a capacity for great emotional depth and empathy – they deeply feel their own and others’ emotions.
How giftedness can be misdiagnosed
It is the combination of these very characteristics that can lead gifted children to receive an inappropriate mental or developmental diagnosis instead of being recognized as gifted.
“By current estimates, at any given time, approximately 11%-20% of children in the United States have a behavioral or emotional disorder as defined in the DSM-5,” Dr. Peters cited. Further, one study found that diagnoses of attention-deficit/hyperactivity disorder have increased 66% between 2000 and 2010, with 90% of those children taking psychostimulant medications – yet a study in the Journal of Health Economics estimated that one in five children diagnosed with ADHD are probably misdiagnosed and are receiving those medications.
Other incorrect diagnoses besides ADHD that gifted youth may commonly receive include anger diagnoses, ideational or anxiety disorders, developmental and personality disorders, mood disorders, and learning disorders.
Twice exceptionalism (2e)
Even more challenging are twice exceptional children, or 2e, those who are both gifted and have a learning or emotional disability or challenge. Common dual diagnoses in gifted children include anxiety disorders, depression (or existential depression), sleep disorders (such as nightmares, night terrors, or sleep walking), allergies, asthma, ADHD, oppositional-defiant disorder, obsessive-compulsive personality disorder, autism spectrum disorder, nonverbal learning disability, social/pragmatic communication disorder, and learning disorders such as dyslexia, dyscalculia, central auditory processing disorder, or sensory-motor integration disorder.
“It’s very complex. What happens is, a lot of people think you’re either gifted or not,” Dr. Peters said. “In the classroom, sometimes the advanced ability overshadows the weakness and so we get a lot of readers with an IQ of 130-150 and reading at the 50% percentile, and everyone says they’re fine, but they’re dyslexic.”
Other times, the weakness overshadows the strength, and sometimes they’re right in the middle where neither their giftedness nor their disability is recognized or addressed, Peters said. 2e children are very difficult to diagnose but also at higher risk for difficulties if one or both (or more) of their diagnoses are missed.
Maximizing gifted children’s developmental potential
Pediatricians have an opportunity to support gifted children by recognizing and accepting them for who they are, while also acknowledging that they want to feel “normal,” and therefore need extra reassurance and support from adults. Pediatricians should seek information about giftedness and 2e children from state and national gifted organizations, and, in the office, frame conversations with families and children’s differential diagnoses in terms of a child’s giftedness. If a pediatrician is themself gifted, they may be “a supportive and kindred spirit” to the child, Dr. Peters said.
In daily life, as well, gifted children need to be accepted for who they are, provided opportunities to be with their intellectual and academic peers, and provided challenges in their areas of strength, interests, or passions. Parents and teachers should follow their lead in learning: Keep up the pace for those who want to learn fast, and go deeper for those who want slower, more in-depth learning. Adults also need to understand their intensities and sensitivities and lead with their strengths in discussions.
Dr. Peters reported no disclosures.
EXPERT ANALYSIS FROM AAP 16
Distinguishing early puberty from pathology
SAN FRANCISCO – You have a female patient come in with apparent breast development but no dark pubic hair – and she’s 7 years old. Is it a case of early puberty, a warning sign to test for possible conditions, or an unremarkable departure from typical development that does not require any intervention?
The answer to situations such as these varies, explained Dennis Styne, MD, professor of pediatrics, and Yocha Dehe Endowed Chair in Pediatric Endocrinology, at the University of California, Davis.
“We don’t know why puberty begins when it does even though we know many of the controlling factors,” Dr. Styne said at the annual meeting of the American Academy of Pediatrics, but it’s important to understand when “early” is so early that you should order lab evaluations, as opposed to simply letting an outlier’s body development continue as it would.
Normal puberty
Dr. Styne reviewed the Tanner stages of puberty for girls’ breast and pubic hair development and boys’ genital and pubic hair development, noting that the classic lower ages of pubertal onset are age 8 years in girls and 9 years in boys. Yet the normal curve may actually start earlier than those ages for U.S. girls, he noted. He shared the results of a 1997 Pediatrics study of 17,077 girls, in which by age 7 years, more than a quarter of black girls (27%) and 7% of white girls had reached at least Tanner stage 2. At age 8, nearly half of black girls (48%) and 15% of white girls had reached at least stage 2 (Pediatrics. 1997 Apr;99[4]:505-12).
Further, breast development, menarche, and early pubic hair development (pubarche) all occur earlier with increased body mass index, which has been increasing among children overall. Another study identified earlier breast development without increased body mass index: Stage 2 development occurred an average 10 months earlier in girls in 2006 than in 1991, regardless of BMI, even though no difference in LH or FSH levels occurred at these ages and estradiol level was even lower. The authors of that Danish study concluded some other factors besides pubertal hormones had to account for the increasingly earlier breast development in girls. Endocrine-disrupting chemicals are a possible cause.
Similarly, puberty in boys is occurring a bit earlier, but less dramatically so: A 2012 study of 4,131 boys found that 5.75% of black boys, 0.54% of white boys, and 1.16% of Hispanic boys had stage 2 pubic hair development by age 6. Meanwhile, 10.9% of black boys, 2% of white boys, and 2.5% of Hispanic boys began puberty with stage 2 pubic hair development at age 8 (Pediatrics 2012;130:e1058-68).
But the boys differ in one key way from the girls: Boys with obesity tend to begin puberty later than those with normal or overweight BMIs, even though overweight boys begin puberty earlier than those with normal weights.
This leaves age 8 years as a normal age to begin puberty in boys but leaves the ages for girls’ start less certain – perhaps 7 years for white girls and 6 years for black girls – but still controversial.
When to be concerned
Various neurotransmitters in the central nervous system control puberty by suppression during childhood, until a trigger for onset occurs that remains mysterious. But gene mutations, such as MKRN3 in girls, as well as brain tumors or trauma, can remove that disinhibition, prompting further investigation. Brain tumors causing precocious puberty are more common in boys than girls.
Rapid growth and bone age advancement, elevated serum levels of sex steroids, and breast development in girls could all indicate precocious puberty. If these signs are accompanied by a rise in gonadotropin values to pubertal levels, early central precocious puberty, which follows the normal course of puberty except that it is earlier, is likely.
With both sex steroids and gonadotropins in the pubertal range, a GnRH agonist could be used to control gonadal steroid production and stop bone age advancement, allowing children to reach a greater adult height if started before age 6 years. If the early puberty is slowly progressing and more subtle, no treatment at all may be necessary if there are no pathologic findings.
Without proper testing, however, a physician might as well be guessing at the cause of the early development.
“You need a highly sensitive assay, and you need pediatric standards, so you’ll probably have to send blood samples out to a national laboratory,” Dr. Styne said.
If sex hormones are being secreted at a higher rate with suppression of gonadotropins, the source is most likely autonomous secretion by the gonads or the adrenal glands.
“If you see a boy with precious puberty, with testes that are not as big as they should be for the pubertal testosterone levels, it could be that the source is the adrenal glands,” Dr. Styne said.
Meanwhile, about 75% of boys will have gynecomastia to some degree during puberty, likely because of a subtle early pubertal imbalance between estrogen and testosterone, Dr. Styne said. The condition usually regresses, but “if it doesn’t regress, there’s a chance scar tissue will develop and remain, leading to the need for surgical correction. Klinefelter syndrome must be ruled out in cases of gynecomastia or, alternatively, rarer cases of disorders of sexual development.
Dr. Styne reported that he had no relevant financial disclosures.
SAN FRANCISCO – You have a female patient come in with apparent breast development but no dark pubic hair – and she’s 7 years old. Is it a case of early puberty, a warning sign to test for possible conditions, or an unremarkable departure from typical development that does not require any intervention?
The answer to situations such as these varies, explained Dennis Styne, MD, professor of pediatrics, and Yocha Dehe Endowed Chair in Pediatric Endocrinology, at the University of California, Davis.
“We don’t know why puberty begins when it does even though we know many of the controlling factors,” Dr. Styne said at the annual meeting of the American Academy of Pediatrics, but it’s important to understand when “early” is so early that you should order lab evaluations, as opposed to simply letting an outlier’s body development continue as it would.
Normal puberty
Dr. Styne reviewed the Tanner stages of puberty for girls’ breast and pubic hair development and boys’ genital and pubic hair development, noting that the classic lower ages of pubertal onset are age 8 years in girls and 9 years in boys. Yet the normal curve may actually start earlier than those ages for U.S. girls, he noted. He shared the results of a 1997 Pediatrics study of 17,077 girls, in which by age 7 years, more than a quarter of black girls (27%) and 7% of white girls had reached at least Tanner stage 2. At age 8, nearly half of black girls (48%) and 15% of white girls had reached at least stage 2 (Pediatrics. 1997 Apr;99[4]:505-12).
Further, breast development, menarche, and early pubic hair development (pubarche) all occur earlier with increased body mass index, which has been increasing among children overall. Another study identified earlier breast development without increased body mass index: Stage 2 development occurred an average 10 months earlier in girls in 2006 than in 1991, regardless of BMI, even though no difference in LH or FSH levels occurred at these ages and estradiol level was even lower. The authors of that Danish study concluded some other factors besides pubertal hormones had to account for the increasingly earlier breast development in girls. Endocrine-disrupting chemicals are a possible cause.
Similarly, puberty in boys is occurring a bit earlier, but less dramatically so: A 2012 study of 4,131 boys found that 5.75% of black boys, 0.54% of white boys, and 1.16% of Hispanic boys had stage 2 pubic hair development by age 6. Meanwhile, 10.9% of black boys, 2% of white boys, and 2.5% of Hispanic boys began puberty with stage 2 pubic hair development at age 8 (Pediatrics 2012;130:e1058-68).
But the boys differ in one key way from the girls: Boys with obesity tend to begin puberty later than those with normal or overweight BMIs, even though overweight boys begin puberty earlier than those with normal weights.
This leaves age 8 years as a normal age to begin puberty in boys but leaves the ages for girls’ start less certain – perhaps 7 years for white girls and 6 years for black girls – but still controversial.
When to be concerned
Various neurotransmitters in the central nervous system control puberty by suppression during childhood, until a trigger for onset occurs that remains mysterious. But gene mutations, such as MKRN3 in girls, as well as brain tumors or trauma, can remove that disinhibition, prompting further investigation. Brain tumors causing precocious puberty are more common in boys than girls.
Rapid growth and bone age advancement, elevated serum levels of sex steroids, and breast development in girls could all indicate precocious puberty. If these signs are accompanied by a rise in gonadotropin values to pubertal levels, early central precocious puberty, which follows the normal course of puberty except that it is earlier, is likely.
With both sex steroids and gonadotropins in the pubertal range, a GnRH agonist could be used to control gonadal steroid production and stop bone age advancement, allowing children to reach a greater adult height if started before age 6 years. If the early puberty is slowly progressing and more subtle, no treatment at all may be necessary if there are no pathologic findings.
Without proper testing, however, a physician might as well be guessing at the cause of the early development.
“You need a highly sensitive assay, and you need pediatric standards, so you’ll probably have to send blood samples out to a national laboratory,” Dr. Styne said.
If sex hormones are being secreted at a higher rate with suppression of gonadotropins, the source is most likely autonomous secretion by the gonads or the adrenal glands.
“If you see a boy with precious puberty, with testes that are not as big as they should be for the pubertal testosterone levels, it could be that the source is the adrenal glands,” Dr. Styne said.
Meanwhile, about 75% of boys will have gynecomastia to some degree during puberty, likely because of a subtle early pubertal imbalance between estrogen and testosterone, Dr. Styne said. The condition usually regresses, but “if it doesn’t regress, there’s a chance scar tissue will develop and remain, leading to the need for surgical correction. Klinefelter syndrome must be ruled out in cases of gynecomastia or, alternatively, rarer cases of disorders of sexual development.
Dr. Styne reported that he had no relevant financial disclosures.
SAN FRANCISCO – You have a female patient come in with apparent breast development but no dark pubic hair – and she’s 7 years old. Is it a case of early puberty, a warning sign to test for possible conditions, or an unremarkable departure from typical development that does not require any intervention?
The answer to situations such as these varies, explained Dennis Styne, MD, professor of pediatrics, and Yocha Dehe Endowed Chair in Pediatric Endocrinology, at the University of California, Davis.
“We don’t know why puberty begins when it does even though we know many of the controlling factors,” Dr. Styne said at the annual meeting of the American Academy of Pediatrics, but it’s important to understand when “early” is so early that you should order lab evaluations, as opposed to simply letting an outlier’s body development continue as it would.
Normal puberty
Dr. Styne reviewed the Tanner stages of puberty for girls’ breast and pubic hair development and boys’ genital and pubic hair development, noting that the classic lower ages of pubertal onset are age 8 years in girls and 9 years in boys. Yet the normal curve may actually start earlier than those ages for U.S. girls, he noted. He shared the results of a 1997 Pediatrics study of 17,077 girls, in which by age 7 years, more than a quarter of black girls (27%) and 7% of white girls had reached at least Tanner stage 2. At age 8, nearly half of black girls (48%) and 15% of white girls had reached at least stage 2 (Pediatrics. 1997 Apr;99[4]:505-12).
Further, breast development, menarche, and early pubic hair development (pubarche) all occur earlier with increased body mass index, which has been increasing among children overall. Another study identified earlier breast development without increased body mass index: Stage 2 development occurred an average 10 months earlier in girls in 2006 than in 1991, regardless of BMI, even though no difference in LH or FSH levels occurred at these ages and estradiol level was even lower. The authors of that Danish study concluded some other factors besides pubertal hormones had to account for the increasingly earlier breast development in girls. Endocrine-disrupting chemicals are a possible cause.
Similarly, puberty in boys is occurring a bit earlier, but less dramatically so: A 2012 study of 4,131 boys found that 5.75% of black boys, 0.54% of white boys, and 1.16% of Hispanic boys had stage 2 pubic hair development by age 6. Meanwhile, 10.9% of black boys, 2% of white boys, and 2.5% of Hispanic boys began puberty with stage 2 pubic hair development at age 8 (Pediatrics 2012;130:e1058-68).
But the boys differ in one key way from the girls: Boys with obesity tend to begin puberty later than those with normal or overweight BMIs, even though overweight boys begin puberty earlier than those with normal weights.
This leaves age 8 years as a normal age to begin puberty in boys but leaves the ages for girls’ start less certain – perhaps 7 years for white girls and 6 years for black girls – but still controversial.
When to be concerned
Various neurotransmitters in the central nervous system control puberty by suppression during childhood, until a trigger for onset occurs that remains mysterious. But gene mutations, such as MKRN3 in girls, as well as brain tumors or trauma, can remove that disinhibition, prompting further investigation. Brain tumors causing precocious puberty are more common in boys than girls.
Rapid growth and bone age advancement, elevated serum levels of sex steroids, and breast development in girls could all indicate precocious puberty. If these signs are accompanied by a rise in gonadotropin values to pubertal levels, early central precocious puberty, which follows the normal course of puberty except that it is earlier, is likely.
With both sex steroids and gonadotropins in the pubertal range, a GnRH agonist could be used to control gonadal steroid production and stop bone age advancement, allowing children to reach a greater adult height if started before age 6 years. If the early puberty is slowly progressing and more subtle, no treatment at all may be necessary if there are no pathologic findings.
Without proper testing, however, a physician might as well be guessing at the cause of the early development.
“You need a highly sensitive assay, and you need pediatric standards, so you’ll probably have to send blood samples out to a national laboratory,” Dr. Styne said.
If sex hormones are being secreted at a higher rate with suppression of gonadotropins, the source is most likely autonomous secretion by the gonads or the adrenal glands.
“If you see a boy with precious puberty, with testes that are not as big as they should be for the pubertal testosterone levels, it could be that the source is the adrenal glands,” Dr. Styne said.
Meanwhile, about 75% of boys will have gynecomastia to some degree during puberty, likely because of a subtle early pubertal imbalance between estrogen and testosterone, Dr. Styne said. The condition usually regresses, but “if it doesn’t regress, there’s a chance scar tissue will develop and remain, leading to the need for surgical correction. Klinefelter syndrome must be ruled out in cases of gynecomastia or, alternatively, rarer cases of disorders of sexual development.
Dr. Styne reported that he had no relevant financial disclosures.
AT AAP 16
Confront youth opioid misuse head on
SAN FRANCISCO – Clinicians treating children should seek out and advocate for resources needed to treat opioid addiction rather than shying away from doing so because of a feeling of helplessness, Pamela Gonzalez, MD, said at the annual meeting of the American Academy of Pediatrics.
Opioid poisonings have nearly doubled among children and adolescents over the past decade and a half, a retrospective analysis of 13,052 national hospital discharge records found. Pediatric hospitalizations for opioid poisonings increased nearly twofold from 1997 to 2012. That is, the annual incidence of hospitalizations for opioid poisonings per 100,000 children aged 1-19 years rose from 1.40 to 3.71, an increase of 165% (P less than.001) (JAMA Pediatr. 2016 Oct 31. doi: 10.1001/jamapediatrics.2016.2154).
“Silence is deadly,” she said. “What’s going to stop this problem? Not being silent, not being quiet about it.
“I hear a lot of people still saying, ‘I don’t have enough resources; I don’t know where to send them to; what am I going to do?’ ” she said. “There are a lot of illnesses that we look for, that we get the diagnosis for, and the outcome may be supportive or may be a difficult conversation with the family, but just because at this point resources aren’t what we want them to be does not mean not to look.”
Understanding the problem
Dr. Gonzalez pointed out how accessible opioids are for children and adolescents. Most youth access prescription opioids for misuse or nonmedical use from legitimate prescriptions diverted from an intended use. The largest source of diverted medication is prescribing to adults, and the problem is worsened by the fact that some youth have an enhanced vulnerability to misuse or nonmedical use of opioids.
“Therapeutic use is still exposure,” she explained, citing a one-third increased risk of nonmedical use during ages 19-23 among youth who were prescribed opioids before 12th grade. Those prescribed opioids before their senior year also have a 2.7 times greater risk of using the opioids recreationally to get high (Pediatrics. 2015 Nov;136[5]:e1169-77).
The problem is exacerbated by the fact that patients at higher risk for substance use disorder also happen to be more likely to be prescribed chronic opioid therapy. Children and teens with preexisting psychiatric conditions have a 2.4 times greater risk of receiving long-term opioids than not receiving opioids at all, and they are 1.8 times more likely to receive long-term opioids than some opioids.
Prescription opioids have begun to replace heroin as the starting point on the path toward opioid use disorder, Dr. Gonzalez pointed out. A study in 2014 found that more than 80% of individuals who began taking opioids in the 1960s started with heroin, whereas 75% of users in the 2000s began their addiction with prescription opioids (JAMA Psychiatry. 2014;71[7]:821-6).
What pediatricians can do
“When our primary and secondary prevention efforts don’t work, we’re going to need to look at treatment options” for opioid use disorder, Dr. Gonzalez said. “Kids do better on some kind of medication than not.”
The most effective medications are buprenorphine and injectable naltrexone, but these are frequently unavailable to the adolescents who need them, she said. One way to begin saving lives is to increase the number of pediatricians who are trained and approved to provide buprenorphine to youth. Physicians can seek a waiver to be able to prescribe buprenorphine to youth with opioid use disorder and learn about treatment with naltrexone by taking an 8-hour online course that is free to AAP members at www.aap.org/mat.
She acknowledged that more resources are needed to address the problem of opioid misuse, something the surgeon general has made a priority as well, but that resource deficit should not be an excuse not to take action. Federal funding is available for states to treat opioid addiction, but some states, such as Minnesota, where Dr. Gonzalez works, may not qualify if there is “not enough of a problem.”
“If every state can’t get it to help with their treatment and prevention resources, that’s not enough money earmarked for it,” she said, “but we can advocate for it.”
At the same time, pediatricians can work toward prevention by screening for mental health symptoms and for substance use – two separate screenings – at every pediatric visit starting no later than age 11 years and at any visit where opioids are being prescribed. Further, before prescribing opioids to youth, doctors should weigh the need to reduce pain against the risks of future addiction to determine if opioids are really the best option for that patient.
Dr. Gonzalez concluded her plenary speech with a plea to her colleagues: “It begins with one pill, but the end begins with us. Every kid matters. We’re not going to save them all. We have to start with one kid at a time. We’re not going to save everybody, but one life for everybody in this room is a lot of kids. Help me save one life today.”
Dr. Gonzalez had no disclosures.
SAN FRANCISCO – Clinicians treating children should seek out and advocate for resources needed to treat opioid addiction rather than shying away from doing so because of a feeling of helplessness, Pamela Gonzalez, MD, said at the annual meeting of the American Academy of Pediatrics.
Opioid poisonings have nearly doubled among children and adolescents over the past decade and a half, a retrospective analysis of 13,052 national hospital discharge records found. Pediatric hospitalizations for opioid poisonings increased nearly twofold from 1997 to 2012. That is, the annual incidence of hospitalizations for opioid poisonings per 100,000 children aged 1-19 years rose from 1.40 to 3.71, an increase of 165% (P less than.001) (JAMA Pediatr. 2016 Oct 31. doi: 10.1001/jamapediatrics.2016.2154).
“Silence is deadly,” she said. “What’s going to stop this problem? Not being silent, not being quiet about it.
“I hear a lot of people still saying, ‘I don’t have enough resources; I don’t know where to send them to; what am I going to do?’ ” she said. “There are a lot of illnesses that we look for, that we get the diagnosis for, and the outcome may be supportive or may be a difficult conversation with the family, but just because at this point resources aren’t what we want them to be does not mean not to look.”
Understanding the problem
Dr. Gonzalez pointed out how accessible opioids are for children and adolescents. Most youth access prescription opioids for misuse or nonmedical use from legitimate prescriptions diverted from an intended use. The largest source of diverted medication is prescribing to adults, and the problem is worsened by the fact that some youth have an enhanced vulnerability to misuse or nonmedical use of opioids.
“Therapeutic use is still exposure,” she explained, citing a one-third increased risk of nonmedical use during ages 19-23 among youth who were prescribed opioids before 12th grade. Those prescribed opioids before their senior year also have a 2.7 times greater risk of using the opioids recreationally to get high (Pediatrics. 2015 Nov;136[5]:e1169-77).
The problem is exacerbated by the fact that patients at higher risk for substance use disorder also happen to be more likely to be prescribed chronic opioid therapy. Children and teens with preexisting psychiatric conditions have a 2.4 times greater risk of receiving long-term opioids than not receiving opioids at all, and they are 1.8 times more likely to receive long-term opioids than some opioids.
Prescription opioids have begun to replace heroin as the starting point on the path toward opioid use disorder, Dr. Gonzalez pointed out. A study in 2014 found that more than 80% of individuals who began taking opioids in the 1960s started with heroin, whereas 75% of users in the 2000s began their addiction with prescription opioids (JAMA Psychiatry. 2014;71[7]:821-6).
What pediatricians can do
“When our primary and secondary prevention efforts don’t work, we’re going to need to look at treatment options” for opioid use disorder, Dr. Gonzalez said. “Kids do better on some kind of medication than not.”
The most effective medications are buprenorphine and injectable naltrexone, but these are frequently unavailable to the adolescents who need them, she said. One way to begin saving lives is to increase the number of pediatricians who are trained and approved to provide buprenorphine to youth. Physicians can seek a waiver to be able to prescribe buprenorphine to youth with opioid use disorder and learn about treatment with naltrexone by taking an 8-hour online course that is free to AAP members at www.aap.org/mat.
She acknowledged that more resources are needed to address the problem of opioid misuse, something the surgeon general has made a priority as well, but that resource deficit should not be an excuse not to take action. Federal funding is available for states to treat opioid addiction, but some states, such as Minnesota, where Dr. Gonzalez works, may not qualify if there is “not enough of a problem.”
“If every state can’t get it to help with their treatment and prevention resources, that’s not enough money earmarked for it,” she said, “but we can advocate for it.”
At the same time, pediatricians can work toward prevention by screening for mental health symptoms and for substance use – two separate screenings – at every pediatric visit starting no later than age 11 years and at any visit where opioids are being prescribed. Further, before prescribing opioids to youth, doctors should weigh the need to reduce pain against the risks of future addiction to determine if opioids are really the best option for that patient.
Dr. Gonzalez concluded her plenary speech with a plea to her colleagues: “It begins with one pill, but the end begins with us. Every kid matters. We’re not going to save them all. We have to start with one kid at a time. We’re not going to save everybody, but one life for everybody in this room is a lot of kids. Help me save one life today.”
Dr. Gonzalez had no disclosures.
SAN FRANCISCO – Clinicians treating children should seek out and advocate for resources needed to treat opioid addiction rather than shying away from doing so because of a feeling of helplessness, Pamela Gonzalez, MD, said at the annual meeting of the American Academy of Pediatrics.
Opioid poisonings have nearly doubled among children and adolescents over the past decade and a half, a retrospective analysis of 13,052 national hospital discharge records found. Pediatric hospitalizations for opioid poisonings increased nearly twofold from 1997 to 2012. That is, the annual incidence of hospitalizations for opioid poisonings per 100,000 children aged 1-19 years rose from 1.40 to 3.71, an increase of 165% (P less than.001) (JAMA Pediatr. 2016 Oct 31. doi: 10.1001/jamapediatrics.2016.2154).
“Silence is deadly,” she said. “What’s going to stop this problem? Not being silent, not being quiet about it.
“I hear a lot of people still saying, ‘I don’t have enough resources; I don’t know where to send them to; what am I going to do?’ ” she said. “There are a lot of illnesses that we look for, that we get the diagnosis for, and the outcome may be supportive or may be a difficult conversation with the family, but just because at this point resources aren’t what we want them to be does not mean not to look.”
Understanding the problem
Dr. Gonzalez pointed out how accessible opioids are for children and adolescents. Most youth access prescription opioids for misuse or nonmedical use from legitimate prescriptions diverted from an intended use. The largest source of diverted medication is prescribing to adults, and the problem is worsened by the fact that some youth have an enhanced vulnerability to misuse or nonmedical use of opioids.
“Therapeutic use is still exposure,” she explained, citing a one-third increased risk of nonmedical use during ages 19-23 among youth who were prescribed opioids before 12th grade. Those prescribed opioids before their senior year also have a 2.7 times greater risk of using the opioids recreationally to get high (Pediatrics. 2015 Nov;136[5]:e1169-77).
The problem is exacerbated by the fact that patients at higher risk for substance use disorder also happen to be more likely to be prescribed chronic opioid therapy. Children and teens with preexisting psychiatric conditions have a 2.4 times greater risk of receiving long-term opioids than not receiving opioids at all, and they are 1.8 times more likely to receive long-term opioids than some opioids.
Prescription opioids have begun to replace heroin as the starting point on the path toward opioid use disorder, Dr. Gonzalez pointed out. A study in 2014 found that more than 80% of individuals who began taking opioids in the 1960s started with heroin, whereas 75% of users in the 2000s began their addiction with prescription opioids (JAMA Psychiatry. 2014;71[7]:821-6).
What pediatricians can do
“When our primary and secondary prevention efforts don’t work, we’re going to need to look at treatment options” for opioid use disorder, Dr. Gonzalez said. “Kids do better on some kind of medication than not.”
The most effective medications are buprenorphine and injectable naltrexone, but these are frequently unavailable to the adolescents who need them, she said. One way to begin saving lives is to increase the number of pediatricians who are trained and approved to provide buprenorphine to youth. Physicians can seek a waiver to be able to prescribe buprenorphine to youth with opioid use disorder and learn about treatment with naltrexone by taking an 8-hour online course that is free to AAP members at www.aap.org/mat.
She acknowledged that more resources are needed to address the problem of opioid misuse, something the surgeon general has made a priority as well, but that resource deficit should not be an excuse not to take action. Federal funding is available for states to treat opioid addiction, but some states, such as Minnesota, where Dr. Gonzalez works, may not qualify if there is “not enough of a problem.”
“If every state can’t get it to help with their treatment and prevention resources, that’s not enough money earmarked for it,” she said, “but we can advocate for it.”
At the same time, pediatricians can work toward prevention by screening for mental health symptoms and for substance use – two separate screenings – at every pediatric visit starting no later than age 11 years and at any visit where opioids are being prescribed. Further, before prescribing opioids to youth, doctors should weigh the need to reduce pain against the risks of future addiction to determine if opioids are really the best option for that patient.
Dr. Gonzalez concluded her plenary speech with a plea to her colleagues: “It begins with one pill, but the end begins with us. Every kid matters. We’re not going to save them all. We have to start with one kid at a time. We’re not going to save everybody, but one life for everybody in this room is a lot of kids. Help me save one life today.”
Dr. Gonzalez had no disclosures.
EXPERT ANALYSIS FROM AAP 16