PAS Annual Meeting 2015

SAN DIEGO – Exposure to various forms of abuse or other early adverse childhood experiences are associated with below-average literacy and attention problems in kindergartners, which in turn are strong predictors of educational trajectory, according to Dr. Manuel Jimenez.

“These findings emphasize the importance of strategies that address the developmental needs of vulnerable children, including strengthening families and early literacy promotion,” said Dr. Jimenez of the Rutgers Robert Wood Johnson Medical School in New Brunswick, N.J.

It’s well established that adverse childhood experiences (ACEs) are associated with adult disability, social problems, and engagement in health-risky behaviors. Much less is known about the impact of early ACEs on the kindergarten experience. This was the impetus for Dr. Jimenez’s analysis of data from the Fragile Families and Child Wellbeing Study. He focused on an urban cohort of 1,008 children evaluated by teacher survey and mother report at age 5 years. Forty-six percent of the children were African American, and 57% of their mothers had a high school diploma or less.

The mother-reported adverse childhood events were defined as in an earlier Centers for Disease Control and Prevention study. There were eight under consideration: exposure to maternal depression, incarceration of a household member, household substance use, the mother having been treated violently, neglect, or physical, sexual, or psychological abuse.

The prevalence of the individual ACEs was in the 10%-16% range with the exception of sexual abuse, which was reported in just 0.6% of the cohort. Forty-eight percent of the children had experienced at least one ACE and 22% two or more.

In teacher ratings conducted in the final month of kindergarten, the presence of any two or more ACEs was associated with a 1.7-fold increased likelihood of below-average literacy skills, a 1.6-fold greater likelihood of below-average math skills, a 1.8-fold increase in child disability, and a 3-fold increase in the likelihood of being in the top 10% of the class in attention problems.

Taking a more in-depth look at the teacher ratings of emergent literary skills, children with two or more ACEs were 1.9-fold more likely to be rated as “not yet” able to easily and quickly name all uppercase and lowercase letters or as “beginning to” do so; 1.8-fold more likely to not yet be able to understand or interpret a story or other text read to them; and 1.7-fold more likely not to demonstrate an understanding of some of the conventions of print.

“It’s reasonable to assume that children at the end of their kindergarten year would have mastered, or be proficient in, each of these skills,” Dr. Jimenez said at the annual meeting of the Pediatric Academic Societies.

Children with two or more ACEs were also 4.4-fold more likely to score in the top 10% for attention problems as rated by parents using the Child Behavior Checklist attention subscale.

All of these significantly increased odds ratios were adjusted for potential confounders in multivariate logistic regression analysis, including race, sex, ethnicity, maternal education at childbirth, and household income, he noted.

One audience member asked whether Dr. Jimenez thinks it’s useful to screen for ACEs in clinical practice.

“We’ve actually thought a lot about this,” he replied. “With problems as big as these, it’s often possible to feel very small. But as pediatricians we really can make an incredible difference in children’s lives because we get to see kids so often. The Bright Futures project (brightfutures.aap.org) is filled with tools we can use to screen for and find ACEs as well as the adverse outcomes that are associated with them. And there is an opportunity to work with families and connect them with community resources that can help build resilience and strength. In my own line of work, I’ve been fortunate to be able to partner with community groups in New Brunswick. We’re actively trying to link pediatricians in the community – the medical home – to the resources that are out there.”

The Fragile Families and Child Wellbeing Study is supported by the National Institute of Child Health and Human Development. Dr. Jimenez reported having no relevant financial disclosures.

[email protected]

SAN DIEGO – Exposure to various forms of abuse or other early adverse childhood experiences are associated with below-average literacy and attention problems in kindergartners, which in turn are strong predictors of educational trajectory, according to Dr. Manuel Jimenez.

“These findings emphasize the importance of strategies that address the developmental needs of vulnerable children, including strengthening families and early literacy promotion,” said Dr. Jimenez of the Rutgers Robert Wood Johnson Medical School in New Brunswick, N.J.

It’s well established that adverse childhood experiences (ACEs) are associated with adult disability, social problems, and engagement in health-risky behaviors. Much less is known about the impact of early ACEs on the kindergarten experience. This was the impetus for Dr. Jimenez’s analysis of data from the Fragile Families and Child Wellbeing Study. He focused on an urban cohort of 1,008 children evaluated by teacher survey and mother report at age 5 years. Forty-six percent of the children were African American, and 57% of their mothers had a high school diploma or less.

The mother-reported adverse childhood events were defined as in an earlier Centers for Disease Control and Prevention study. There were eight under consideration: exposure to maternal depression, incarceration of a household member, household substance use, the mother having been treated violently, neglect, or physical, sexual, or psychological abuse.

The prevalence of the individual ACEs was in the 10%-16% range with the exception of sexual abuse, which was reported in just 0.6% of the cohort. Forty-eight percent of the children had experienced at least one ACE and 22% two or more.

In teacher ratings conducted in the final month of kindergarten, the presence of any two or more ACEs was associated with a 1.7-fold increased likelihood of below-average literacy skills, a 1.6-fold greater likelihood of below-average math skills, a 1.8-fold increase in child disability, and a 3-fold increase in the likelihood of being in the top 10% of the class in attention problems.

Taking a more in-depth look at the teacher ratings of emergent literary skills, children with two or more ACEs were 1.9-fold more likely to be rated as “not yet” able to easily and quickly name all uppercase and lowercase letters or as “beginning to” do so; 1.8-fold more likely to not yet be able to understand or interpret a story or other text read to them; and 1.7-fold more likely not to demonstrate an understanding of some of the conventions of print.

“It’s reasonable to assume that children at the end of their kindergarten year would have mastered, or be proficient in, each of these skills,” Dr. Jimenez said at the annual meeting of the Pediatric Academic Societies.

Children with two or more ACEs were also 4.4-fold more likely to score in the top 10% for attention problems as rated by parents using the Child Behavior Checklist attention subscale.

All of these significantly increased odds ratios were adjusted for potential confounders in multivariate logistic regression analysis, including race, sex, ethnicity, maternal education at childbirth, and household income, he noted.

One audience member asked whether Dr. Jimenez thinks it’s useful to screen for ACEs in clinical practice.

“We’ve actually thought a lot about this,” he replied. “With problems as big as these, it’s often possible to feel very small. But as pediatricians we really can make an incredible difference in children’s lives because we get to see kids so often. The Bright Futures project (brightfutures.aap.org) is filled with tools we can use to screen for and find ACEs as well as the adverse outcomes that are associated with them. And there is an opportunity to work with families and connect them with community resources that can help build resilience and strength. In my own line of work, I’ve been fortunate to be able to partner with community groups in New Brunswick. We’re actively trying to link pediatricians in the community – the medical home – to the resources that are out there.”

The Fragile Families and Child Wellbeing Study is supported by the National Institute of Child Health and Human Development. Dr. Jimenez reported having no relevant financial disclosures.

[email protected]

SAN DIEGO – Exposure to various forms of abuse or other early adverse childhood experiences are associated with below-average literacy and attention problems in kindergartners, which in turn are strong predictors of educational trajectory, according to Dr. Manuel Jimenez.

“These findings emphasize the importance of strategies that address the developmental needs of vulnerable children, including strengthening families and early literacy promotion,” said Dr. Jimenez of the Rutgers Robert Wood Johnson Medical School in New Brunswick, N.J.

It’s well established that adverse childhood experiences (ACEs) are associated with adult disability, social problems, and engagement in health-risky behaviors. Much less is known about the impact of early ACEs on the kindergarten experience. This was the impetus for Dr. Jimenez’s analysis of data from the Fragile Families and Child Wellbeing Study. He focused on an urban cohort of 1,008 children evaluated by teacher survey and mother report at age 5 years. Forty-six percent of the children were African American, and 57% of their mothers had a high school diploma or less.

The mother-reported adverse childhood events were defined as in an earlier Centers for Disease Control and Prevention study. There were eight under consideration: exposure to maternal depression, incarceration of a household member, household substance use, the mother having been treated violently, neglect, or physical, sexual, or psychological abuse.

The prevalence of the individual ACEs was in the 10%-16% range with the exception of sexual abuse, which was reported in just 0.6% of the cohort. Forty-eight percent of the children had experienced at least one ACE and 22% two or more.

In teacher ratings conducted in the final month of kindergarten, the presence of any two or more ACEs was associated with a 1.7-fold increased likelihood of below-average literacy skills, a 1.6-fold greater likelihood of below-average math skills, a 1.8-fold increase in child disability, and a 3-fold increase in the likelihood of being in the top 10% of the class in attention problems.

Taking a more in-depth look at the teacher ratings of emergent literary skills, children with two or more ACEs were 1.9-fold more likely to be rated as “not yet” able to easily and quickly name all uppercase and lowercase letters or as “beginning to” do so; 1.8-fold more likely to not yet be able to understand or interpret a story or other text read to them; and 1.7-fold more likely not to demonstrate an understanding of some of the conventions of print.

“It’s reasonable to assume that children at the end of their kindergarten year would have mastered, or be proficient in, each of these skills,” Dr. Jimenez said at the annual meeting of the Pediatric Academic Societies.

Children with two or more ACEs were also 4.4-fold more likely to score in the top 10% for attention problems as rated by parents using the Child Behavior Checklist attention subscale.

All of these significantly increased odds ratios were adjusted for potential confounders in multivariate logistic regression analysis, including race, sex, ethnicity, maternal education at childbirth, and household income, he noted.

One audience member asked whether Dr. Jimenez thinks it’s useful to screen for ACEs in clinical practice.

“We’ve actually thought a lot about this,” he replied. “With problems as big as these, it’s often possible to feel very small. But as pediatricians we really can make an incredible difference in children’s lives because we get to see kids so often. The Bright Futures project (brightfutures.aap.org) is filled with tools we can use to screen for and find ACEs as well as the adverse outcomes that are associated with them. And there is an opportunity to work with families and connect them with community resources that can help build resilience and strength. In my own line of work, I’ve been fortunate to be able to partner with community groups in New Brunswick. We’re actively trying to link pediatricians in the community – the medical home – to the resources that are out there.”

The Fragile Families and Child Wellbeing Study is supported by the National Institute of Child Health and Human Development. Dr. Jimenez reported having no relevant financial disclosures.

[email protected]

SAN DIEGO – The bulk of outpatient pediatric mental health care is provided solely by primary care physicians, not psychiatrists, according to a national study.

The national data also showed that primary care physicians (PCPs) are more likely than psychiatrists to prescribe psychotropic medications for children and adolescents with mental health conditions, L. Elizabeth Anderson reported at the annual meeting of the Pediatric Academic Societies.

Bruce Jancin/Frontline Medical News

She presented an analysis of the Agency for Healthcare Quality and Research’s Medical Expenditure Panel Survey(MEPS), which contains data on a nationally representative cohort’s types of outpatient visits, the specialties of the physicians seen, conditions diagnosed, prescribed medications, and sociodemographic factors.

The MEPS data highlight just how commonly children and adolescents seek professional help for anxiety, depression, conduct disorders, and behavioral disorders. Extrapolating from this analysis of 1,778 youths aged 2-21 years with a mental disorder, an estimated 5.2% of U.S. children and adolescents have had one or more outpatient mental health visits within the past year, according to Ms. Anderson, a medical student at the University of Tennessee, Memphis.

Attention-deficit/hyperactivity disorder accounted for 65% of these outpatient visits, mood disorders 24%, anxiety 19%, pervasive developmental disorder 7%, and psychoses 1.3%. Patients could have more than one diagnosis.

Fully 35% of the youths received their outpatient care for mental health conditions solely from a PCP. Another 26% saw a psychiatrist only, and 15% saw a psychologist and/or social worker only. Roughly one-quarter of subjects saw multiple providers of mental health services, but patient comanagement by a PCP and psychiatrist occurred in only 6.7% of cases.

Primary care physicians appeared to be more comfortable serving as sole care providers for youths with ADHD than those with anxiety and/or mood disorders: 41% of youths with ADHD had a PCP as their sole provider, compared with 17% of those with an anxiety and/or mood disorder.

Sixty-nine percent of patients with a mental health disorder that was managed solely by a PCP received a prescription for psychotropic medication, as did 62% of those seen by a psychiatrist only. The difference in prescribing patterns was more marked in patients with ADHD: 73% of those treated by a PCP received a prescription, compared with 58% of those treated by a psychiatrist.

Thus, the likelihood that a patient with ADHD who was seen by a PCP would receive a prescription for a stimulant or atomoxetine was 65% greater than if seen by a psychiatrist, Ms. Anderson continued.

No consistent associations were seen between provider type or medication prescribing and sociodemographic factors including ethnicity, household income, or geographic locale.

With only 8.6 child and adolescent psychiatrists available per 100,000 U.S. pediatric patients, these study findings showing that PCPs now provide a substantial amount of pediatric mental health care provide a strong argument for programs aimed at improving quality of care via point-of-care advice to PCPs from mental health specialists, she said.

Ms. Anderson’s study was supported by a grant from the American Pediatric Society/Society for Pediatric Research student research training program. She reported having no financial conflicts.

[email protected]

SAN DIEGO – The bulk of outpatient pediatric mental health care is provided solely by primary care physicians, not psychiatrists, according to a national study.

The national data also showed that primary care physicians (PCPs) are more likely than psychiatrists to prescribe psychotropic medications for children and adolescents with mental health conditions, L. Elizabeth Anderson reported at the annual meeting of the Pediatric Academic Societies.

Bruce Jancin/Frontline Medical News

She presented an analysis of the Agency for Healthcare Quality and Research’s Medical Expenditure Panel Survey(MEPS), which contains data on a nationally representative cohort’s types of outpatient visits, the specialties of the physicians seen, conditions diagnosed, prescribed medications, and sociodemographic factors.

The MEPS data highlight just how commonly children and adolescents seek professional help for anxiety, depression, conduct disorders, and behavioral disorders. Extrapolating from this analysis of 1,778 youths aged 2-21 years with a mental disorder, an estimated 5.2% of U.S. children and adolescents have had one or more outpatient mental health visits within the past year, according to Ms. Anderson, a medical student at the University of Tennessee, Memphis.

Attention-deficit/hyperactivity disorder accounted for 65% of these outpatient visits, mood disorders 24%, anxiety 19%, pervasive developmental disorder 7%, and psychoses 1.3%. Patients could have more than one diagnosis.

Fully 35% of the youths received their outpatient care for mental health conditions solely from a PCP. Another 26% saw a psychiatrist only, and 15% saw a psychologist and/or social worker only. Roughly one-quarter of subjects saw multiple providers of mental health services, but patient comanagement by a PCP and psychiatrist occurred in only 6.7% of cases.

Primary care physicians appeared to be more comfortable serving as sole care providers for youths with ADHD than those with anxiety and/or mood disorders: 41% of youths with ADHD had a PCP as their sole provider, compared with 17% of those with an anxiety and/or mood disorder.

Sixty-nine percent of patients with a mental health disorder that was managed solely by a PCP received a prescription for psychotropic medication, as did 62% of those seen by a psychiatrist only. The difference in prescribing patterns was more marked in patients with ADHD: 73% of those treated by a PCP received a prescription, compared with 58% of those treated by a psychiatrist.

Thus, the likelihood that a patient with ADHD who was seen by a PCP would receive a prescription for a stimulant or atomoxetine was 65% greater than if seen by a psychiatrist, Ms. Anderson continued.

No consistent associations were seen between provider type or medication prescribing and sociodemographic factors including ethnicity, household income, or geographic locale.

With only 8.6 child and adolescent psychiatrists available per 100,000 U.S. pediatric patients, these study findings showing that PCPs now provide a substantial amount of pediatric mental health care provide a strong argument for programs aimed at improving quality of care via point-of-care advice to PCPs from mental health specialists, she said.

Ms. Anderson’s study was supported by a grant from the American Pediatric Society/Society for Pediatric Research student research training program. She reported having no financial conflicts.

[email protected]

SAN DIEGO – The bulk of outpatient pediatric mental health care is provided solely by primary care physicians, not psychiatrists, according to a national study.

The national data also showed that primary care physicians (PCPs) are more likely than psychiatrists to prescribe psychotropic medications for children and adolescents with mental health conditions, L. Elizabeth Anderson reported at the annual meeting of the Pediatric Academic Societies.

Bruce Jancin/Frontline Medical News

She presented an analysis of the Agency for Healthcare Quality and Research’s Medical Expenditure Panel Survey(MEPS), which contains data on a nationally representative cohort’s types of outpatient visits, the specialties of the physicians seen, conditions diagnosed, prescribed medications, and sociodemographic factors.

The MEPS data highlight just how commonly children and adolescents seek professional help for anxiety, depression, conduct disorders, and behavioral disorders. Extrapolating from this analysis of 1,778 youths aged 2-21 years with a mental disorder, an estimated 5.2% of U.S. children and adolescents have had one or more outpatient mental health visits within the past year, according to Ms. Anderson, a medical student at the University of Tennessee, Memphis.

Attention-deficit/hyperactivity disorder accounted for 65% of these outpatient visits, mood disorders 24%, anxiety 19%, pervasive developmental disorder 7%, and psychoses 1.3%. Patients could have more than one diagnosis.

Fully 35% of the youths received their outpatient care for mental health conditions solely from a PCP. Another 26% saw a psychiatrist only, and 15% saw a psychologist and/or social worker only. Roughly one-quarter of subjects saw multiple providers of mental health services, but patient comanagement by a PCP and psychiatrist occurred in only 6.7% of cases.

Primary care physicians appeared to be more comfortable serving as sole care providers for youths with ADHD than those with anxiety and/or mood disorders: 41% of youths with ADHD had a PCP as their sole provider, compared with 17% of those with an anxiety and/or mood disorder.

Sixty-nine percent of patients with a mental health disorder that was managed solely by a PCP received a prescription for psychotropic medication, as did 62% of those seen by a psychiatrist only. The difference in prescribing patterns was more marked in patients with ADHD: 73% of those treated by a PCP received a prescription, compared with 58% of those treated by a psychiatrist.

Thus, the likelihood that a patient with ADHD who was seen by a PCP would receive a prescription for a stimulant or atomoxetine was 65% greater than if seen by a psychiatrist, Ms. Anderson continued.

No consistent associations were seen between provider type or medication prescribing and sociodemographic factors including ethnicity, household income, or geographic locale.

With only 8.6 child and adolescent psychiatrists available per 100,000 U.S. pediatric patients, these study findings showing that PCPs now provide a substantial amount of pediatric mental health care provide a strong argument for programs aimed at improving quality of care via point-of-care advice to PCPs from mental health specialists, she said.

Ms. Anderson’s study was supported by a grant from the American Pediatric Society/Society for Pediatric Research student research training program. She reported having no financial conflicts.

[email protected]

SAN DIEGO– Children exposed to antibiotics are at a significantly heightened risk to develop extended-spectrum cephalosporin-resistant (ESC-R) and carbapenem-resistant (CR) Enterobacteriaceae infections within 30 days of said exposure, according to a prospective, case-controlled study.

Dr. Matthew P. Kronman, a pediatric infectious disease specialist at Seattle Children’s Hospital, and several coinvestigators examined data on 1,263 children from four hospital centers in the United States – Seattle Children’s Hospital; Washington University, St. Louis; Children’s Mercy Hospital, Kansas City, Mo.; and Children’s Hospital of Philadelphia – from Oct. 1, 2009, through Sept. 30, 2013.

“The CDC [Centers for Disease Control and Prevention] estimates that 2 million Americans get multidrug resistant organism [MDRO] infections each year, and 23,000 die,” said Dr. Kronman, adding that while it’s known that prior exposure to antibiotics is a key risk factor for colonization and development of an infection in adults, similar data among children with respect to ampC and extended-spectrum beta-lactamase (ESBL) are conflicting.

The study population included 95 subjects with ampC infections, 213 with ESBL infections, and 955 controls, for a total of 1,263 children. Prior exposure to antibiotics within the previous month or 3 months before infection was associated with infection of either ESC-R or CR Enterobacteriaceae (P < .01). A cumulative effect was noted, with increased exposure to antibiotics increasing the likelihood of developing an MDRO infection within 3 months (odds ratio 1.28 per month, P < .01), Dr. Kronman reported at the annual meeting of the Pediatric Academic Societies.

Those with ESBL infections were more likely to have any antibiotic exposure in the 30 days prior to their infection than were their control counterparts (OR > 2), but a similar, statistically significant relationship among those with ampC infections was not observed. When the researchers looked at broad-spectrum antibiotic exposures – defined as “carbapenems, beta-lactams, beta-lactase inhibitors, tetracyclines, and so on” – those with ESBL infections were more likely to have broad-spectrum antibiotic exposures in the month prior to their infection, which was not the case for those with ampC infections.

Both ESBL and ampC subjects were more likely to have been exposed to extended-spectrum cephalosporin use in the month prior to infection than controls. “When we looked just the use of antibiotics with anaerobic activity only, neither ESBL nor ampC infections were more likely than their control counterparts to have had exposure to anaerobic antibiotics in the month prior to infection,” Dr. Kronman said.

Patients had Escherichia coli and Klebsiella pneumoniae isolates collected from normally sterile sites; 91% were isolated from urine, and 46% were found to be associated with “community onset infection.” Samples were phenotypically resistant to extended spectrum cephalosporins, but were genotyped at Seattle Children’s Hospital to determine if the resistant strain was ampC or an ESBL. E. coli cases dominated the study population (85%), compared with cases of K. pneumoniae (15%). Results were adjusted for age, gender, prior hospitalization, underlying medical conditions, immunosuppression, and presence of indwelling devices. Median age of subjects was 5 years.

Those with resistant infections were more likely to have a “significant past medical history” of urologic conditions or malignancies; to have had hospitalization within the previous year; to be on immunosuppression at the time of the infection; or to have an indwelling device at the time of the infection. Resistant infections were less likely to originate in the community and were more commonly health care associated.

Dr. Kronman did not report any relevant financial disclosures.

[email protected]

SAN DIEGO– Children exposed to antibiotics are at a significantly heightened risk to develop extended-spectrum cephalosporin-resistant (ESC-R) and carbapenem-resistant (CR) Enterobacteriaceae infections within 30 days of said exposure, according to a prospective, case-controlled study.

Dr. Matthew P. Kronman, a pediatric infectious disease specialist at Seattle Children’s Hospital, and several coinvestigators examined data on 1,263 children from four hospital centers in the United States – Seattle Children’s Hospital; Washington University, St. Louis; Children’s Mercy Hospital, Kansas City, Mo.; and Children’s Hospital of Philadelphia – from Oct. 1, 2009, through Sept. 30, 2013.

“The CDC [Centers for Disease Control and Prevention] estimates that 2 million Americans get multidrug resistant organism [MDRO] infections each year, and 23,000 die,” said Dr. Kronman, adding that while it’s known that prior exposure to antibiotics is a key risk factor for colonization and development of an infection in adults, similar data among children with respect to ampC and extended-spectrum beta-lactamase (ESBL) are conflicting.

The study population included 95 subjects with ampC infections, 213 with ESBL infections, and 955 controls, for a total of 1,263 children. Prior exposure to antibiotics within the previous month or 3 months before infection was associated with infection of either ESC-R or CR Enterobacteriaceae (P < .01). A cumulative effect was noted, with increased exposure to antibiotics increasing the likelihood of developing an MDRO infection within 3 months (odds ratio 1.28 per month, P < .01), Dr. Kronman reported at the annual meeting of the Pediatric Academic Societies.

Those with ESBL infections were more likely to have any antibiotic exposure in the 30 days prior to their infection than were their control counterparts (OR > 2), but a similar, statistically significant relationship among those with ampC infections was not observed. When the researchers looked at broad-spectrum antibiotic exposures – defined as “carbapenems, beta-lactams, beta-lactase inhibitors, tetracyclines, and so on” – those with ESBL infections were more likely to have broad-spectrum antibiotic exposures in the month prior to their infection, which was not the case for those with ampC infections.

Both ESBL and ampC subjects were more likely to have been exposed to extended-spectrum cephalosporin use in the month prior to infection than controls. “When we looked just the use of antibiotics with anaerobic activity only, neither ESBL nor ampC infections were more likely than their control counterparts to have had exposure to anaerobic antibiotics in the month prior to infection,” Dr. Kronman said.

Patients had Escherichia coli and Klebsiella pneumoniae isolates collected from normally sterile sites; 91% were isolated from urine, and 46% were found to be associated with “community onset infection.” Samples were phenotypically resistant to extended spectrum cephalosporins, but were genotyped at Seattle Children’s Hospital to determine if the resistant strain was ampC or an ESBL. E. coli cases dominated the study population (85%), compared with cases of K. pneumoniae (15%). Results were adjusted for age, gender, prior hospitalization, underlying medical conditions, immunosuppression, and presence of indwelling devices. Median age of subjects was 5 years.

Those with resistant infections were more likely to have a “significant past medical history” of urologic conditions or malignancies; to have had hospitalization within the previous year; to be on immunosuppression at the time of the infection; or to have an indwelling device at the time of the infection. Resistant infections were less likely to originate in the community and were more commonly health care associated.

Dr. Kronman did not report any relevant financial disclosures.

[email protected]

SAN DIEGO– Children exposed to antibiotics are at a significantly heightened risk to develop extended-spectrum cephalosporin-resistant (ESC-R) and carbapenem-resistant (CR) Enterobacteriaceae infections within 30 days of said exposure, according to a prospective, case-controlled study.

Dr. Matthew P. Kronman, a pediatric infectious disease specialist at Seattle Children’s Hospital, and several coinvestigators examined data on 1,263 children from four hospital centers in the United States – Seattle Children’s Hospital; Washington University, St. Louis; Children’s Mercy Hospital, Kansas City, Mo.; and Children’s Hospital of Philadelphia – from Oct. 1, 2009, through Sept. 30, 2013.

“The CDC [Centers for Disease Control and Prevention] estimates that 2 million Americans get multidrug resistant organism [MDRO] infections each year, and 23,000 die,” said Dr. Kronman, adding that while it’s known that prior exposure to antibiotics is a key risk factor for colonization and development of an infection in adults, similar data among children with respect to ampC and extended-spectrum beta-lactamase (ESBL) are conflicting.

The study population included 95 subjects with ampC infections, 213 with ESBL infections, and 955 controls, for a total of 1,263 children. Prior exposure to antibiotics within the previous month or 3 months before infection was associated with infection of either ESC-R or CR Enterobacteriaceae (P < .01). A cumulative effect was noted, with increased exposure to antibiotics increasing the likelihood of developing an MDRO infection within 3 months (odds ratio 1.28 per month, P < .01), Dr. Kronman reported at the annual meeting of the Pediatric Academic Societies.

Those with ESBL infections were more likely to have any antibiotic exposure in the 30 days prior to their infection than were their control counterparts (OR > 2), but a similar, statistically significant relationship among those with ampC infections was not observed. When the researchers looked at broad-spectrum antibiotic exposures – defined as “carbapenems, beta-lactams, beta-lactase inhibitors, tetracyclines, and so on” – those with ESBL infections were more likely to have broad-spectrum antibiotic exposures in the month prior to their infection, which was not the case for those with ampC infections.

Both ESBL and ampC subjects were more likely to have been exposed to extended-spectrum cephalosporin use in the month prior to infection than controls. “When we looked just the use of antibiotics with anaerobic activity only, neither ESBL nor ampC infections were more likely than their control counterparts to have had exposure to anaerobic antibiotics in the month prior to infection,” Dr. Kronman said.

Patients had Escherichia coli and Klebsiella pneumoniae isolates collected from normally sterile sites; 91% were isolated from urine, and 46% were found to be associated with “community onset infection.” Samples were phenotypically resistant to extended spectrum cephalosporins, but were genotyped at Seattle Children’s Hospital to determine if the resistant strain was ampC or an ESBL. E. coli cases dominated the study population (85%), compared with cases of K. pneumoniae (15%). Results were adjusted for age, gender, prior hospitalization, underlying medical conditions, immunosuppression, and presence of indwelling devices. Median age of subjects was 5 years.

Those with resistant infections were more likely to have a “significant past medical history” of urologic conditions or malignancies; to have had hospitalization within the previous year; to be on immunosuppression at the time of the infection; or to have an indwelling device at the time of the infection. Resistant infections were less likely to originate in the community and were more commonly health care associated.

Dr. Kronman did not report any relevant financial disclosures.

[email protected]

SAN DIEGO– Instituting a standardized protocol for scoring and treating neonatal abstinence syndrome (NAS) patients can significantly decrease overall hospital costs, length of stay, and use of pharmacologic therapy on these young patients, according to a prospective study presented at the annual meeting of the Pediatric Academic Societies.

“Our project aims were to implement a standard care process for NAS at our institution, including consistent scoring, reduced transfers between units, decreased length of stay for treated babies, and decreased costs of NAS hospitalization for both opioid-exposed and NAS-affected newborns,” said Dr. Alison V. Holmes of Dartmouth College, Hanover, N.H., whose institution implemented the “coordinated [and] standardized program of care” in January 2013.

Bruce Jancin/Frontline Medical News

Under the new protocols, pharmacologic treatment of infants with NAS fell from 45% in 2012 to 25% in 2014, with a 37% rate of treatment over the last 3 years as a whole. Infants born at the hospital were treated pharmacologically at a rate of 36% in 2012, down to 15% in the second and third quarter of 2014, and adjunctive use of phenobarbital decreased from 11% to 5% over the same time period.

Mean length of stay decreased significantly, from 18.2 days to 13.6 days per patient, and the mean number of transfers between departments decreased from 2.1 to 1.5. Shorter hospital stays and fewer interdepartmental transfers decreased the overall hospitalization costs per patient from a mean of $20,225 to $11,318.

Despite all the changes, all-cause 30-day readmission rates and cumulative morphine doses did not change significantly over the course of the study. The total study population was 160 infants, 21% of whom were born in outside facilities before being brought to Dartmouth for NAS treatment; no adverse events were reported.

As explained by Dr. Holmes, the new protocols dictated that infants who did not require critical care were allowed to stay with their mothers in a mother/baby unit. Infants were transferred to the neonatal intensive care unit (NICU) only for treatment related to NAS; they stayed with their mothers or in the general pediatric ward for all other forms of treatment or observation.

This is vastly different from the previous model, which used infants’ Finnegan scores to determine if the baby should be moved to NICU for increased observation. When the infant’s condition improved, that infant was returned to rooming in with its mother. If increased symptoms returned, the baby would then go back to NICU for monitoring and treatment initiation, with the mother often discharged home in the interim. Once stable and on decreasing oral morphine doses, the baby would move back to the general pediatric ward to continue weaning, but if symptoms increased again and caused an increase in morphine dose, then the baby went back to NICU.

Under the new system, explained Dr. Holmes, the treatment team can safely interpret Finnegan scores in context of what is important to the newborn, assessments and scoring can be done on an infant schedule and can involve family, and costs for both treated and at-risk newborns can be halved.

“The implications are that centers with a length of stay of a month or more can significantly shorten their hospital course, and if this model is adopted widely, the potential cost savings and positive impact on families is tremendous,” Dr. Holmes concluded, adding that a limitation of this study is that it was a single-center study of a homogeneous patient population in a rural setting.

Dr. Holmes did not report any relevant financial disclosures.

[email protected]

This article was updated 5/15/2015.

SAN DIEGO– Instituting a standardized protocol for scoring and treating neonatal abstinence syndrome (NAS) patients can significantly decrease overall hospital costs, length of stay, and use of pharmacologic therapy on these young patients, according to a prospective study presented at the annual meeting of the Pediatric Academic Societies.

“Our project aims were to implement a standard care process for NAS at our institution, including consistent scoring, reduced transfers between units, decreased length of stay for treated babies, and decreased costs of NAS hospitalization for both opioid-exposed and NAS-affected newborns,” said Dr. Alison V. Holmes of Dartmouth College, Hanover, N.H., whose institution implemented the “coordinated [and] standardized program of care” in January 2013.

Bruce Jancin/Frontline Medical News

Under the new protocols, pharmacologic treatment of infants with NAS fell from 45% in 2012 to 25% in 2014, with a 37% rate of treatment over the last 3 years as a whole. Infants born at the hospital were treated pharmacologically at a rate of 36% in 2012, down to 15% in the second and third quarter of 2014, and adjunctive use of phenobarbital decreased from 11% to 5% over the same time period.

Mean length of stay decreased significantly, from 18.2 days to 13.6 days per patient, and the mean number of transfers between departments decreased from 2.1 to 1.5. Shorter hospital stays and fewer interdepartmental transfers decreased the overall hospitalization costs per patient from a mean of $20,225 to $11,318.

Despite all the changes, all-cause 30-day readmission rates and cumulative morphine doses did not change significantly over the course of the study. The total study population was 160 infants, 21% of whom were born in outside facilities before being brought to Dartmouth for NAS treatment; no adverse events were reported.

As explained by Dr. Holmes, the new protocols dictated that infants who did not require critical care were allowed to stay with their mothers in a mother/baby unit. Infants were transferred to the neonatal intensive care unit (NICU) only for treatment related to NAS; they stayed with their mothers or in the general pediatric ward for all other forms of treatment or observation.

This is vastly different from the previous model, which used infants’ Finnegan scores to determine if the baby should be moved to NICU for increased observation. When the infant’s condition improved, that infant was returned to rooming in with its mother. If increased symptoms returned, the baby would then go back to NICU for monitoring and treatment initiation, with the mother often discharged home in the interim. Once stable and on decreasing oral morphine doses, the baby would move back to the general pediatric ward to continue weaning, but if symptoms increased again and caused an increase in morphine dose, then the baby went back to NICU.

Under the new system, explained Dr. Holmes, the treatment team can safely interpret Finnegan scores in context of what is important to the newborn, assessments and scoring can be done on an infant schedule and can involve family, and costs for both treated and at-risk newborns can be halved.

“The implications are that centers with a length of stay of a month or more can significantly shorten their hospital course, and if this model is adopted widely, the potential cost savings and positive impact on families is tremendous,” Dr. Holmes concluded, adding that a limitation of this study is that it was a single-center study of a homogeneous patient population in a rural setting.

Dr. Holmes did not report any relevant financial disclosures.

[email protected]

This article was updated 5/15/2015.

SAN DIEGO– Instituting a standardized protocol for scoring and treating neonatal abstinence syndrome (NAS) patients can significantly decrease overall hospital costs, length of stay, and use of pharmacologic therapy on these young patients, according to a prospective study presented at the annual meeting of the Pediatric Academic Societies.

“Our project aims were to implement a standard care process for NAS at our institution, including consistent scoring, reduced transfers between units, decreased length of stay for treated babies, and decreased costs of NAS hospitalization for both opioid-exposed and NAS-affected newborns,” said Dr. Alison V. Holmes of Dartmouth College, Hanover, N.H., whose institution implemented the “coordinated [and] standardized program of care” in January 2013.

Bruce Jancin/Frontline Medical News

Under the new protocols, pharmacologic treatment of infants with NAS fell from 45% in 2012 to 25% in 2014, with a 37% rate of treatment over the last 3 years as a whole. Infants born at the hospital were treated pharmacologically at a rate of 36% in 2012, down to 15% in the second and third quarter of 2014, and adjunctive use of phenobarbital decreased from 11% to 5% over the same time period.

Mean length of stay decreased significantly, from 18.2 days to 13.6 days per patient, and the mean number of transfers between departments decreased from 2.1 to 1.5. Shorter hospital stays and fewer interdepartmental transfers decreased the overall hospitalization costs per patient from a mean of $20,225 to $11,318.

Despite all the changes, all-cause 30-day readmission rates and cumulative morphine doses did not change significantly over the course of the study. The total study population was 160 infants, 21% of whom were born in outside facilities before being brought to Dartmouth for NAS treatment; no adverse events were reported.

As explained by Dr. Holmes, the new protocols dictated that infants who did not require critical care were allowed to stay with their mothers in a mother/baby unit. Infants were transferred to the neonatal intensive care unit (NICU) only for treatment related to NAS; they stayed with their mothers or in the general pediatric ward for all other forms of treatment or observation.

This is vastly different from the previous model, which used infants’ Finnegan scores to determine if the baby should be moved to NICU for increased observation. When the infant’s condition improved, that infant was returned to rooming in with its mother. If increased symptoms returned, the baby would then go back to NICU for monitoring and treatment initiation, with the mother often discharged home in the interim. Once stable and on decreasing oral morphine doses, the baby would move back to the general pediatric ward to continue weaning, but if symptoms increased again and caused an increase in morphine dose, then the baby went back to NICU.

Under the new system, explained Dr. Holmes, the treatment team can safely interpret Finnegan scores in context of what is important to the newborn, assessments and scoring can be done on an infant schedule and can involve family, and costs for both treated and at-risk newborns can be halved.

“The implications are that centers with a length of stay of a month or more can significantly shorten their hospital course, and if this model is adopted widely, the potential cost savings and positive impact on families is tremendous,” Dr. Holmes concluded, adding that a limitation of this study is that it was a single-center study of a homogeneous patient population in a rural setting.

Dr. Holmes did not report any relevant financial disclosures.

[email protected]

This article was updated 5/15/2015.

SAN DIEGO – As little as 2-3 days of neonatal antibiotic exposure are sufficient to disrupt the development of the gut microbiota at 1 and 6 months of age, according to a case-control study.

The study design enabled investigators to conclude that the aberrant gut colonization was due to the brief course of antibiotics rather than the supposed infection for which the drugs were prescribed, Dr. Samuli Rautava said at the annual meeting of the Pediatric Academic Societies.

Bruce Jancin/Frontline Medical News

“I’m surprised that all of the effects on the microbiota we see are more prominent at 6 months of age than at 1 month. We do not have direct evidence that these relatively long-term perturbations of the gut microbiota lead to increased risk of disease, but if you go through the literature, I think it’s worrisome,” said Dr. Rautava, a pediatrician at the University of Turku (Finland).

He noted that prior studies have linked early antibiotic exposure to increased risks of developing necrotizing enterocolitis, asthma, inflammatory bowel disease, and most recently obesity (Pediatrics 2015;135:617-26).

Dr. Rautava reported on a prospective comparison of gut microbiota development in 36 term or late-preterm infants. The study population consisted of 6 infants with a documented infection for which they received a 7-day course of gentamicin or penicillin G beginning within the first 3 days after birth, 6 infants who received the same drugs on an empiric basis for up to 2-3 days before treatment was discontinued because infection had been ruled out, and 24 non–antibiotic exposed controls matched for duration of breastfeeding, mode of birth, and maternal use of probiotics.

The purpose of the study was to tease out the relative impact on gut microbiota development of early antibiotic exposure versus the infections for which the drugs are given. Gut microbiota composition was analyzed from fecal samples assessed at 1 and 6 months of age by quantitative polymerase chain reaction, 16S rRNA pyrosequencing, and denaturing gradient gel electrophoresis.

Among the key findings: Both groups of antibiotic-exposed neonates had markedly low levels of Bifidobacterium species, including B. bifidum, at 1 and 6 months. These are “good” gut microbes, and low levels early in life have been associated with obesity and allergies.

Bacteroides species were virtually absent at 1 month of age in both groups with early antibiotic exposure. Again, low levels early in life have been linked to obesity and allergies.

“The situation is a little better at age 6 months, but there is still some scarcity of Bacteroides species in these infants at that time,” according to the pediatrician.

In contrast, Clostridium species are more abundant in the gut microbiota of antibiotic-exposed children at both 1 and 6 months than in controls. This makes sense, since gentamicin and penicillin G are not effective against Clostridium species, which have been linked to disease.

Dr. Rautava said these study findings have significant implications for clinical practice: “We cannot not give antibiotics to infants who might have sepsis, but we need to develop means of finding the bacterially infected neonates who truly need the antibiotics so we can avoid unnecessary antibiotic exposure during this vulnerable period.”

“I told my post-doc when we did this study that the scientist in me wants to see huge changes in the gut microbiota, but the clinician in me wants to see no changes at all. So I’m torn: I’m happy to have something to report, but I’m devastated at what we’re actually doing with our early antibiotic therapy,” Dr. Rautava said.

Dr. Rautava’s study was funded by the University of Turku and other noncommercial sources. He reported having no financial conflicts.

[email protected]

SAN DIEGO – As little as 2-3 days of neonatal antibiotic exposure are sufficient to disrupt the development of the gut microbiota at 1 and 6 months of age, according to a case-control study.

The study design enabled investigators to conclude that the aberrant gut colonization was due to the brief course of antibiotics rather than the supposed infection for which the drugs were prescribed, Dr. Samuli Rautava said at the annual meeting of the Pediatric Academic Societies.

Bruce Jancin/Frontline Medical News

“I’m surprised that all of the effects on the microbiota we see are more prominent at 6 months of age than at 1 month. We do not have direct evidence that these relatively long-term perturbations of the gut microbiota lead to increased risk of disease, but if you go through the literature, I think it’s worrisome,” said Dr. Rautava, a pediatrician at the University of Turku (Finland).

He noted that prior studies have linked early antibiotic exposure to increased risks of developing necrotizing enterocolitis, asthma, inflammatory bowel disease, and most recently obesity (Pediatrics 2015;135:617-26).

Dr. Rautava reported on a prospective comparison of gut microbiota development in 36 term or late-preterm infants. The study population consisted of 6 infants with a documented infection for which they received a 7-day course of gentamicin or penicillin G beginning within the first 3 days after birth, 6 infants who received the same drugs on an empiric basis for up to 2-3 days before treatment was discontinued because infection had been ruled out, and 24 non–antibiotic exposed controls matched for duration of breastfeeding, mode of birth, and maternal use of probiotics.

The purpose of the study was to tease out the relative impact on gut microbiota development of early antibiotic exposure versus the infections for which the drugs are given. Gut microbiota composition was analyzed from fecal samples assessed at 1 and 6 months of age by quantitative polymerase chain reaction, 16S rRNA pyrosequencing, and denaturing gradient gel electrophoresis.

Among the key findings: Both groups of antibiotic-exposed neonates had markedly low levels of Bifidobacterium species, including B. bifidum, at 1 and 6 months. These are “good” gut microbes, and low levels early in life have been associated with obesity and allergies.

Bacteroides species were virtually absent at 1 month of age in both groups with early antibiotic exposure. Again, low levels early in life have been linked to obesity and allergies.

“The situation is a little better at age 6 months, but there is still some scarcity of Bacteroides species in these infants at that time,” according to the pediatrician.

In contrast, Clostridium species are more abundant in the gut microbiota of antibiotic-exposed children at both 1 and 6 months than in controls. This makes sense, since gentamicin and penicillin G are not effective against Clostridium species, which have been linked to disease.

Dr. Rautava said these study findings have significant implications for clinical practice: “We cannot not give antibiotics to infants who might have sepsis, but we need to develop means of finding the bacterially infected neonates who truly need the antibiotics so we can avoid unnecessary antibiotic exposure during this vulnerable period.”

“I told my post-doc when we did this study that the scientist in me wants to see huge changes in the gut microbiota, but the clinician in me wants to see no changes at all. So I’m torn: I’m happy to have something to report, but I’m devastated at what we’re actually doing with our early antibiotic therapy,” Dr. Rautava said.

Dr. Rautava’s study was funded by the University of Turku and other noncommercial sources. He reported having no financial conflicts.

[email protected]

SAN DIEGO – As little as 2-3 days of neonatal antibiotic exposure are sufficient to disrupt the development of the gut microbiota at 1 and 6 months of age, according to a case-control study.

The study design enabled investigators to conclude that the aberrant gut colonization was due to the brief course of antibiotics rather than the supposed infection for which the drugs were prescribed, Dr. Samuli Rautava said at the annual meeting of the Pediatric Academic Societies.

Bruce Jancin/Frontline Medical News

“I’m surprised that all of the effects on the microbiota we see are more prominent at 6 months of age than at 1 month. We do not have direct evidence that these relatively long-term perturbations of the gut microbiota lead to increased risk of disease, but if you go through the literature, I think it’s worrisome,” said Dr. Rautava, a pediatrician at the University of Turku (Finland).

He noted that prior studies have linked early antibiotic exposure to increased risks of developing necrotizing enterocolitis, asthma, inflammatory bowel disease, and most recently obesity (Pediatrics 2015;135:617-26).

Dr. Rautava reported on a prospective comparison of gut microbiota development in 36 term or late-preterm infants. The study population consisted of 6 infants with a documented infection for which they received a 7-day course of gentamicin or penicillin G beginning within the first 3 days after birth, 6 infants who received the same drugs on an empiric basis for up to 2-3 days before treatment was discontinued because infection had been ruled out, and 24 non–antibiotic exposed controls matched for duration of breastfeeding, mode of birth, and maternal use of probiotics.

The purpose of the study was to tease out the relative impact on gut microbiota development of early antibiotic exposure versus the infections for which the drugs are given. Gut microbiota composition was analyzed from fecal samples assessed at 1 and 6 months of age by quantitative polymerase chain reaction, 16S rRNA pyrosequencing, and denaturing gradient gel electrophoresis.

Among the key findings: Both groups of antibiotic-exposed neonates had markedly low levels of Bifidobacterium species, including B. bifidum, at 1 and 6 months. These are “good” gut microbes, and low levels early in life have been associated with obesity and allergies.

Bacteroides species were virtually absent at 1 month of age in both groups with early antibiotic exposure. Again, low levels early in life have been linked to obesity and allergies.

“The situation is a little better at age 6 months, but there is still some scarcity of Bacteroides species in these infants at that time,” according to the pediatrician.

In contrast, Clostridium species are more abundant in the gut microbiota of antibiotic-exposed children at both 1 and 6 months than in controls. This makes sense, since gentamicin and penicillin G are not effective against Clostridium species, which have been linked to disease.

Dr. Rautava said these study findings have significant implications for clinical practice: “We cannot not give antibiotics to infants who might have sepsis, but we need to develop means of finding the bacterially infected neonates who truly need the antibiotics so we can avoid unnecessary antibiotic exposure during this vulnerable period.”

“I told my post-doc when we did this study that the scientist in me wants to see huge changes in the gut microbiota, but the clinician in me wants to see no changes at all. So I’m torn: I’m happy to have something to report, but I’m devastated at what we’re actually doing with our early antibiotic therapy,” Dr. Rautava said.

Dr. Rautava’s study was funded by the University of Turku and other noncommercial sources. He reported having no financial conflicts.

[email protected]

AT THE PAS ANNUAL MEETING

SAN DIEGO – Text message reminders sent to parents on human papillomavirus (HPV) vaccine series completion were more effective than were phone call reminders, in a study of three urban practices.

“Practices should offer patients preferences for how to be reached for reminders, and consider using text messaging if they are not already doing so,” Dr. Cynthia M. Rand said in an interview prior to a poster session at the annual meeting of the Pediatric Academic Societies.

In what she said is the first study of its kind, Dr. Rand of the University of Rochester (N.Y.) Medical Center, and her associates, set out to examine the effect of phone or text message reminders to parents regarding HPV vaccine series completion for inner-city adolescents aged 11-17 years in Rochester, N.Y.

The adolescents had already started the HPV vaccine series at one of three area primary care clinics. The parents chose which method they preferred (phone call or text message), and were randomized to receive or not receive a reminder. As many as three reminders for each dose due were sent to the phone and text intervention groups. The main outcome measure was time to receipt of three doses of HPV vaccine.

The researchers enrolled 178 adolescents and 180 age-matched controls in the phone intervention group, and 191 participants and 200 controls in the text intervention group. Their mean age was 14 years. Two-thirds of the adolescents (66%) were black, 66% were male, and 80% were publicly insured.

At the end of the study, 48% of those in the phone intervention group (vs. 40% of controls) had received three HPV vaccine doses, compared with 49% of adolescents in the text intervention group (vs. 31% of controls). In a multivariate survival analysis controlled for gender, age, type of practice, and insurance, there was no significant difference in time from enrollment to receipt of the third HPV vaccine dose for those receiving a phone reminder, compared with controls (hazard ratio 1.26; P =.16), but there was a significant difference in those receiving a text reminder, compared with controls (HR 2.28; P less than .0001).

“Practice differences occurred, with significantly higher rates of HPV vaccine completion for those receiving phone reminders in the pediatric and family medicine practices compared to the combined medicine-pediatrics practices,” the researchers wrote in their abstract. “Compared to males, females were 77% more likely to complete the HPV vaccine series in the text intervention arm of the study.”

The study was funded by the Agency for Healthcare Research and Quality. Dr. Rand reported having no relevant financial disclosures.

[email protected]

On Twitter @dougbrunk

AT THE PAS ANNUAL MEETING

SAN DIEGO – Text message reminders sent to parents on human papillomavirus (HPV) vaccine series completion were more effective than were phone call reminders, in a study of three urban practices.

“Practices should offer patients preferences for how to be reached for reminders, and consider using text messaging if they are not already doing so,” Dr. Cynthia M. Rand said in an interview prior to a poster session at the annual meeting of the Pediatric Academic Societies.

In what she said is the first study of its kind, Dr. Rand of the University of Rochester (N.Y.) Medical Center, and her associates, set out to examine the effect of phone or text message reminders to parents regarding HPV vaccine series completion for inner-city adolescents aged 11-17 years in Rochester, N.Y.

The adolescents had already started the HPV vaccine series at one of three area primary care clinics. The parents chose which method they preferred (phone call or text message), and were randomized to receive or not receive a reminder. As many as three reminders for each dose due were sent to the phone and text intervention groups. The main outcome measure was time to receipt of three doses of HPV vaccine.

The researchers enrolled 178 adolescents and 180 age-matched controls in the phone intervention group, and 191 participants and 200 controls in the text intervention group. Their mean age was 14 years. Two-thirds of the adolescents (66%) were black, 66% were male, and 80% were publicly insured.

At the end of the study, 48% of those in the phone intervention group (vs. 40% of controls) had received three HPV vaccine doses, compared with 49% of adolescents in the text intervention group (vs. 31% of controls). In a multivariate survival analysis controlled for gender, age, type of practice, and insurance, there was no significant difference in time from enrollment to receipt of the third HPV vaccine dose for those receiving a phone reminder, compared with controls (hazard ratio 1.26; P =.16), but there was a significant difference in those receiving a text reminder, compared with controls (HR 2.28; P less than .0001).

“Practice differences occurred, with significantly higher rates of HPV vaccine completion for those receiving phone reminders in the pediatric and family medicine practices compared to the combined medicine-pediatrics practices,” the researchers wrote in their abstract. “Compared to males, females were 77% more likely to complete the HPV vaccine series in the text intervention arm of the study.”

The study was funded by the Agency for Healthcare Research and Quality. Dr. Rand reported having no relevant financial disclosures.

[email protected]

On Twitter @dougbrunk

AT THE PAS ANNUAL MEETING

SAN DIEGO – Text message reminders sent to parents on human papillomavirus (HPV) vaccine series completion were more effective than were phone call reminders, in a study of three urban practices.

“Practices should offer patients preferences for how to be reached for reminders, and consider using text messaging if they are not already doing so,” Dr. Cynthia M. Rand said in an interview prior to a poster session at the annual meeting of the Pediatric Academic Societies.

In what she said is the first study of its kind, Dr. Rand of the University of Rochester (N.Y.) Medical Center, and her associates, set out to examine the effect of phone or text message reminders to parents regarding HPV vaccine series completion for inner-city adolescents aged 11-17 years in Rochester, N.Y.

The adolescents had already started the HPV vaccine series at one of three area primary care clinics. The parents chose which method they preferred (phone call or text message), and were randomized to receive or not receive a reminder. As many as three reminders for each dose due were sent to the phone and text intervention groups. The main outcome measure was time to receipt of three doses of HPV vaccine.

The researchers enrolled 178 adolescents and 180 age-matched controls in the phone intervention group, and 191 participants and 200 controls in the text intervention group. Their mean age was 14 years. Two-thirds of the adolescents (66%) were black, 66% were male, and 80% were publicly insured.

At the end of the study, 48% of those in the phone intervention group (vs. 40% of controls) had received three HPV vaccine doses, compared with 49% of adolescents in the text intervention group (vs. 31% of controls). In a multivariate survival analysis controlled for gender, age, type of practice, and insurance, there was no significant difference in time from enrollment to receipt of the third HPV vaccine dose for those receiving a phone reminder, compared with controls (hazard ratio 1.26; P =.16), but there was a significant difference in those receiving a text reminder, compared with controls (HR 2.28; P less than .0001).

“Practice differences occurred, with significantly higher rates of HPV vaccine completion for those receiving phone reminders in the pediatric and family medicine practices compared to the combined medicine-pediatrics practices,” the researchers wrote in their abstract. “Compared to males, females were 77% more likely to complete the HPV vaccine series in the text intervention arm of the study.”

The study was funded by the Agency for Healthcare Research and Quality. Dr. Rand reported having no relevant financial disclosures.

[email protected]

On Twitter @dougbrunk

SAN DIEGO – Watching at least 1 hour of television daily was associated with increased likelihood of overweight and obesity in kindergartners and first graders in a large national longitudinal study.

The American Academy of Pediatrics recommends that children watch less than 2 hours of TV daily, but this new analysis indicates that watching at least 1 hour but less than 2 hours is associated with unhealthy weight gain, Dr. Mark D. DeBoer said at the annual meeting of the Pediatric Academic Societies.

Bruce Jancin/Frontline Medical News

“The AAP may wish to consider reducing the recommended limits of TV viewing, with an emphasis on replacing this time with physical activities and learning opportunities,” declared Dr. DeBoer, a pediatrician at the University of Virginia, Charlottesville.

He and his coinvestigators analyzed data on 12,389 young children participating in the nationally representative Early Childhood Longitudinal Study-Kindergarten Cohort 2011. The study collected parentally reported hours and minutes of weekly daytime TV watching and determined body mass index z scores when the children were in kindergarten and again a year later as first graders.

As kindergartners, participants averaged 2.0 hours of TV per day, with 33% of the children exceeding the AAP-recommended 2-hour limit. As first graders, they averaged 1.6 hours of TV daily, and 15.7% of them exceeded 2 hours; however, when the first graders’ computer screen time was added in, 36.7% of them exceeded the AAP recommendation.

In a logistic regression analysis adjusted for race/ethnicity, gender, socioeconomic status, and amount of computer use, kindergartners who watched at least 1 hour and less than 2 hours of TV daily were 43% more likely to be overweight and 47% more likely to be obese than their peers who watched less than 1 hour. Moreover, kindergartners who watched 2 or more hours of TV per day were 58% and 75% more likely to be overweight and obese, respectively, than those who watched less than 1 hour.

A similar cross-sectional analysis conducted during first grade showed much the same: Children who watched at least 1 but less than 2 hours of TV daily were 40% more likely to be overweight and 48% more likely to be obese than those watching less than 1 hour per day. Children who watched at least 2 hours of TV daily were 53% and 61% more likely to be overweight and obese, respectively.

Dr. DeBoer and coworkers also conducted a longitudinal analysis examining the relationship between TV time and change in BMI z scores over the course of 1 year of follow-up from kindergarten and first grade. The group watching less than 1 hour of TV per day showed a slight decrease in BMI z score during the year, while those watching 1 to less than 2 hours had a mean 0.16-point increase in z score, which translates into roughly a 0.3-kg weight gain for an average-height child in this age group.

Computer use and video game time had no association with weight status.

The mechanism for the relationship between TV viewing and weight gain in children is believed to involve the sedentary nature of the activity along with exposure to advertisements for snack foods.

Several audience members rose to take issue with Dr. DeBoer’s call for the AAP to lower its recommended maximum amount of TV viewing.

“You’ve described an association,” one pediatrician said. “It isn’t necessarily the case that if you reduce the TV time, you reduce obesity in these individuals.”

Dr. DeBoer agreed that the observed association “may or may not be causal,” but he noted further, “There have been some studies that targeted reducing TV viewing that have shown favorable effects on BMI over time, so that is supportive.”

The Early Childhood Longitudinal Study-Kindergarten Cohort 2011 is funded by the U.S. Department of Education’s National Center for Education Statistics. The TV time/body weight analysis was funded by the Doris Duke Foundation. Dr. DeBoer reported having no financial conflicts.

[email protected]

SAN DIEGO – Watching at least 1 hour of television daily was associated with increased likelihood of overweight and obesity in kindergartners and first graders in a large national longitudinal study.

The American Academy of Pediatrics recommends that children watch less than 2 hours of TV daily, but this new analysis indicates that watching at least 1 hour but less than 2 hours is associated with unhealthy weight gain, Dr. Mark D. DeBoer said at the annual meeting of the Pediatric Academic Societies.

Bruce Jancin/Frontline Medical News

“The AAP may wish to consider reducing the recommended limits of TV viewing, with an emphasis on replacing this time with physical activities and learning opportunities,” declared Dr. DeBoer, a pediatrician at the University of Virginia, Charlottesville.

He and his coinvestigators analyzed data on 12,389 young children participating in the nationally representative Early Childhood Longitudinal Study-Kindergarten Cohort 2011. The study collected parentally reported hours and minutes of weekly daytime TV watching and determined body mass index z scores when the children were in kindergarten and again a year later as first graders.

As kindergartners, participants averaged 2.0 hours of TV per day, with 33% of the children exceeding the AAP-recommended 2-hour limit. As first graders, they averaged 1.6 hours of TV daily, and 15.7% of them exceeded 2 hours; however, when the first graders’ computer screen time was added in, 36.7% of them exceeded the AAP recommendation.

In a logistic regression analysis adjusted for race/ethnicity, gender, socioeconomic status, and amount of computer use, kindergartners who watched at least 1 hour and less than 2 hours of TV daily were 43% more likely to be overweight and 47% more likely to be obese than their peers who watched less than 1 hour. Moreover, kindergartners who watched 2 or more hours of TV per day were 58% and 75% more likely to be overweight and obese, respectively, than those who watched less than 1 hour.

A similar cross-sectional analysis conducted during first grade showed much the same: Children who watched at least 1 but less than 2 hours of TV daily were 40% more likely to be overweight and 48% more likely to be obese than those watching less than 1 hour per day. Children who watched at least 2 hours of TV daily were 53% and 61% more likely to be overweight and obese, respectively.

Dr. DeBoer and coworkers also conducted a longitudinal analysis examining the relationship between TV time and change in BMI z scores over the course of 1 year of follow-up from kindergarten and first grade. The group watching less than 1 hour of TV per day showed a slight decrease in BMI z score during the year, while those watching 1 to less than 2 hours had a mean 0.16-point increase in z score, which translates into roughly a 0.3-kg weight gain for an average-height child in this age group.

Computer use and video game time had no association with weight status.

The mechanism for the relationship between TV viewing and weight gain in children is believed to involve the sedentary nature of the activity along with exposure to advertisements for snack foods.

Several audience members rose to take issue with Dr. DeBoer’s call for the AAP to lower its recommended maximum amount of TV viewing.

“You’ve described an association,” one pediatrician said. “It isn’t necessarily the case that if you reduce the TV time, you reduce obesity in these individuals.”

Dr. DeBoer agreed that the observed association “may or may not be causal,” but he noted further, “There have been some studies that targeted reducing TV viewing that have shown favorable effects on BMI over time, so that is supportive.”

The Early Childhood Longitudinal Study-Kindergarten Cohort 2011 is funded by the U.S. Department of Education’s National Center for Education Statistics. The TV time/body weight analysis was funded by the Doris Duke Foundation. Dr. DeBoer reported having no financial conflicts.

[email protected]

SAN DIEGO – Watching at least 1 hour of television daily was associated with increased likelihood of overweight and obesity in kindergartners and first graders in a large national longitudinal study.

The American Academy of Pediatrics recommends that children watch less than 2 hours of TV daily, but this new analysis indicates that watching at least 1 hour but less than 2 hours is associated with unhealthy weight gain, Dr. Mark D. DeBoer said at the annual meeting of the Pediatric Academic Societies.

Bruce Jancin/Frontline Medical News

“The AAP may wish to consider reducing the recommended limits of TV viewing, with an emphasis on replacing this time with physical activities and learning opportunities,” declared Dr. DeBoer, a pediatrician at the University of Virginia, Charlottesville.

He and his coinvestigators analyzed data on 12,389 young children participating in the nationally representative Early Childhood Longitudinal Study-Kindergarten Cohort 2011. The study collected parentally reported hours and minutes of weekly daytime TV watching and determined body mass index z scores when the children were in kindergarten and again a year later as first graders.

As kindergartners, participants averaged 2.0 hours of TV per day, with 33% of the children exceeding the AAP-recommended 2-hour limit. As first graders, they averaged 1.6 hours of TV daily, and 15.7% of them exceeded 2 hours; however, when the first graders’ computer screen time was added in, 36.7% of them exceeded the AAP recommendation.

In a logistic regression analysis adjusted for race/ethnicity, gender, socioeconomic status, and amount of computer use, kindergartners who watched at least 1 hour and less than 2 hours of TV daily were 43% more likely to be overweight and 47% more likely to be obese than their peers who watched less than 1 hour. Moreover, kindergartners who watched 2 or more hours of TV per day were 58% and 75% more likely to be overweight and obese, respectively, than those who watched less than 1 hour.

A similar cross-sectional analysis conducted during first grade showed much the same: Children who watched at least 1 but less than 2 hours of TV daily were 40% more likely to be overweight and 48% more likely to be obese than those watching less than 1 hour per day. Children who watched at least 2 hours of TV daily were 53% and 61% more likely to be overweight and obese, respectively.

Dr. DeBoer and coworkers also conducted a longitudinal analysis examining the relationship between TV time and change in BMI z scores over the course of 1 year of follow-up from kindergarten and first grade. The group watching less than 1 hour of TV per day showed a slight decrease in BMI z score during the year, while those watching 1 to less than 2 hours had a mean 0.16-point increase in z score, which translates into roughly a 0.3-kg weight gain for an average-height child in this age group.

Computer use and video game time had no association with weight status.

The mechanism for the relationship between TV viewing and weight gain in children is believed to involve the sedentary nature of the activity along with exposure to advertisements for snack foods.

Several audience members rose to take issue with Dr. DeBoer’s call for the AAP to lower its recommended maximum amount of TV viewing.

“You’ve described an association,” one pediatrician said. “It isn’t necessarily the case that if you reduce the TV time, you reduce obesity in these individuals.”

Dr. DeBoer agreed that the observed association “may or may not be causal,” but he noted further, “There have been some studies that targeted reducing TV viewing that have shown favorable effects on BMI over time, so that is supportive.”

The Early Childhood Longitudinal Study-Kindergarten Cohort 2011 is funded by the U.S. Department of Education’s National Center for Education Statistics. The TV time/body weight analysis was funded by the Doris Duke Foundation. Dr. DeBoer reported having no financial conflicts.

[email protected]

SAN DIEGO – The proportion of children with asthma receiving the influenza vaccine has continued to increase in the past decade or so, though not as quickly as for children without asthma, results from national survey data found.

While the influenza vaccine is recommended for all children aged 6 months and older, trends in influenza vaccination for early (August-October) versus late (November-May) vaccination in children with asthma have not been examined, lead study author Dr. Alan E. Simon said during a poster session at the annual meeting of the Pediatric Academic Societies.

Doug Brunk/Frontline Medical News

Dr. Simon, a medical officer with the office of analysis and epidemiology at the National Center for Health Statistics, Hyattsville, Md., and his associates evaluated National Health Interview Survey (NHIS) sample child files for 2005-2013. They limited the analysis to children aged 2-17 years and defined current asthma as a “yes” response to two questions: “Has your doctor ever told you that your child has asthma?” and “Does your child still have asthma?” A total of 31,668 NHIS interviews conducted between April and July 2005-2013 were assessed for vaccine receipt between August and May of the previous flu season. The researchers conducted logistic regression with predictive margins with receipt of flu shot as the dependent variable, and year, current asthma, and the interaction between year and asthma as dependent variables.

Dr. Simon reported that the percentage of children with asthma who received a flu shot increased an average of 3.2 percentage points per year during the time period, reaching 55% in 2012-2013. At the same time, the percentage of children without asthma who received a flu shot increased an average of 4.2 percentage points per year, reaching 45% in 2012-2013. Meanwhile, the percentage of children in both groups who received early vaccination increased about 1.5% per year, reaching 32% in children with asthma and 27% among children without asthma in 2012-2013.

The researchers also found that over the last three flu seasons, the following characteristics were predictive of children with asthma having a longer time to vaccination or a lower probability of vaccination: being aged 12-17 years vs. 2-5 years (adjusted hazard ratio of 0.75; P less than .01); being uninsured vs. privately insured (aHR 0.52; P less than .01), and living in the South or the West vs. the Northeast (aHR 0.79; P less than .05).

Dr. Simon said that similar overall results were observed when he and his associates conducted a separate analysis that assessed 85,087 NHIS interviews from 2005 to 2013 and used Kaplan-Meier survival statistics to estimate yearly vaccination estimates and early vaccination estimates.

The study was funded by the Centers for Disease Control and Prevention. Dr. Simon reported having no relevant financial conflicts.

[email protected]

On Twitter @dougbrunk

SAN DIEGO – The proportion of children with asthma receiving the influenza vaccine has continued to increase in the past decade or so, though not as quickly as for children without asthma, results from national survey data found.

While the influenza vaccine is recommended for all children aged 6 months and older, trends in influenza vaccination for early (August-October) versus late (November-May) vaccination in children with asthma have not been examined, lead study author Dr. Alan E. Simon said during a poster session at the annual meeting of the Pediatric Academic Societies.

Doug Brunk/Frontline Medical News

Dr. Simon, a medical officer with the office of analysis and epidemiology at the National Center for Health Statistics, Hyattsville, Md., and his associates evaluated National Health Interview Survey (NHIS) sample child files for 2005-2013. They limited the analysis to children aged 2-17 years and defined current asthma as a “yes” response to two questions: “Has your doctor ever told you that your child has asthma?” and “Does your child still have asthma?” A total of 31,668 NHIS interviews conducted between April and July 2005-2013 were assessed for vaccine receipt between August and May of the previous flu season. The researchers conducted logistic regression with predictive margins with receipt of flu shot as the dependent variable, and year, current asthma, and the interaction between year and asthma as dependent variables.

Dr. Simon reported that the percentage of children with asthma who received a flu shot increased an average of 3.2 percentage points per year during the time period, reaching 55% in 2012-2013. At the same time, the percentage of children without asthma who received a flu shot increased an average of 4.2 percentage points per year, reaching 45% in 2012-2013. Meanwhile, the percentage of children in both groups who received early vaccination increased about 1.5% per year, reaching 32% in children with asthma and 27% among children without asthma in 2012-2013.

The researchers also found that over the last three flu seasons, the following characteristics were predictive of children with asthma having a longer time to vaccination or a lower probability of vaccination: being aged 12-17 years vs. 2-5 years (adjusted hazard ratio of 0.75; P less than .01); being uninsured vs. privately insured (aHR 0.52; P less than .01), and living in the South or the West vs. the Northeast (aHR 0.79; P less than .05).

Dr. Simon said that similar overall results were observed when he and his associates conducted a separate analysis that assessed 85,087 NHIS interviews from 2005 to 2013 and used Kaplan-Meier survival statistics to estimate yearly vaccination estimates and early vaccination estimates.

The study was funded by the Centers for Disease Control and Prevention. Dr. Simon reported having no relevant financial conflicts.

[email protected]

On Twitter @dougbrunk

SAN DIEGO – The proportion of children with asthma receiving the influenza vaccine has continued to increase in the past decade or so, though not as quickly as for children without asthma, results from national survey data found.

While the influenza vaccine is recommended for all children aged 6 months and older, trends in influenza vaccination for early (August-October) versus late (November-May) vaccination in children with asthma have not been examined, lead study author Dr. Alan E. Simon said during a poster session at the annual meeting of the Pediatric Academic Societies.

Doug Brunk/Frontline Medical News

Dr. Simon, a medical officer with the office of analysis and epidemiology at the National Center for Health Statistics, Hyattsville, Md., and his associates evaluated National Health Interview Survey (NHIS) sample child files for 2005-2013. They limited the analysis to children aged 2-17 years and defined current asthma as a “yes” response to two questions: “Has your doctor ever told you that your child has asthma?” and “Does your child still have asthma?” A total of 31,668 NHIS interviews conducted between April and July 2005-2013 were assessed for vaccine receipt between August and May of the previous flu season. The researchers conducted logistic regression with predictive margins with receipt of flu shot as the dependent variable, and year, current asthma, and the interaction between year and asthma as dependent variables.

Dr. Simon reported that the percentage of children with asthma who received a flu shot increased an average of 3.2 percentage points per year during the time period, reaching 55% in 2012-2013. At the same time, the percentage of children without asthma who received a flu shot increased an average of 4.2 percentage points per year, reaching 45% in 2012-2013. Meanwhile, the percentage of children in both groups who received early vaccination increased about 1.5% per year, reaching 32% in children with asthma and 27% among children without asthma in 2012-2013.

The researchers also found that over the last three flu seasons, the following characteristics were predictive of children with asthma having a longer time to vaccination or a lower probability of vaccination: being aged 12-17 years vs. 2-5 years (adjusted hazard ratio of 0.75; P less than .01); being uninsured vs. privately insured (aHR 0.52; P less than .01), and living in the South or the West vs. the Northeast (aHR 0.79; P less than .05).

Dr. Simon said that similar overall results were observed when he and his associates conducted a separate analysis that assessed 85,087 NHIS interviews from 2005 to 2013 and used Kaplan-Meier survival statistics to estimate yearly vaccination estimates and early vaccination estimates.

The study was funded by the Centers for Disease Control and Prevention. Dr. Simon reported having no relevant financial conflicts.

[email protected]

On Twitter @dougbrunk

SAN DIEGO – Of children and teens on psychotropic medication prescribed by their primary care pediatrician or family physician, 21% simultaneously receive two or more different classes of the drugs for at least 3 months, according to a massive study.

“Given that the safety of pediatric monotherapy for some of these psychotropic medications is unexplored, these patterns of polypharmacy prescribing are alarming and warrant further investigation,” Dr. Robert Grundmeier said in presenting the study results at the annual meeting of the Pediatric Academic Societies.

He presented a study of 891,717 patients up to 18 years of age who received health care at 1 of 222 primary care pediatric or family medicine sites participating in the Comparative Effectiveness Research Through Collaborative Electronic Reporting (CER2) Consortium. He described CER2 as a “supernetwork” comprised of multiple electronic health record–based networks and led by the American Academy of Pediatrics. The consortium was designed to carry out very large pharmacoepidemiologic and comparative effectiveness studies.

The initial study population consisted of more than 1.2 million patients up to age 18 years, a figure that investigators whittled down to just under 900,000 by excluding those with a seizure disorder or less than 12 months of follow-up data.

Among the 891,717 subjects, 8.3% of boys and 5.3% of girls were treated with psychotropic medication by their primary care physician at some point. Of these 60,430 patients, 21% simultaneously received psychotropic drugs from two or more different classes for at least 3 months. Another 5,813 patients – 0.9% of all boys and 0.4% of all girls in the study – got psychotropic medications from three or more classes simultaneously, reported Dr. Grundmeier of Children’s Hospital of Philadelphia.

The most frequently prescribed category of medication was stimulants/
atomoxetine, a treatment mainstay in attention-deficit/hyperactivity disorder. Antidepressants were No. 2 and were prescribed in 2.1% of all boys and 2.8% of girls. Atypical antipsychotics were prescribed for 1.4% of boys and 0.8% of girls.

The most widely prescribed two-class combination among patients receiving psychotropic medication was a stimulant and an alpha-agonist, given to 10.7% of boys and 5.6% of girls. The second most popular two-drug combination was a stimulant and an antidepressant, which was prescribed for 7.3% of boys and 7.1% of girls who took psychotropic medication.

The use of combination therapy incorporating an atypical antipsychotic was of particular interest because health policy makers have identified this as an issue of concern. The drugs aren’t approved by the Food and Drug Administration for patients younger than 5 years old, and yet the Agency for Healthcare Research and Quality has reported that the use of these medications in very young children with behavior problems doubled between 1999-2001 and 2007. Moreover, more than three-quarters of youths on Medicaid are taking an atypical antipsychotic for non–FDA-approved indications, including ADHD and aggressive behavior, according to Centers for Medicare & Medicaid Services data.

Dr. Grundmeier reported that a stimulant and an atypical antipsychotic were prescribed together for 7.5% of boys and 4.4% of girls on psychotropic medication, and an antidepressant and an atypical antipsychotic were given to 4.9% of boys and 6.4% of girls.

These CER2 data probably underestimate the true rate of psychotropic drug prescribing for children and adolescents, since prescriptions written by a psychiatrist wouldn’t necessarily be included in the primary care electronic medical record, Dr. Grundmeier said.

Audience member Dr. James M. Perrin, professor of pediatrics at Harvard Medical School and director of general pediatrics at Massachusetts General Hospital, both in Boston, commented, “One of the interesting things about these polypharmacy kids is they come in in acute crisis and someone adds a third or fourth drug, but when the kid gets out of the crisis, no one thinks about taking the drug away; he’s always on it.”

Dr. Grundmeier agreed that’s the classic pattern. Accordingly, a likely next step in this research project will be to scrutinize the CER2 Consortium data set in search of patterns of subtracting psychotropic drugs and simplifying management on the part of some primary care physicians. The ultimate goal is to gain an understanding of the effectiveness and potential adverse effects of psychotropic polypharmacy in order to develop evidence-based tools, such as clinical pathways to help support primary care physicians who are treating these young patients.

Another audience member, a pediatric critical care specialist at an urban public hospital, commented that the high rates of off-label psychotropic polypharmacy by primary care physicians documented in the CER2 study constitute an indictment of widespread inadequate psychiatric services for young Medicaid patients.

“There’s not a night on call when I’m not admitting a teenager trying to kill himself. So when I see your data, I split it into the ADHD group and the antidepressant group. And the patients admitted for suicidality have to leave the hospital after a maximum of 3 days, generally without psychiatric or social support services to supplement these medications,” she said.

This study was funded by the Health Resources and Services Administration. Dr. Grundmeier reported having no relevant financial conflicts.

[email protected]

SAN DIEGO – Of children and teens on psychotropic medication prescribed by their primary care pediatrician or family physician, 21% simultaneously receive two or more different classes of the drugs for at least 3 months, according to a massive study.

“Given that the safety of pediatric monotherapy for some of these psychotropic medications is unexplored, these patterns of polypharmacy prescribing are alarming and warrant further investigation,” Dr. Robert Grundmeier said in presenting the study results at the annual meeting of the Pediatric Academic Societies.

He presented a study of 891,717 patients up to 18 years of age who received health care at 1 of 222 primary care pediatric or family medicine sites participating in the Comparative Effectiveness Research Through Collaborative Electronic Reporting (CER2) Consortium. He described CER2 as a “supernetwork” comprised of multiple electronic health record–based networks and led by the American Academy of Pediatrics. The consortium was designed to carry out very large pharmacoepidemiologic and comparative effectiveness studies.

The initial study population consisted of more than 1.2 million patients up to age 18 years, a figure that investigators whittled down to just under 900,000 by excluding those with a seizure disorder or less than 12 months of follow-up data.

Among the 891,717 subjects, 8.3% of boys and 5.3% of girls were treated with psychotropic medication by their primary care physician at some point. Of these 60,430 patients, 21% simultaneously received psychotropic drugs from two or more different classes for at least 3 months. Another 5,813 patients – 0.9% of all boys and 0.4% of all girls in the study – got psychotropic medications from three or more classes simultaneously, reported Dr. Grundmeier of Children’s Hospital of Philadelphia.

The most frequently prescribed category of medication was stimulants/
atomoxetine, a treatment mainstay in attention-deficit/hyperactivity disorder. Antidepressants were No. 2 and were prescribed in 2.1% of all boys and 2.8% of girls. Atypical antipsychotics were prescribed for 1.4% of boys and 0.8% of girls.

The most widely prescribed two-class combination among patients receiving psychotropic medication was a stimulant and an alpha-agonist, given to 10.7% of boys and 5.6% of girls. The second most popular two-drug combination was a stimulant and an antidepressant, which was prescribed for 7.3% of boys and 7.1% of girls who took psychotropic medication.

The use of combination therapy incorporating an atypical antipsychotic was of particular interest because health policy makers have identified this as an issue of concern. The drugs aren’t approved by the Food and Drug Administration for patients younger than 5 years old, and yet the Agency for Healthcare Research and Quality has reported that the use of these medications in very young children with behavior problems doubled between 1999-2001 and 2007. Moreover, more than three-quarters of youths on Medicaid are taking an atypical antipsychotic for non–FDA-approved indications, including ADHD and aggressive behavior, according to Centers for Medicare & Medicaid Services data.

Dr. Grundmeier reported that a stimulant and an atypical antipsychotic were prescribed together for 7.5% of boys and 4.4% of girls on psychotropic medication, and an antidepressant and an atypical antipsychotic were given to 4.9% of boys and 6.4% of girls.

These CER2 data probably underestimate the true rate of psychotropic drug prescribing for children and adolescents, since prescriptions written by a psychiatrist wouldn’t necessarily be included in the primary care electronic medical record, Dr. Grundmeier said.

Audience member Dr. James M. Perrin, professor of pediatrics at Harvard Medical School and director of general pediatrics at Massachusetts General Hospital, both in Boston, commented, “One of the interesting things about these polypharmacy kids is they come in in acute crisis and someone adds a third or fourth drug, but when the kid gets out of the crisis, no one thinks about taking the drug away; he’s always on it.”

Dr. Grundmeier agreed that’s the classic pattern. Accordingly, a likely next step in this research project will be to scrutinize the CER2 Consortium data set in search of patterns of subtracting psychotropic drugs and simplifying management on the part of some primary care physicians. The ultimate goal is to gain an understanding of the effectiveness and potential adverse effects of psychotropic polypharmacy in order to develop evidence-based tools, such as clinical pathways to help support primary care physicians who are treating these young patients.

Another audience member, a pediatric critical care specialist at an urban public hospital, commented that the high rates of off-label psychotropic polypharmacy by primary care physicians documented in the CER2 study constitute an indictment of widespread inadequate psychiatric services for young Medicaid patients.

“There’s not a night on call when I’m not admitting a teenager trying to kill himself. So when I see your data, I split it into the ADHD group and the antidepressant group. And the patients admitted for suicidality have to leave the hospital after a maximum of 3 days, generally without psychiatric or social support services to supplement these medications,” she said.

This study was funded by the Health Resources and Services Administration. Dr. Grundmeier reported having no relevant financial conflicts.

[email protected]

SAN DIEGO – Of children and teens on psychotropic medication prescribed by their primary care pediatrician or family physician, 21% simultaneously receive two or more different classes of the drugs for at least 3 months, according to a massive study.

“Given that the safety of pediatric monotherapy for some of these psychotropic medications is unexplored, these patterns of polypharmacy prescribing are alarming and warrant further investigation,” Dr. Robert Grundmeier said in presenting the study results at the annual meeting of the Pediatric Academic Societies.

He presented a study of 891,717 patients up to 18 years of age who received health care at 1 of 222 primary care pediatric or family medicine sites participating in the Comparative Effectiveness Research Through Collaborative Electronic Reporting (CER2) Consortium. He described CER2 as a “supernetwork” comprised of multiple electronic health record–based networks and led by the American Academy of Pediatrics. The consortium was designed to carry out very large pharmacoepidemiologic and comparative effectiveness studies.

The initial study population consisted of more than 1.2 million patients up to age 18 years, a figure that investigators whittled down to just under 900,000 by excluding those with a seizure disorder or less than 12 months of follow-up data.

Among the 891,717 subjects, 8.3% of boys and 5.3% of girls were treated with psychotropic medication by their primary care physician at some point. Of these 60,430 patients, 21% simultaneously received psychotropic drugs from two or more different classes for at least 3 months. Another 5,813 patients – 0.9% of all boys and 0.4% of all girls in the study – got psychotropic medications from three or more classes simultaneously, reported Dr. Grundmeier of Children’s Hospital of Philadelphia.

The most frequently prescribed category of medication was stimulants/
atomoxetine, a treatment mainstay in attention-deficit/hyperactivity disorder. Antidepressants were No. 2 and were prescribed in 2.1% of all boys and 2.8% of girls. Atypical antipsychotics were prescribed for 1.4% of boys and 0.8% of girls.

The most widely prescribed two-class combination among patients receiving psychotropic medication was a stimulant and an alpha-agonist, given to 10.7% of boys and 5.6% of girls. The second most popular two-drug combination was a stimulant and an antidepressant, which was prescribed for 7.3% of boys and 7.1% of girls who took psychotropic medication.

The use of combination therapy incorporating an atypical antipsychotic was of particular interest because health policy makers have identified this as an issue of concern. The drugs aren’t approved by the Food and Drug Administration for patients younger than 5 years old, and yet the Agency for Healthcare Research and Quality has reported that the use of these medications in very young children with behavior problems doubled between 1999-2001 and 2007. Moreover, more than three-quarters of youths on Medicaid are taking an atypical antipsychotic for non–FDA-approved indications, including ADHD and aggressive behavior, according to Centers for Medicare & Medicaid Services data.

Dr. Grundmeier reported that a stimulant and an atypical antipsychotic were prescribed together for 7.5% of boys and 4.4% of girls on psychotropic medication, and an antidepressant and an atypical antipsychotic were given to 4.9% of boys and 6.4% of girls.

These CER2 data probably underestimate the true rate of psychotropic drug prescribing for children and adolescents, since prescriptions written by a psychiatrist wouldn’t necessarily be included in the primary care electronic medical record, Dr. Grundmeier said.

Audience member Dr. James M. Perrin, professor of pediatrics at Harvard Medical School and director of general pediatrics at Massachusetts General Hospital, both in Boston, commented, “One of the interesting things about these polypharmacy kids is they come in in acute crisis and someone adds a third or fourth drug, but when the kid gets out of the crisis, no one thinks about taking the drug away; he’s always on it.”

Dr. Grundmeier agreed that’s the classic pattern. Accordingly, a likely next step in this research project will be to scrutinize the CER2 Consortium data set in search of patterns of subtracting psychotropic drugs and simplifying management on the part of some primary care physicians. The ultimate goal is to gain an understanding of the effectiveness and potential adverse effects of psychotropic polypharmacy in order to develop evidence-based tools, such as clinical pathways to help support primary care physicians who are treating these young patients.

Another audience member, a pediatric critical care specialist at an urban public hospital, commented that the high rates of off-label psychotropic polypharmacy by primary care physicians documented in the CER2 study constitute an indictment of widespread inadequate psychiatric services for young Medicaid patients.

“There’s not a night on call when I’m not admitting a teenager trying to kill himself. So when I see your data, I split it into the ADHD group and the antidepressant group. And the patients admitted for suicidality have to leave the hospital after a maximum of 3 days, generally without psychiatric or social support services to supplement these medications,” she said.

This study was funded by the Health Resources and Services Administration. Dr. Grundmeier reported having no relevant financial conflicts.

[email protected]

SAN DIEGO – Specific patterns of undervaccination in the first year of life, which may indicate parental vaccine refusal, are relatively uncommon, a large study showed.

“We should be encouraged, because it doesn’t seem like this is a problem greatly increasing in magnitude,” lead study author Dr. Matthew F. Daley said in an interview during a poster session at the annual meeting of the Pediatric Academic Societies. “But it still takes a lot of time and effort on the part of frontline clinicians to talk to these families and convince them to vaccinate. That goes on day in and day out, but at least the rates of parents who are deliberately refusing or spacing out vaccines seems stable over time.”

For the study, Dr. Daley, a pediatrician and senior investigator at Kaiser Permanente Colorado, Denver, and his associates evaluated the records of all children born from 2004 through 2013 who were part of six managed care organizations (MCOs) participating in the Vaccine Safety Datalink: Kaiser Permanente Colorado, Group Health Cooperative, Kaiser Permanente Northwest, Kaiser Permanente Southern California, Marshfield Clinic, and Kaiser Permanente Northern California. To be eligible, the children had to be enrolled continuously in their MCO from 6 weeks of age to their first birthday and have at least one well-child visit during the first year of life. The goal of the study ”was to identify nonstandard approaches to vaccination commonly endorsed by vaccine-hesitant parents,” the researchers wrote in their abstract. “There are many causes of undervaccination other than parental vaccine hesitancy; these were not the focus of the current study.”

The investigators focused on identifying five patterns: no vaccines (completely unvaccinated); first vaccine at 4-5 months of age; first vaccine at 6-11 months of age; pneumococcal conjugate (PCV7 or PCV13) and Haemophilus influenzae type b vaccines given on different days from diphtheria, tetanus, and acellular pertussis vaccine; and consistent limiting of vaccines (two or fewer vaccines per visit).

©luiscar/Thinkstockphotos.com

After data on patients with vaccine data errors and those without a well-child visit in the first year of life were excluded from the analysis, the final cohort included 444,679 patients. Dr. Daley and his associates found that from 2006 through 2008, all patients had a significant increasing trend for each pattern (P less than .01). From 2009 through 2013, there was no change for most trends (P greater than .05), except for the number of children with no vaccines (increasing, with a P value of less than .0001), and the number of children who received their first vaccine at 4-5 months of age (decreasing, P =.01).

Specific patterns of undervaccination occurred in about 515/10,000 children born in 2013, “which seems to indicate that parental hesitancy to vaccinate their children is still uncommon,” Dr. Daley said. “The one trend that’s increasing is the no vaccines received [pattern]. That seems like it’s still going up, but it’s still a slow change, and it’s still rare – about 1.5% of the total population. That’s a trend to keep an eye on, though, because those are kids who haven’t received any vaccines at all.”

Dr. Daley acknowledged certain limitations of the study, including the potential for misclassification, as children could have received their vaccines outside of the participating MCOs. He also said that the findings are likely to differ in an underinsured or uninsured population.

The study was funded by the Centers for Disease Control and Prevention. Dr. Daley reported having no relevant financial conflicts.

[email protected]
On Twitter @dougbrunk

SAN DIEGO – Specific patterns of undervaccination in the first year of life, which may indicate parental vaccine refusal, are relatively uncommon, a large study showed.

“We should be encouraged, because it doesn’t seem like this is a problem greatly increasing in magnitude,” lead study author Dr. Matthew F. Daley said in an interview during a poster session at the annual meeting of the Pediatric Academic Societies. “But it still takes a lot of time and effort on the part of frontline clinicians to talk to these families and convince them to vaccinate. That goes on day in and day out, but at least the rates of parents who are deliberately refusing or spacing out vaccines seems stable over time.”

For the study, Dr. Daley, a pediatrician and senior investigator at Kaiser Permanente Colorado, Denver, and his associates evaluated the records of all children born from 2004 through 2013 who were part of six managed care organizations (MCOs) participating in the Vaccine Safety Datalink: Kaiser Permanente Colorado, Group Health Cooperative, Kaiser Permanente Northwest, Kaiser Permanente Southern California, Marshfield Clinic, and Kaiser Permanente Northern California. To be eligible, the children had to be enrolled continuously in their MCO from 6 weeks of age to their first birthday and have at least one well-child visit during the first year of life. The goal of the study ”was to identify nonstandard approaches to vaccination commonly endorsed by vaccine-hesitant parents,” the researchers wrote in their abstract. “There are many causes of undervaccination other than parental vaccine hesitancy; these were not the focus of the current study.”

The investigators focused on identifying five patterns: no vaccines (completely unvaccinated); first vaccine at 4-5 months of age; first vaccine at 6-11 months of age; pneumococcal conjugate (PCV7 or PCV13) and Haemophilus influenzae type b vaccines given on different days from diphtheria, tetanus, and acellular pertussis vaccine; and consistent limiting of vaccines (two or fewer vaccines per visit).

©luiscar/Thinkstockphotos.com

After data on patients with vaccine data errors and those without a well-child visit in the first year of life were excluded from the analysis, the final cohort included 444,679 patients. Dr. Daley and his associates found that from 2006 through 2008, all patients had a significant increasing trend for each pattern (P less than .01). From 2009 through 2013, there was no change for most trends (P greater than .05), except for the number of children with no vaccines (increasing, with a P value of less than .0001), and the number of children who received their first vaccine at 4-5 months of age (decreasing, P =.01).

Specific patterns of undervaccination occurred in about 515/10,000 children born in 2013, “which seems to indicate that parental hesitancy to vaccinate their children is still uncommon,” Dr. Daley said. “The one trend that’s increasing is the no vaccines received [pattern]. That seems like it’s still going up, but it’s still a slow change, and it’s still rare – about 1.5% of the total population. That’s a trend to keep an eye on, though, because those are kids who haven’t received any vaccines at all.”

Dr. Daley acknowledged certain limitations of the study, including the potential for misclassification, as children could have received their vaccines outside of the participating MCOs. He also said that the findings are likely to differ in an underinsured or uninsured population.

The study was funded by the Centers for Disease Control and Prevention. Dr. Daley reported having no relevant financial conflicts.

[email protected]
On Twitter @dougbrunk

SAN DIEGO – Specific patterns of undervaccination in the first year of life, which may indicate parental vaccine refusal, are relatively uncommon, a large study showed.

“We should be encouraged, because it doesn’t seem like this is a problem greatly increasing in magnitude,” lead study author Dr. Matthew F. Daley said in an interview during a poster session at the annual meeting of the Pediatric Academic Societies. “But it still takes a lot of time and effort on the part of frontline clinicians to talk to these families and convince them to vaccinate. That goes on day in and day out, but at least the rates of parents who are deliberately refusing or spacing out vaccines seems stable over time.”

For the study, Dr. Daley, a pediatrician and senior investigator at Kaiser Permanente Colorado, Denver, and his associates evaluated the records of all children born from 2004 through 2013 who were part of six managed care organizations (MCOs) participating in the Vaccine Safety Datalink: Kaiser Permanente Colorado, Group Health Cooperative, Kaiser Permanente Northwest, Kaiser Permanente Southern California, Marshfield Clinic, and Kaiser Permanente Northern California. To be eligible, the children had to be enrolled continuously in their MCO from 6 weeks of age to their first birthday and have at least one well-child visit during the first year of life. The goal of the study ”was to identify nonstandard approaches to vaccination commonly endorsed by vaccine-hesitant parents,” the researchers wrote in their abstract. “There are many causes of undervaccination other than parental vaccine hesitancy; these were not the focus of the current study.”

The investigators focused on identifying five patterns: no vaccines (completely unvaccinated); first vaccine at 4-5 months of age; first vaccine at 6-11 months of age; pneumococcal conjugate (PCV7 or PCV13) and Haemophilus influenzae type b vaccines given on different days from diphtheria, tetanus, and acellular pertussis vaccine; and consistent limiting of vaccines (two or fewer vaccines per visit).

©luiscar/Thinkstockphotos.com

After data on patients with vaccine data errors and those without a well-child visit in the first year of life were excluded from the analysis, the final cohort included 444,679 patients. Dr. Daley and his associates found that from 2006 through 2008, all patients had a significant increasing trend for each pattern (P less than .01). From 2009 through 2013, there was no change for most trends (P greater than .05), except for the number of children with no vaccines (increasing, with a P value of less than .0001), and the number of children who received their first vaccine at 4-5 months of age (decreasing, P =.01).

Specific patterns of undervaccination occurred in about 515/10,000 children born in 2013, “which seems to indicate that parental hesitancy to vaccinate their children is still uncommon,” Dr. Daley said. “The one trend that’s increasing is the no vaccines received [pattern]. That seems like it’s still going up, but it’s still a slow change, and it’s still rare – about 1.5% of the total population. That’s a trend to keep an eye on, though, because those are kids who haven’t received any vaccines at all.”

Dr. Daley acknowledged certain limitations of the study, including the potential for misclassification, as children could have received their vaccines outside of the participating MCOs. He also said that the findings are likely to differ in an underinsured or uninsured population.

The study was funded by the Centers for Disease Control and Prevention. Dr. Daley reported having no relevant financial conflicts.

[email protected]
On Twitter @dougbrunk