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AHS White Paper Guides Treatment of Posttraumatic Headache in Youth
The guidance document, the first of its kind, covers risk factors for prolonged recovery, along with pharmacologic and nonpharmacologic management strategies, and supports an emphasis on multidisciplinary care, lead author Carlyn Patterson Gentile, MD, PhD, attending physician in the Division of Neurology at Children’s Hospital of Philadelphia in Pennsylvania, and colleagues reported.
“There are no guidelines to inform the management of posttraumatic headache in youth, but multiple studies have been conducted over the past 2 decades,” the authors wrote in Headache. “This white paper aims to provide a thorough review of the current literature, identify gaps in knowledge, and provide a road map for [posttraumatic headache] management in youth based on available evidence and expert opinion.”
Clarity for an Underrecognized Issue
According to Russell Lonser, MD, professor and chair of neurological surgery at Ohio State University, Columbus, the white paper is important because it offers concrete guidance for health care providers who may be less familiar with posttraumatic headache in youth.
“It brings together all of the previous literature ... in a very well-written way,” Dr. Lonser said in an interview. “More than anything, it could reassure [providers] that they shouldn’t be hunting down potentially magical cures, and reassure them in symptomatic management.”
Meeryo C. Choe, MD, associate clinical professor of pediatric neurology at UCLA Health in Calabasas, California, said the paper also helps shine a light on what may be a more common condition than the public suspects.
“While the media focuses on the effects of concussion in professional sports athletes, the biggest population of athletes is in our youth population,” Dr. Choe said in a written comment. “Almost 25 million children participate in sports throughout the country, and yet we lack guidelines on how to treat posttraumatic headache which can often develop into persistent postconcussive symptoms.”
This white paper, she noted, builds on Dr. Gentile’s 2021 systematic review, introduces new management recommendations, and aligns with the latest consensus statement from the Concussion in Sport Group.
Risk Factors
The white paper first emphasizes the importance of early identification of youth at high risk for prolonged recovery from posttraumatic headache. Risk factors include female sex, adolescent age, a high number of acute symptoms following the initial injury, and social determinants of health.
“I agree that it is important to identify these patients early to improve the recovery trajectory,” Dr. Choe said.
Identifying these individuals quickly allows for timely intervention with both pharmacologic and nonpharmacologic therapies, Dr. Gentile and colleagues noted, potentially mitigating persistent symptoms. Clinicians are encouraged to perform thorough initial assessments to identify these risk factors and initiate early, personalized management plans.
Initial Management of Acute Posttraumatic Headache
For the initial management of acute posttraumatic headache, the white paper recommends a scheduled dosing regimen of simple analgesics. Ibuprofen at a dosage of 10 mg/kg every 6-8 hours (up to a maximum of 600 mg per dose) combined with acetaminophen has shown the best evidence for efficacy. Provided the patient is clinically stable, this regimen should be initiated within 48 hours of the injury and maintained with scheduled dosing for 3-10 days.
If effective, these medications can subsequently be used on an as-needed basis. Careful usage of analgesics is crucial, the white paper cautions, as overadministration can lead to medication-overuse headaches, complicating the recovery process.
Secondary Treatment Options
In cases where first-line oral medications are ineffective, the AHS white paper outlines several secondary treatment options. These include acute intravenous therapies such as ketorolac, dopamine receptor antagonists, and intravenous fluids. Nerve blocks and oral corticosteroid bridges may also be considered.
The white paper stresses the importance of individualized treatment plans that consider the specific needs and responses of each patient, noting that the evidence supporting these approaches is primarily derived from retrospective studies and case reports.
“Patient preferences should be factored in,” said Sean Rose, MD, pediatric neurologist and codirector of the Complex Concussion Clinic at Nationwide Children’s Hospital, Columbus, Ohio.
Supplements and Preventive Measures
For adolescents and young adults at high risk of prolonged posttraumatic headache, the white paper suggests the use of riboflavin and magnesium supplements. Small randomized clinical trials suggest that these supplements may aid in speeding recovery when administered for 1-2 weeks within 48 hours of injury.
If significant headache persists after 2 weeks, a regimen of riboflavin 400 mg daily and magnesium 400-500 mg nightly can be trialed for 6-8 weeks, in line with recommendations for migraine prevention. Additionally, melatonin at a dose of 3-5 mg nightly for an 8-week course may be considered for patients experiencing comorbid sleep disturbances.
Targeted Preventative Therapy
The white paper emphasizes the importance of targeting preventative therapy to the primary headache phenotype.
For instance, patients presenting with a migraine phenotype, or those with a personal or family history of migraines, may be most likely to respond to medications proven effective in migraine prevention, such as amitriptyline, topiramate, and propranolol.
“Most research evidence [for treating posttraumatic headache in youth] is still based on the treatment of migraine,” Dr. Rose pointed out in a written comment.
Dr. Gentile and colleagues recommend initiating preventive therapies 4-6 weeks post injury if headaches are not improving, occur more than 1-2 days per week, or significantly impact daily functioning.
Specialist Referrals and Physical Activity
Referral to a headache specialist is advised for patients who do not respond to first-line acute and preventive therapies. Specialists can offer advanced diagnostic and therapeutic options, the authors noted, ensuring a comprehensive approach to managing posttraumatic headache.
The white paper also recommends noncontact, sub–symptom threshold aerobic physical activity and activities of daily living after an initial 24-48 hour period of symptom-limited cognitive and physical rest. Engaging in these activities may promote faster recovery and help patients gradually return to their normal routines.
“This has been a shift in the concussion treatment approach over the last decade, and is one of the most important interventions we can recommend as physicians,” Dr. Choe noted. “This is where pediatricians and emergency department physicians seeing children acutely can really make a difference in the recovery trajectory for a child after a concussion. ‘Cocoon therapy’ has been proven not only to not work, but be detrimental to recovery.”
Nonpharmacologic Interventions
Based on clinical assessment, nonpharmacologic interventions may also be considered, according to the white paper. These interventions include cervico-vestibular therapy, which addresses neck and balance issues, and cognitive-behavioral therapy, which helps manage the psychological aspects of chronic headache. Dr. Gentile and colleagues highlighted the potential benefits of a collaborative care model that incorporates these nonpharmacologic interventions alongside pharmacologic treatments, providing a holistic approach to posttraumatic headache management.
“Persisting headaches after concussion are often driven by multiple factors,” Dr. Rose said. “Multidisciplinary concussion clinics can offer multiple treatment approaches such as behavioral, physical therapy, exercise, and medication options.”
Unmet Needs
The white paper concludes by calling for high-quality prospective cohort studies and placebo-controlled, randomized, controlled trials to further advance the understanding and treatment of posttraumatic headache in children.
Dr. Lonser, Dr. Choe, and Dr. Rose all agreed.
“More focused treatment trials are needed to gauge efficacy in children with headache after concussion,” Dr. Rose said.
Specifically, Dr. Gentile and colleagues underscored the need to standardize data collection via common elements, which could improve the ability to compare results across studies and develop more effective treatments. In addition, research into the underlying pathophysiology of posttraumatic headache is crucial for identifying new therapeutic targets and clinical and biological markers that can personalize patient care.
They also stressed the importance of exploring the impact of health disparities and social determinants on posttraumatic headache outcomes, aiming to develop interventions that are equitable and accessible to all patient populations.The white paper was approved by the AHS, and supported by the National Institutes of Health/National Institute of Neurological Disorders and Stroke K23 NS124986. The authors disclosed relationships with Eli Lilly, Pfizer, Amgen, and others. The interviewees disclosed no conflicts of interest.
The guidance document, the first of its kind, covers risk factors for prolonged recovery, along with pharmacologic and nonpharmacologic management strategies, and supports an emphasis on multidisciplinary care, lead author Carlyn Patterson Gentile, MD, PhD, attending physician in the Division of Neurology at Children’s Hospital of Philadelphia in Pennsylvania, and colleagues reported.
“There are no guidelines to inform the management of posttraumatic headache in youth, but multiple studies have been conducted over the past 2 decades,” the authors wrote in Headache. “This white paper aims to provide a thorough review of the current literature, identify gaps in knowledge, and provide a road map for [posttraumatic headache] management in youth based on available evidence and expert opinion.”
Clarity for an Underrecognized Issue
According to Russell Lonser, MD, professor and chair of neurological surgery at Ohio State University, Columbus, the white paper is important because it offers concrete guidance for health care providers who may be less familiar with posttraumatic headache in youth.
“It brings together all of the previous literature ... in a very well-written way,” Dr. Lonser said in an interview. “More than anything, it could reassure [providers] that they shouldn’t be hunting down potentially magical cures, and reassure them in symptomatic management.”
Meeryo C. Choe, MD, associate clinical professor of pediatric neurology at UCLA Health in Calabasas, California, said the paper also helps shine a light on what may be a more common condition than the public suspects.
“While the media focuses on the effects of concussion in professional sports athletes, the biggest population of athletes is in our youth population,” Dr. Choe said in a written comment. “Almost 25 million children participate in sports throughout the country, and yet we lack guidelines on how to treat posttraumatic headache which can often develop into persistent postconcussive symptoms.”
This white paper, she noted, builds on Dr. Gentile’s 2021 systematic review, introduces new management recommendations, and aligns with the latest consensus statement from the Concussion in Sport Group.
Risk Factors
The white paper first emphasizes the importance of early identification of youth at high risk for prolonged recovery from posttraumatic headache. Risk factors include female sex, adolescent age, a high number of acute symptoms following the initial injury, and social determinants of health.
“I agree that it is important to identify these patients early to improve the recovery trajectory,” Dr. Choe said.
Identifying these individuals quickly allows for timely intervention with both pharmacologic and nonpharmacologic therapies, Dr. Gentile and colleagues noted, potentially mitigating persistent symptoms. Clinicians are encouraged to perform thorough initial assessments to identify these risk factors and initiate early, personalized management plans.
Initial Management of Acute Posttraumatic Headache
For the initial management of acute posttraumatic headache, the white paper recommends a scheduled dosing regimen of simple analgesics. Ibuprofen at a dosage of 10 mg/kg every 6-8 hours (up to a maximum of 600 mg per dose) combined with acetaminophen has shown the best evidence for efficacy. Provided the patient is clinically stable, this regimen should be initiated within 48 hours of the injury and maintained with scheduled dosing for 3-10 days.
If effective, these medications can subsequently be used on an as-needed basis. Careful usage of analgesics is crucial, the white paper cautions, as overadministration can lead to medication-overuse headaches, complicating the recovery process.
Secondary Treatment Options
In cases where first-line oral medications are ineffective, the AHS white paper outlines several secondary treatment options. These include acute intravenous therapies such as ketorolac, dopamine receptor antagonists, and intravenous fluids. Nerve blocks and oral corticosteroid bridges may also be considered.
The white paper stresses the importance of individualized treatment plans that consider the specific needs and responses of each patient, noting that the evidence supporting these approaches is primarily derived from retrospective studies and case reports.
“Patient preferences should be factored in,” said Sean Rose, MD, pediatric neurologist and codirector of the Complex Concussion Clinic at Nationwide Children’s Hospital, Columbus, Ohio.
Supplements and Preventive Measures
For adolescents and young adults at high risk of prolonged posttraumatic headache, the white paper suggests the use of riboflavin and magnesium supplements. Small randomized clinical trials suggest that these supplements may aid in speeding recovery when administered for 1-2 weeks within 48 hours of injury.
If significant headache persists after 2 weeks, a regimen of riboflavin 400 mg daily and magnesium 400-500 mg nightly can be trialed for 6-8 weeks, in line with recommendations for migraine prevention. Additionally, melatonin at a dose of 3-5 mg nightly for an 8-week course may be considered for patients experiencing comorbid sleep disturbances.
Targeted Preventative Therapy
The white paper emphasizes the importance of targeting preventative therapy to the primary headache phenotype.
For instance, patients presenting with a migraine phenotype, or those with a personal or family history of migraines, may be most likely to respond to medications proven effective in migraine prevention, such as amitriptyline, topiramate, and propranolol.
“Most research evidence [for treating posttraumatic headache in youth] is still based on the treatment of migraine,” Dr. Rose pointed out in a written comment.
Dr. Gentile and colleagues recommend initiating preventive therapies 4-6 weeks post injury if headaches are not improving, occur more than 1-2 days per week, or significantly impact daily functioning.
Specialist Referrals and Physical Activity
Referral to a headache specialist is advised for patients who do not respond to first-line acute and preventive therapies. Specialists can offer advanced diagnostic and therapeutic options, the authors noted, ensuring a comprehensive approach to managing posttraumatic headache.
The white paper also recommends noncontact, sub–symptom threshold aerobic physical activity and activities of daily living after an initial 24-48 hour period of symptom-limited cognitive and physical rest. Engaging in these activities may promote faster recovery and help patients gradually return to their normal routines.
“This has been a shift in the concussion treatment approach over the last decade, and is one of the most important interventions we can recommend as physicians,” Dr. Choe noted. “This is where pediatricians and emergency department physicians seeing children acutely can really make a difference in the recovery trajectory for a child after a concussion. ‘Cocoon therapy’ has been proven not only to not work, but be detrimental to recovery.”
Nonpharmacologic Interventions
Based on clinical assessment, nonpharmacologic interventions may also be considered, according to the white paper. These interventions include cervico-vestibular therapy, which addresses neck and balance issues, and cognitive-behavioral therapy, which helps manage the psychological aspects of chronic headache. Dr. Gentile and colleagues highlighted the potential benefits of a collaborative care model that incorporates these nonpharmacologic interventions alongside pharmacologic treatments, providing a holistic approach to posttraumatic headache management.
“Persisting headaches after concussion are often driven by multiple factors,” Dr. Rose said. “Multidisciplinary concussion clinics can offer multiple treatment approaches such as behavioral, physical therapy, exercise, and medication options.”
Unmet Needs
The white paper concludes by calling for high-quality prospective cohort studies and placebo-controlled, randomized, controlled trials to further advance the understanding and treatment of posttraumatic headache in children.
Dr. Lonser, Dr. Choe, and Dr. Rose all agreed.
“More focused treatment trials are needed to gauge efficacy in children with headache after concussion,” Dr. Rose said.
Specifically, Dr. Gentile and colleagues underscored the need to standardize data collection via common elements, which could improve the ability to compare results across studies and develop more effective treatments. In addition, research into the underlying pathophysiology of posttraumatic headache is crucial for identifying new therapeutic targets and clinical and biological markers that can personalize patient care.
They also stressed the importance of exploring the impact of health disparities and social determinants on posttraumatic headache outcomes, aiming to develop interventions that are equitable and accessible to all patient populations.The white paper was approved by the AHS, and supported by the National Institutes of Health/National Institute of Neurological Disorders and Stroke K23 NS124986. The authors disclosed relationships with Eli Lilly, Pfizer, Amgen, and others. The interviewees disclosed no conflicts of interest.
The guidance document, the first of its kind, covers risk factors for prolonged recovery, along with pharmacologic and nonpharmacologic management strategies, and supports an emphasis on multidisciplinary care, lead author Carlyn Patterson Gentile, MD, PhD, attending physician in the Division of Neurology at Children’s Hospital of Philadelphia in Pennsylvania, and colleagues reported.
“There are no guidelines to inform the management of posttraumatic headache in youth, but multiple studies have been conducted over the past 2 decades,” the authors wrote in Headache. “This white paper aims to provide a thorough review of the current literature, identify gaps in knowledge, and provide a road map for [posttraumatic headache] management in youth based on available evidence and expert opinion.”
Clarity for an Underrecognized Issue
According to Russell Lonser, MD, professor and chair of neurological surgery at Ohio State University, Columbus, the white paper is important because it offers concrete guidance for health care providers who may be less familiar with posttraumatic headache in youth.
“It brings together all of the previous literature ... in a very well-written way,” Dr. Lonser said in an interview. “More than anything, it could reassure [providers] that they shouldn’t be hunting down potentially magical cures, and reassure them in symptomatic management.”
Meeryo C. Choe, MD, associate clinical professor of pediatric neurology at UCLA Health in Calabasas, California, said the paper also helps shine a light on what may be a more common condition than the public suspects.
“While the media focuses on the effects of concussion in professional sports athletes, the biggest population of athletes is in our youth population,” Dr. Choe said in a written comment. “Almost 25 million children participate in sports throughout the country, and yet we lack guidelines on how to treat posttraumatic headache which can often develop into persistent postconcussive symptoms.”
This white paper, she noted, builds on Dr. Gentile’s 2021 systematic review, introduces new management recommendations, and aligns with the latest consensus statement from the Concussion in Sport Group.
Risk Factors
The white paper first emphasizes the importance of early identification of youth at high risk for prolonged recovery from posttraumatic headache. Risk factors include female sex, adolescent age, a high number of acute symptoms following the initial injury, and social determinants of health.
“I agree that it is important to identify these patients early to improve the recovery trajectory,” Dr. Choe said.
Identifying these individuals quickly allows for timely intervention with both pharmacologic and nonpharmacologic therapies, Dr. Gentile and colleagues noted, potentially mitigating persistent symptoms. Clinicians are encouraged to perform thorough initial assessments to identify these risk factors and initiate early, personalized management plans.
Initial Management of Acute Posttraumatic Headache
For the initial management of acute posttraumatic headache, the white paper recommends a scheduled dosing regimen of simple analgesics. Ibuprofen at a dosage of 10 mg/kg every 6-8 hours (up to a maximum of 600 mg per dose) combined with acetaminophen has shown the best evidence for efficacy. Provided the patient is clinically stable, this regimen should be initiated within 48 hours of the injury and maintained with scheduled dosing for 3-10 days.
If effective, these medications can subsequently be used on an as-needed basis. Careful usage of analgesics is crucial, the white paper cautions, as overadministration can lead to medication-overuse headaches, complicating the recovery process.
Secondary Treatment Options
In cases where first-line oral medications are ineffective, the AHS white paper outlines several secondary treatment options. These include acute intravenous therapies such as ketorolac, dopamine receptor antagonists, and intravenous fluids. Nerve blocks and oral corticosteroid bridges may also be considered.
The white paper stresses the importance of individualized treatment plans that consider the specific needs and responses of each patient, noting that the evidence supporting these approaches is primarily derived from retrospective studies and case reports.
“Patient preferences should be factored in,” said Sean Rose, MD, pediatric neurologist and codirector of the Complex Concussion Clinic at Nationwide Children’s Hospital, Columbus, Ohio.
Supplements and Preventive Measures
For adolescents and young adults at high risk of prolonged posttraumatic headache, the white paper suggests the use of riboflavin and magnesium supplements. Small randomized clinical trials suggest that these supplements may aid in speeding recovery when administered for 1-2 weeks within 48 hours of injury.
If significant headache persists after 2 weeks, a regimen of riboflavin 400 mg daily and magnesium 400-500 mg nightly can be trialed for 6-8 weeks, in line with recommendations for migraine prevention. Additionally, melatonin at a dose of 3-5 mg nightly for an 8-week course may be considered for patients experiencing comorbid sleep disturbances.
Targeted Preventative Therapy
The white paper emphasizes the importance of targeting preventative therapy to the primary headache phenotype.
For instance, patients presenting with a migraine phenotype, or those with a personal or family history of migraines, may be most likely to respond to medications proven effective in migraine prevention, such as amitriptyline, topiramate, and propranolol.
“Most research evidence [for treating posttraumatic headache in youth] is still based on the treatment of migraine,” Dr. Rose pointed out in a written comment.
Dr. Gentile and colleagues recommend initiating preventive therapies 4-6 weeks post injury if headaches are not improving, occur more than 1-2 days per week, or significantly impact daily functioning.
Specialist Referrals and Physical Activity
Referral to a headache specialist is advised for patients who do not respond to first-line acute and preventive therapies. Specialists can offer advanced diagnostic and therapeutic options, the authors noted, ensuring a comprehensive approach to managing posttraumatic headache.
The white paper also recommends noncontact, sub–symptom threshold aerobic physical activity and activities of daily living after an initial 24-48 hour period of symptom-limited cognitive and physical rest. Engaging in these activities may promote faster recovery and help patients gradually return to their normal routines.
“This has been a shift in the concussion treatment approach over the last decade, and is one of the most important interventions we can recommend as physicians,” Dr. Choe noted. “This is where pediatricians and emergency department physicians seeing children acutely can really make a difference in the recovery trajectory for a child after a concussion. ‘Cocoon therapy’ has been proven not only to not work, but be detrimental to recovery.”
Nonpharmacologic Interventions
Based on clinical assessment, nonpharmacologic interventions may also be considered, according to the white paper. These interventions include cervico-vestibular therapy, which addresses neck and balance issues, and cognitive-behavioral therapy, which helps manage the psychological aspects of chronic headache. Dr. Gentile and colleagues highlighted the potential benefits of a collaborative care model that incorporates these nonpharmacologic interventions alongside pharmacologic treatments, providing a holistic approach to posttraumatic headache management.
“Persisting headaches after concussion are often driven by multiple factors,” Dr. Rose said. “Multidisciplinary concussion clinics can offer multiple treatment approaches such as behavioral, physical therapy, exercise, and medication options.”
Unmet Needs
The white paper concludes by calling for high-quality prospective cohort studies and placebo-controlled, randomized, controlled trials to further advance the understanding and treatment of posttraumatic headache in children.
Dr. Lonser, Dr. Choe, and Dr. Rose all agreed.
“More focused treatment trials are needed to gauge efficacy in children with headache after concussion,” Dr. Rose said.
Specifically, Dr. Gentile and colleagues underscored the need to standardize data collection via common elements, which could improve the ability to compare results across studies and develop more effective treatments. In addition, research into the underlying pathophysiology of posttraumatic headache is crucial for identifying new therapeutic targets and clinical and biological markers that can personalize patient care.
They also stressed the importance of exploring the impact of health disparities and social determinants on posttraumatic headache outcomes, aiming to develop interventions that are equitable and accessible to all patient populations.The white paper was approved by the AHS, and supported by the National Institutes of Health/National Institute of Neurological Disorders and Stroke K23 NS124986. The authors disclosed relationships with Eli Lilly, Pfizer, Amgen, and others. The interviewees disclosed no conflicts of interest.
FROM HEADACHE
New Guidance on Genetic Testing for Kidney Disease
A new consensus statement recommended genetic testing for all categories of kidney diseases whenever a genetic cause is suspected and offered guidance on who to test, which tests are the most useful, and how to talk to patients about results.
The statement, published online in the American Journal of Kidney Diseases, is the work of four dozen authors — including patients, nephrologists, experts in clinical and laboratory genetics, kidney pathology, genetic counseling, and ethics. The experts were brought together by the National Kidney Foundation (NKF) with the goal of broadening use and understanding of the tests.
About 10% or more of kidney diseases in adults and 70% of selected chronic kidney diseases (CKDs) in children have genetic causes. But nephrologists have reported a lack of education about genetic testing, and other barriers to wider use, including limited access to testing, cost, insurance coverage, and a small number of genetic counselors who are versed in kidney genetics.
Genetic testing “in the kidney field is a little less developed than in other fields,” said co–lead author Nora Franceschini, MD, MPH, a professor of epidemiology at the University of North Carolina Gillings School of Global Public Health, Chapel Hill, and a nephrologist who studies the genetic epidemiology of hypertension and kidney and cardiovascular diseases.
There are already many known variants that play a role in various kidney diseases and more are on the horizon, Dr. Franceschini told this news organization. More genetic tests will be available in the near future. “The workforce needs to be prepared,” she said.
The statement is an initial step that gets clinicians thinking about testing in a more systematic way, said Dr. Franceschini. “Genetic testing is just another test that physicians can use to complete the story when evaluating patients.
“I think clinicians are ready to implement” testing, said Dr. Franceschini. “We just need to have better guidance.”
Who, When, What to Test
The NKF statement is not the first to try to address gaps in use and knowledge. A European Renal Association Working Group published guidelines in 2022.
The NKF Working Group came up with 56 recommendations and separate algorithms to guide testing for adult and pediatric individuals who are considered at-risk (and currently asymptomatic) and for those who already have clinical disease.
Testing can help determine a cause if there’s an atypical clinical presentation, and it can help avoid biopsies, said the group. Tests can also guide choice of therapy.
For at-risk individuals, there are two broad situations in which testing might be considered: In family members of a patient who already has kidney disease and in potential kidney donors. But testing at-risk children younger than 18 years should only be done if there is an intervention available that could prevent, treat, or slow progression of disease, said the authors.
For patients with an established genetic diagnosis, at-risk family members should be tested with the known single-gene variant diagnostic instead of a broad panel, said the group.
Single-gene variant testing is most appropriate in situations when clinical disease is already evident or when there is known genetic disease in the family, according to the NKF panel. A large diagnostic panel that covers the many common genetic causes of kidney disease is recommended for the majority of patients.
The group recommended that apolipoprotein L1 (APOL1) testing should be included in gene panels for CKD, and it should be offered to any patient “with clinical findings suggestive of APOL1-association nephropathy, regardless of race and ethnicity.”
High-risk APOL1 genotypes confer a 5- to 10-fold increased risk for CKD and are found in one out of seven individuals of African ancestry, which means the focus has largely been on testing those with that ancestry.
However, with many unknowns about APOL1, the NKF panel did not want to “profile” individuals and suggest that testing should not be based on skin color or race/ethnicity, said Dr. Franceschini.
In addition, only about 10% of those with the variant develop disease, so testing is not currently warranted for those who do not already have kidney disease, said the group.
They also recommended against the use of polygenic risk scores, saying that there are not enough data from diverse populations in genome-wide association studies for kidney disease or on their clinical utility.
More Education Needed; Many Barriers
The authors acknowledged that nephrologists generally receive little education in genetics and lack support for interpreting and discussing results.
“Nephrologists should be provided with training and best practice resources to interpret genetic testing and discuss the results with individuals and their families,” they wrote, adding that there’s a need for genomic medicine boards at academic centers that would be available to help nephrologists interpret results and plot clinical management.
The group did not, however, cite some of the other barriers to adoption of testing, including a limited number of sites offering testing, cost, and lack of insurance coverage for the diagnostics.
Medicare may cover genetic testing for kidney disease when an individual has symptoms and there is a Food and Drug Administration–approved test. Joseph Vassalotti, MD, chief medical officer for the NKF, said private insurance may cover the testing if the nephrologist deems it medically necessary, but that he usually confirms coverage before initiating testing. The often-used Renasight panel, which tests for 385 genes related to kidney diseases, costs $300-$400 out of pocket, Dr. Vassalotti told this news organization.
In a survey of 149 nephrologists conducted in 2021, both users (46%) and nonusers of the tests (69%) said that high cost was the most significant perceived barrier to implementing widespread testing. A third of users and almost two thirds of nonusers said that poor availability or lack of ease of testing was the second most significant barrier.
Clinics that test for kidney genes “are largely confined to large academic centers and some specialty clinics,” said Dominic Raj, MD, the Bert B. Brooks chair, and Divya Shankaranarayanan, MD, director of the Kidney Precision Medicine Clinic, both at George Washington University School of Medicine & Health Sciences, Washington, DC, in an email.
Testing is also limited by cultural barriers, lack of genetic literacy, and patients’ concerns that a positive result could lead to a loss of health insurance coverage, said Dr. Raj and Dr. Shankaranarayanan.
Paper Will Help Expand Use
A lack of consensus has also held back expansion. The new statement “may lead to increased and possibly judicious utilization of genetic testing in nephrology practices,” said Dr. Raj and Dr. Shankaranarayanan. “Most importantly, the panel has given specific guidance as to what type of genetic test platform is likely to yield the best and most cost-effective yield.”
The most effective use is “in monogenic kidney diseases and to a lesser extent in oligogenic kidney disease,” said Dr. Raj and Dr. Shankaranarayanan, adding that testing is of less-certain utility in polygenic kidney diseases, “where complex genetic and epigenetic factors determine the phenotype.”
Genetic testing might be especially useful “in atypical clinical presentations” and can help clinicians avoid unnecessary expensive and extensive investigations when multiple organ systems are involved, they said.
“Most importantly, [testing] might prevent unnecessary and potentially harmful treatment and enable targeted specific treatment, when available,” said Dr. Raj and Dr. Shankaranarayanan.
Dr. Franceschini and Dr. Shankaranarayanan reported no relevant financial relationships. Dr. Raj disclosed that he received consulting fees and honoraria from Novo Nordisk and is a national leader for the company’s Zeus trial, studying whether ziltivekimab reduces the risk for cardiovascular events in cardiovascular disease, CKD, and inflammation. He also participated in a study of Natera’s Renasight, a 385-gene panel for kidney disease.
A version of this article first appeared on Medscape.com.
A new consensus statement recommended genetic testing for all categories of kidney diseases whenever a genetic cause is suspected and offered guidance on who to test, which tests are the most useful, and how to talk to patients about results.
The statement, published online in the American Journal of Kidney Diseases, is the work of four dozen authors — including patients, nephrologists, experts in clinical and laboratory genetics, kidney pathology, genetic counseling, and ethics. The experts were brought together by the National Kidney Foundation (NKF) with the goal of broadening use and understanding of the tests.
About 10% or more of kidney diseases in adults and 70% of selected chronic kidney diseases (CKDs) in children have genetic causes. But nephrologists have reported a lack of education about genetic testing, and other barriers to wider use, including limited access to testing, cost, insurance coverage, and a small number of genetic counselors who are versed in kidney genetics.
Genetic testing “in the kidney field is a little less developed than in other fields,” said co–lead author Nora Franceschini, MD, MPH, a professor of epidemiology at the University of North Carolina Gillings School of Global Public Health, Chapel Hill, and a nephrologist who studies the genetic epidemiology of hypertension and kidney and cardiovascular diseases.
There are already many known variants that play a role in various kidney diseases and more are on the horizon, Dr. Franceschini told this news organization. More genetic tests will be available in the near future. “The workforce needs to be prepared,” she said.
The statement is an initial step that gets clinicians thinking about testing in a more systematic way, said Dr. Franceschini. “Genetic testing is just another test that physicians can use to complete the story when evaluating patients.
“I think clinicians are ready to implement” testing, said Dr. Franceschini. “We just need to have better guidance.”
Who, When, What to Test
The NKF statement is not the first to try to address gaps in use and knowledge. A European Renal Association Working Group published guidelines in 2022.
The NKF Working Group came up with 56 recommendations and separate algorithms to guide testing for adult and pediatric individuals who are considered at-risk (and currently asymptomatic) and for those who already have clinical disease.
Testing can help determine a cause if there’s an atypical clinical presentation, and it can help avoid biopsies, said the group. Tests can also guide choice of therapy.
For at-risk individuals, there are two broad situations in which testing might be considered: In family members of a patient who already has kidney disease and in potential kidney donors. But testing at-risk children younger than 18 years should only be done if there is an intervention available that could prevent, treat, or slow progression of disease, said the authors.
For patients with an established genetic diagnosis, at-risk family members should be tested with the known single-gene variant diagnostic instead of a broad panel, said the group.
Single-gene variant testing is most appropriate in situations when clinical disease is already evident or when there is known genetic disease in the family, according to the NKF panel. A large diagnostic panel that covers the many common genetic causes of kidney disease is recommended for the majority of patients.
The group recommended that apolipoprotein L1 (APOL1) testing should be included in gene panels for CKD, and it should be offered to any patient “with clinical findings suggestive of APOL1-association nephropathy, regardless of race and ethnicity.”
High-risk APOL1 genotypes confer a 5- to 10-fold increased risk for CKD and are found in one out of seven individuals of African ancestry, which means the focus has largely been on testing those with that ancestry.
However, with many unknowns about APOL1, the NKF panel did not want to “profile” individuals and suggest that testing should not be based on skin color or race/ethnicity, said Dr. Franceschini.
In addition, only about 10% of those with the variant develop disease, so testing is not currently warranted for those who do not already have kidney disease, said the group.
They also recommended against the use of polygenic risk scores, saying that there are not enough data from diverse populations in genome-wide association studies for kidney disease or on their clinical utility.
More Education Needed; Many Barriers
The authors acknowledged that nephrologists generally receive little education in genetics and lack support for interpreting and discussing results.
“Nephrologists should be provided with training and best practice resources to interpret genetic testing and discuss the results with individuals and their families,” they wrote, adding that there’s a need for genomic medicine boards at academic centers that would be available to help nephrologists interpret results and plot clinical management.
The group did not, however, cite some of the other barriers to adoption of testing, including a limited number of sites offering testing, cost, and lack of insurance coverage for the diagnostics.
Medicare may cover genetic testing for kidney disease when an individual has symptoms and there is a Food and Drug Administration–approved test. Joseph Vassalotti, MD, chief medical officer for the NKF, said private insurance may cover the testing if the nephrologist deems it medically necessary, but that he usually confirms coverage before initiating testing. The often-used Renasight panel, which tests for 385 genes related to kidney diseases, costs $300-$400 out of pocket, Dr. Vassalotti told this news organization.
In a survey of 149 nephrologists conducted in 2021, both users (46%) and nonusers of the tests (69%) said that high cost was the most significant perceived barrier to implementing widespread testing. A third of users and almost two thirds of nonusers said that poor availability or lack of ease of testing was the second most significant barrier.
Clinics that test for kidney genes “are largely confined to large academic centers and some specialty clinics,” said Dominic Raj, MD, the Bert B. Brooks chair, and Divya Shankaranarayanan, MD, director of the Kidney Precision Medicine Clinic, both at George Washington University School of Medicine & Health Sciences, Washington, DC, in an email.
Testing is also limited by cultural barriers, lack of genetic literacy, and patients’ concerns that a positive result could lead to a loss of health insurance coverage, said Dr. Raj and Dr. Shankaranarayanan.
Paper Will Help Expand Use
A lack of consensus has also held back expansion. The new statement “may lead to increased and possibly judicious utilization of genetic testing in nephrology practices,” said Dr. Raj and Dr. Shankaranarayanan. “Most importantly, the panel has given specific guidance as to what type of genetic test platform is likely to yield the best and most cost-effective yield.”
The most effective use is “in monogenic kidney diseases and to a lesser extent in oligogenic kidney disease,” said Dr. Raj and Dr. Shankaranarayanan, adding that testing is of less-certain utility in polygenic kidney diseases, “where complex genetic and epigenetic factors determine the phenotype.”
Genetic testing might be especially useful “in atypical clinical presentations” and can help clinicians avoid unnecessary expensive and extensive investigations when multiple organ systems are involved, they said.
“Most importantly, [testing] might prevent unnecessary and potentially harmful treatment and enable targeted specific treatment, when available,” said Dr. Raj and Dr. Shankaranarayanan.
Dr. Franceschini and Dr. Shankaranarayanan reported no relevant financial relationships. Dr. Raj disclosed that he received consulting fees and honoraria from Novo Nordisk and is a national leader for the company’s Zeus trial, studying whether ziltivekimab reduces the risk for cardiovascular events in cardiovascular disease, CKD, and inflammation. He also participated in a study of Natera’s Renasight, a 385-gene panel for kidney disease.
A version of this article first appeared on Medscape.com.
A new consensus statement recommended genetic testing for all categories of kidney diseases whenever a genetic cause is suspected and offered guidance on who to test, which tests are the most useful, and how to talk to patients about results.
The statement, published online in the American Journal of Kidney Diseases, is the work of four dozen authors — including patients, nephrologists, experts in clinical and laboratory genetics, kidney pathology, genetic counseling, and ethics. The experts were brought together by the National Kidney Foundation (NKF) with the goal of broadening use and understanding of the tests.
About 10% or more of kidney diseases in adults and 70% of selected chronic kidney diseases (CKDs) in children have genetic causes. But nephrologists have reported a lack of education about genetic testing, and other barriers to wider use, including limited access to testing, cost, insurance coverage, and a small number of genetic counselors who are versed in kidney genetics.
Genetic testing “in the kidney field is a little less developed than in other fields,” said co–lead author Nora Franceschini, MD, MPH, a professor of epidemiology at the University of North Carolina Gillings School of Global Public Health, Chapel Hill, and a nephrologist who studies the genetic epidemiology of hypertension and kidney and cardiovascular diseases.
There are already many known variants that play a role in various kidney diseases and more are on the horizon, Dr. Franceschini told this news organization. More genetic tests will be available in the near future. “The workforce needs to be prepared,” she said.
The statement is an initial step that gets clinicians thinking about testing in a more systematic way, said Dr. Franceschini. “Genetic testing is just another test that physicians can use to complete the story when evaluating patients.
“I think clinicians are ready to implement” testing, said Dr. Franceschini. “We just need to have better guidance.”
Who, When, What to Test
The NKF statement is not the first to try to address gaps in use and knowledge. A European Renal Association Working Group published guidelines in 2022.
The NKF Working Group came up with 56 recommendations and separate algorithms to guide testing for adult and pediatric individuals who are considered at-risk (and currently asymptomatic) and for those who already have clinical disease.
Testing can help determine a cause if there’s an atypical clinical presentation, and it can help avoid biopsies, said the group. Tests can also guide choice of therapy.
For at-risk individuals, there are two broad situations in which testing might be considered: In family members of a patient who already has kidney disease and in potential kidney donors. But testing at-risk children younger than 18 years should only be done if there is an intervention available that could prevent, treat, or slow progression of disease, said the authors.
For patients with an established genetic diagnosis, at-risk family members should be tested with the known single-gene variant diagnostic instead of a broad panel, said the group.
Single-gene variant testing is most appropriate in situations when clinical disease is already evident or when there is known genetic disease in the family, according to the NKF panel. A large diagnostic panel that covers the many common genetic causes of kidney disease is recommended for the majority of patients.
The group recommended that apolipoprotein L1 (APOL1) testing should be included in gene panels for CKD, and it should be offered to any patient “with clinical findings suggestive of APOL1-association nephropathy, regardless of race and ethnicity.”
High-risk APOL1 genotypes confer a 5- to 10-fold increased risk for CKD and are found in one out of seven individuals of African ancestry, which means the focus has largely been on testing those with that ancestry.
However, with many unknowns about APOL1, the NKF panel did not want to “profile” individuals and suggest that testing should not be based on skin color or race/ethnicity, said Dr. Franceschini.
In addition, only about 10% of those with the variant develop disease, so testing is not currently warranted for those who do not already have kidney disease, said the group.
They also recommended against the use of polygenic risk scores, saying that there are not enough data from diverse populations in genome-wide association studies for kidney disease or on their clinical utility.
More Education Needed; Many Barriers
The authors acknowledged that nephrologists generally receive little education in genetics and lack support for interpreting and discussing results.
“Nephrologists should be provided with training and best practice resources to interpret genetic testing and discuss the results with individuals and their families,” they wrote, adding that there’s a need for genomic medicine boards at academic centers that would be available to help nephrologists interpret results and plot clinical management.
The group did not, however, cite some of the other barriers to adoption of testing, including a limited number of sites offering testing, cost, and lack of insurance coverage for the diagnostics.
Medicare may cover genetic testing for kidney disease when an individual has symptoms and there is a Food and Drug Administration–approved test. Joseph Vassalotti, MD, chief medical officer for the NKF, said private insurance may cover the testing if the nephrologist deems it medically necessary, but that he usually confirms coverage before initiating testing. The often-used Renasight panel, which tests for 385 genes related to kidney diseases, costs $300-$400 out of pocket, Dr. Vassalotti told this news organization.
In a survey of 149 nephrologists conducted in 2021, both users (46%) and nonusers of the tests (69%) said that high cost was the most significant perceived barrier to implementing widespread testing. A third of users and almost two thirds of nonusers said that poor availability or lack of ease of testing was the second most significant barrier.
Clinics that test for kidney genes “are largely confined to large academic centers and some specialty clinics,” said Dominic Raj, MD, the Bert B. Brooks chair, and Divya Shankaranarayanan, MD, director of the Kidney Precision Medicine Clinic, both at George Washington University School of Medicine & Health Sciences, Washington, DC, in an email.
Testing is also limited by cultural barriers, lack of genetic literacy, and patients’ concerns that a positive result could lead to a loss of health insurance coverage, said Dr. Raj and Dr. Shankaranarayanan.
Paper Will Help Expand Use
A lack of consensus has also held back expansion. The new statement “may lead to increased and possibly judicious utilization of genetic testing in nephrology practices,” said Dr. Raj and Dr. Shankaranarayanan. “Most importantly, the panel has given specific guidance as to what type of genetic test platform is likely to yield the best and most cost-effective yield.”
The most effective use is “in monogenic kidney diseases and to a lesser extent in oligogenic kidney disease,” said Dr. Raj and Dr. Shankaranarayanan, adding that testing is of less-certain utility in polygenic kidney diseases, “where complex genetic and epigenetic factors determine the phenotype.”
Genetic testing might be especially useful “in atypical clinical presentations” and can help clinicians avoid unnecessary expensive and extensive investigations when multiple organ systems are involved, they said.
“Most importantly, [testing] might prevent unnecessary and potentially harmful treatment and enable targeted specific treatment, when available,” said Dr. Raj and Dr. Shankaranarayanan.
Dr. Franceschini and Dr. Shankaranarayanan reported no relevant financial relationships. Dr. Raj disclosed that he received consulting fees and honoraria from Novo Nordisk and is a national leader for the company’s Zeus trial, studying whether ziltivekimab reduces the risk for cardiovascular events in cardiovascular disease, CKD, and inflammation. He also participated in a study of Natera’s Renasight, a 385-gene panel for kidney disease.
A version of this article first appeared on Medscape.com.
FROM THE AMERICAN JOURNAL OF KIDNEY DISEASES
Free Med School Alone Won’t Boost Diversity
This transcript has been edited for clarity.
We need more diverse students — more students from disadvantaged and underrepresented backgrounds in medical school. That is not a controversial take. That’s not even a new thought.
What is a hot take, however, is that free medical school alone is not going to accomplish this goal. In fact, based on data and what people think and are saying, that’s just reality.
I recently chatted about whether or not free medical school would motivate more students to pursue primary care. That was New York University’s (NYU’s) goal. If you haven’t seen that video, check it out. Now I want to explore whether free medical school would actually create a more diverse medical student body.
This topic is especially important now because, in 2023, the Supreme Court ended affirmative action for college admissions, and this naturally has a downstream effect when it comes to getting into medical school. Right now, about 6% of US physicians are Black or Hispanic/Latina, and around 0.1%-0.3% identify as Indigenous Americans, Native Hawaiians, or Pacific Islanders.
Is free medical school the answer? Well, that’s based on a huge assumption that the cost of medical school — incoming debt — is the single greatest barrier for students from diverse backgrounds, as if every single student from every background had the same level of resources in the same opportunity and were all equally competitive prior to applying, and just the prospect of debt is what caused the disparity. I don’t know if that’s reality. Let’s take a look at NYU.
After the free tuition announcement, total applications to the medical school went up nearly 50%. And from underrepresented groups, it was 100%. In 2019, the associate dean for admissions said, “A key driver was to remove a financial disincentive that dissuades people from pursuing a path in medicine.” But the acceptance rate stayed under 3%, and the average Medical College Admission Test (MCAT) and grade point average (GPA) to get in went up. Basically, the school just became more competitive.
I will always commend anyone, anywhere, who is making medical school more affordable and more accessible. With NYU, it seems a tuition gift just made it harder for students from disadvantaged backgrounds to actually get in. I mean, congratulations, you got more applications. This probably helped in ratings, and you got mentioned in news headlines, but are you actually achieving your mission?
At NYU, over the last few years, Black students made up about 11% of the medical school class, which is actually down from 2017 before the tuition gift. Students from low-income backgrounds, whom this would really benefit, used to make up around 12% of the class prior to the free tuition announcement, and now it’s around 3%-7%.
According to students from underrepresented backgrounds, the outreach and the equal opportunity need to start way earlier. The K-12 process needs to be addressed, as do mentorship opportunities and guidance throughout college, MCAT prep, resources for interviews, research opportunities, and so much more.
The following quote is from an interview with an interventional cardiology fellow who came here as a refugee: “For me, growing up, basic necessities like a quiet study space, high-speed internet, healthy meals and proper sleep were luxuries of which I could only dream. After resettling in the US as a political refugee, I lived in circumstances where such comforts were out of reach, and my path to medical school seemed insurmountable.”
I also spoke to a friend in pediatric cancer, Michael Galvez, MD, who was outspoken about the need to improve representation in medicine, about what he thought would actually work to diversify medical schools. He mentioned adversity scores or looking at the distance traveled for applicants, as well as efforts to recruit from local, state, and community colleges, which often reflect local underserved populations.
Dr. Galvez also agreed that although such metrics as GPA and MCAT are important, medical schools should also consider the impact applicants may have had for local, underserved communities and life experiences that may represent significant potential contributions applicants can make for public health.
The effort needs to start early. If we take a look at one of the most diverse medical schools in the country, UC Davis, we can see how this makes a difference. At UC Davis, in the class of 2026, about half of the 133 students come from underrepresented backgrounds in medicine. I’m taking a look at their website from the Office of Student and Resident Diversity, and it lists:
- K-12 outreach programs
- Undergraduate and community college programs
- Specific plans for postbaccalaureate students
- Support systems
- Resources for students that extend far beyond just premedical students
My home institution, Stanford School of Medicine, has similar programs as well, with similar ways for students from underrepresented backgrounds to find support and mentorship. This all makes a huge difference.
Regarding the actual admissions process for medical school, I’ll highlight the Johns Hopkins School of Medicine and the adaptions they’ve made to create a more fair and holistic process. It includes:
- A clear mission statement about diversity enhancement
- Anonymous voting
- A larger group to avoid bias
- Not showing academic metrics to interviewers
- Implicit association tests and trainings
- Removing photos from applications
- Appointing women, minorities, and young people with less implicit bias to the committees
Does this seem like a lot? It is, because a comprehensive approach is what it takes to build a more diverse US physician workforce, which will provide more culturally competent care, empower future generations, break down barriers and disparities in health care, and ultimately improve public health. Free tuition is awesome. I’m jealous. But on its own to solve these problems? This all feels like a misguided attempt.
Dr. Patel is clinical instructor, Department of Pediatrics, Columbia University College of Physicians and Surgeons, and pediatric hospitalist at Morgan Stanley Children’s Hospital of NewYork-Presbyterian, New York, and Benioff Children’s Hospital, University of California, San Francisco. He disclosed ties with Medumo Inc.
A version of this article first appeared on Medscape.com.
This transcript has been edited for clarity.
We need more diverse students — more students from disadvantaged and underrepresented backgrounds in medical school. That is not a controversial take. That’s not even a new thought.
What is a hot take, however, is that free medical school alone is not going to accomplish this goal. In fact, based on data and what people think and are saying, that’s just reality.
I recently chatted about whether or not free medical school would motivate more students to pursue primary care. That was New York University’s (NYU’s) goal. If you haven’t seen that video, check it out. Now I want to explore whether free medical school would actually create a more diverse medical student body.
This topic is especially important now because, in 2023, the Supreme Court ended affirmative action for college admissions, and this naturally has a downstream effect when it comes to getting into medical school. Right now, about 6% of US physicians are Black or Hispanic/Latina, and around 0.1%-0.3% identify as Indigenous Americans, Native Hawaiians, or Pacific Islanders.
Is free medical school the answer? Well, that’s based on a huge assumption that the cost of medical school — incoming debt — is the single greatest barrier for students from diverse backgrounds, as if every single student from every background had the same level of resources in the same opportunity and were all equally competitive prior to applying, and just the prospect of debt is what caused the disparity. I don’t know if that’s reality. Let’s take a look at NYU.
After the free tuition announcement, total applications to the medical school went up nearly 50%. And from underrepresented groups, it was 100%. In 2019, the associate dean for admissions said, “A key driver was to remove a financial disincentive that dissuades people from pursuing a path in medicine.” But the acceptance rate stayed under 3%, and the average Medical College Admission Test (MCAT) and grade point average (GPA) to get in went up. Basically, the school just became more competitive.
I will always commend anyone, anywhere, who is making medical school more affordable and more accessible. With NYU, it seems a tuition gift just made it harder for students from disadvantaged backgrounds to actually get in. I mean, congratulations, you got more applications. This probably helped in ratings, and you got mentioned in news headlines, but are you actually achieving your mission?
At NYU, over the last few years, Black students made up about 11% of the medical school class, which is actually down from 2017 before the tuition gift. Students from low-income backgrounds, whom this would really benefit, used to make up around 12% of the class prior to the free tuition announcement, and now it’s around 3%-7%.
According to students from underrepresented backgrounds, the outreach and the equal opportunity need to start way earlier. The K-12 process needs to be addressed, as do mentorship opportunities and guidance throughout college, MCAT prep, resources for interviews, research opportunities, and so much more.
The following quote is from an interview with an interventional cardiology fellow who came here as a refugee: “For me, growing up, basic necessities like a quiet study space, high-speed internet, healthy meals and proper sleep were luxuries of which I could only dream. After resettling in the US as a political refugee, I lived in circumstances where such comforts were out of reach, and my path to medical school seemed insurmountable.”
I also spoke to a friend in pediatric cancer, Michael Galvez, MD, who was outspoken about the need to improve representation in medicine, about what he thought would actually work to diversify medical schools. He mentioned adversity scores or looking at the distance traveled for applicants, as well as efforts to recruit from local, state, and community colleges, which often reflect local underserved populations.
Dr. Galvez also agreed that although such metrics as GPA and MCAT are important, medical schools should also consider the impact applicants may have had for local, underserved communities and life experiences that may represent significant potential contributions applicants can make for public health.
The effort needs to start early. If we take a look at one of the most diverse medical schools in the country, UC Davis, we can see how this makes a difference. At UC Davis, in the class of 2026, about half of the 133 students come from underrepresented backgrounds in medicine. I’m taking a look at their website from the Office of Student and Resident Diversity, and it lists:
- K-12 outreach programs
- Undergraduate and community college programs
- Specific plans for postbaccalaureate students
- Support systems
- Resources for students that extend far beyond just premedical students
My home institution, Stanford School of Medicine, has similar programs as well, with similar ways for students from underrepresented backgrounds to find support and mentorship. This all makes a huge difference.
Regarding the actual admissions process for medical school, I’ll highlight the Johns Hopkins School of Medicine and the adaptions they’ve made to create a more fair and holistic process. It includes:
- A clear mission statement about diversity enhancement
- Anonymous voting
- A larger group to avoid bias
- Not showing academic metrics to interviewers
- Implicit association tests and trainings
- Removing photos from applications
- Appointing women, minorities, and young people with less implicit bias to the committees
Does this seem like a lot? It is, because a comprehensive approach is what it takes to build a more diverse US physician workforce, which will provide more culturally competent care, empower future generations, break down barriers and disparities in health care, and ultimately improve public health. Free tuition is awesome. I’m jealous. But on its own to solve these problems? This all feels like a misguided attempt.
Dr. Patel is clinical instructor, Department of Pediatrics, Columbia University College of Physicians and Surgeons, and pediatric hospitalist at Morgan Stanley Children’s Hospital of NewYork-Presbyterian, New York, and Benioff Children’s Hospital, University of California, San Francisco. He disclosed ties with Medumo Inc.
A version of this article first appeared on Medscape.com.
This transcript has been edited for clarity.
We need more diverse students — more students from disadvantaged and underrepresented backgrounds in medical school. That is not a controversial take. That’s not even a new thought.
What is a hot take, however, is that free medical school alone is not going to accomplish this goal. In fact, based on data and what people think and are saying, that’s just reality.
I recently chatted about whether or not free medical school would motivate more students to pursue primary care. That was New York University’s (NYU’s) goal. If you haven’t seen that video, check it out. Now I want to explore whether free medical school would actually create a more diverse medical student body.
This topic is especially important now because, in 2023, the Supreme Court ended affirmative action for college admissions, and this naturally has a downstream effect when it comes to getting into medical school. Right now, about 6% of US physicians are Black or Hispanic/Latina, and around 0.1%-0.3% identify as Indigenous Americans, Native Hawaiians, or Pacific Islanders.
Is free medical school the answer? Well, that’s based on a huge assumption that the cost of medical school — incoming debt — is the single greatest barrier for students from diverse backgrounds, as if every single student from every background had the same level of resources in the same opportunity and were all equally competitive prior to applying, and just the prospect of debt is what caused the disparity. I don’t know if that’s reality. Let’s take a look at NYU.
After the free tuition announcement, total applications to the medical school went up nearly 50%. And from underrepresented groups, it was 100%. In 2019, the associate dean for admissions said, “A key driver was to remove a financial disincentive that dissuades people from pursuing a path in medicine.” But the acceptance rate stayed under 3%, and the average Medical College Admission Test (MCAT) and grade point average (GPA) to get in went up. Basically, the school just became more competitive.
I will always commend anyone, anywhere, who is making medical school more affordable and more accessible. With NYU, it seems a tuition gift just made it harder for students from disadvantaged backgrounds to actually get in. I mean, congratulations, you got more applications. This probably helped in ratings, and you got mentioned in news headlines, but are you actually achieving your mission?
At NYU, over the last few years, Black students made up about 11% of the medical school class, which is actually down from 2017 before the tuition gift. Students from low-income backgrounds, whom this would really benefit, used to make up around 12% of the class prior to the free tuition announcement, and now it’s around 3%-7%.
According to students from underrepresented backgrounds, the outreach and the equal opportunity need to start way earlier. The K-12 process needs to be addressed, as do mentorship opportunities and guidance throughout college, MCAT prep, resources for interviews, research opportunities, and so much more.
The following quote is from an interview with an interventional cardiology fellow who came here as a refugee: “For me, growing up, basic necessities like a quiet study space, high-speed internet, healthy meals and proper sleep were luxuries of which I could only dream. After resettling in the US as a political refugee, I lived in circumstances where such comforts were out of reach, and my path to medical school seemed insurmountable.”
I also spoke to a friend in pediatric cancer, Michael Galvez, MD, who was outspoken about the need to improve representation in medicine, about what he thought would actually work to diversify medical schools. He mentioned adversity scores or looking at the distance traveled for applicants, as well as efforts to recruit from local, state, and community colleges, which often reflect local underserved populations.
Dr. Galvez also agreed that although such metrics as GPA and MCAT are important, medical schools should also consider the impact applicants may have had for local, underserved communities and life experiences that may represent significant potential contributions applicants can make for public health.
The effort needs to start early. If we take a look at one of the most diverse medical schools in the country, UC Davis, we can see how this makes a difference. At UC Davis, in the class of 2026, about half of the 133 students come from underrepresented backgrounds in medicine. I’m taking a look at their website from the Office of Student and Resident Diversity, and it lists:
- K-12 outreach programs
- Undergraduate and community college programs
- Specific plans for postbaccalaureate students
- Support systems
- Resources for students that extend far beyond just premedical students
My home institution, Stanford School of Medicine, has similar programs as well, with similar ways for students from underrepresented backgrounds to find support and mentorship. This all makes a huge difference.
Regarding the actual admissions process for medical school, I’ll highlight the Johns Hopkins School of Medicine and the adaptions they’ve made to create a more fair and holistic process. It includes:
- A clear mission statement about diversity enhancement
- Anonymous voting
- A larger group to avoid bias
- Not showing academic metrics to interviewers
- Implicit association tests and trainings
- Removing photos from applications
- Appointing women, minorities, and young people with less implicit bias to the committees
Does this seem like a lot? It is, because a comprehensive approach is what it takes to build a more diverse US physician workforce, which will provide more culturally competent care, empower future generations, break down barriers and disparities in health care, and ultimately improve public health. Free tuition is awesome. I’m jealous. But on its own to solve these problems? This all feels like a misguided attempt.
Dr. Patel is clinical instructor, Department of Pediatrics, Columbia University College of Physicians and Surgeons, and pediatric hospitalist at Morgan Stanley Children’s Hospital of NewYork-Presbyterian, New York, and Benioff Children’s Hospital, University of California, San Francisco. He disclosed ties with Medumo Inc.
A version of this article first appeared on Medscape.com.
Why Is Mom’s Type 1 Diabetes Half as Likely as Dad’s to Pass to Child?
TOPLINE:
METHODOLOGY:
- Individuals with a family history of type 1 diabetes face 8-15 times higher risk for this condition than the general population, with the risk of inheritance from mothers with type 1 diabetes being about half that of fathers with type 1 diabetes; however, it is unclear if the effect continues past childhood and what is responsible for the difference in risk.
- Researchers performed a meta-analysis across five cohort studies involving 11,475 individuals diagnosed with type 1 diabetes aged 0-88 years to evaluate if maternal type 1 diabetes conferred relative protection only to young children.
- They compared the proportion of individuals with type 1 diabetes with affected fathers versus mothers and explored if this comparison was altered by the age at diagnosis and the timing of parental diagnosis relative to the birth of the offspring.
- Lastly, the inherited genetic risk for type 1 diabetes was compared between those with affected mothers versus fathers using a risk score composed of more than 60 different gene variants associated with type 1 diabetes.
TAKEAWAY:
- Individuals with type 1 diabetes were almost twice as likely to have a father with the condition than a mother (odds ratio, 1.79; P < .0001).
- The protective effect of maternal diabetes was seen regardless of whether the individuals were diagnosed with type 1 diabetes before or after age 18 years (P < .0001).
- Maternal diabetes was linked to a lower risk for type 1 diabetes in children only if the mother had type 1 diabetes during pregnancy.
- The genetic risk score for type 1 diabetes was not significantly different between those with affected fathers versus mothers (P = .31).
IN PRACTICE:
“Understanding why having a mother compared with a father with type 1 diabetes offers a relative protection against type 1 diabetes could help us develop new ways to prevent type 1 diabetes, such as treatments that mimic some of the protective elements from mothers,” study author Lowri Allen, MBChB, said in a news release.
SOURCE:
The study was led by Dr. Allen from the Diabetes Research Group, Cardiff University, Cardiff, Wales, and was published as an early release from the annual meeting of the European Association for the Study of Diabetes.
LIMITATIONS:
This abstract did not discuss any limitations. The number of individuals and parents with type 1 diabetes in the meta-analysis was not disclosed. The baseline risk for type 1 diabetes among individuals with a mother, father, or both or no parent with type 1 diabetes was not disclosed. The number of people with type 1 diabetes under and over age 18 was not disclosed, nor were the numbers of mothers and fathers with type 1 diabetes. The relative risk in individuals having no parent with type 1 diabetes was not disclosed. Moreover, the race and ethnicity of the study populations were not disclosed.
DISCLOSURES:
The Wellcome Trust supported this study. The authors declared no relevant conflicts of interest.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.
TOPLINE:
METHODOLOGY:
- Individuals with a family history of type 1 diabetes face 8-15 times higher risk for this condition than the general population, with the risk of inheritance from mothers with type 1 diabetes being about half that of fathers with type 1 diabetes; however, it is unclear if the effect continues past childhood and what is responsible for the difference in risk.
- Researchers performed a meta-analysis across five cohort studies involving 11,475 individuals diagnosed with type 1 diabetes aged 0-88 years to evaluate if maternal type 1 diabetes conferred relative protection only to young children.
- They compared the proportion of individuals with type 1 diabetes with affected fathers versus mothers and explored if this comparison was altered by the age at diagnosis and the timing of parental diagnosis relative to the birth of the offspring.
- Lastly, the inherited genetic risk for type 1 diabetes was compared between those with affected mothers versus fathers using a risk score composed of more than 60 different gene variants associated with type 1 diabetes.
TAKEAWAY:
- Individuals with type 1 diabetes were almost twice as likely to have a father with the condition than a mother (odds ratio, 1.79; P < .0001).
- The protective effect of maternal diabetes was seen regardless of whether the individuals were diagnosed with type 1 diabetes before or after age 18 years (P < .0001).
- Maternal diabetes was linked to a lower risk for type 1 diabetes in children only if the mother had type 1 diabetes during pregnancy.
- The genetic risk score for type 1 diabetes was not significantly different between those with affected fathers versus mothers (P = .31).
IN PRACTICE:
“Understanding why having a mother compared with a father with type 1 diabetes offers a relative protection against type 1 diabetes could help us develop new ways to prevent type 1 diabetes, such as treatments that mimic some of the protective elements from mothers,” study author Lowri Allen, MBChB, said in a news release.
SOURCE:
The study was led by Dr. Allen from the Diabetes Research Group, Cardiff University, Cardiff, Wales, and was published as an early release from the annual meeting of the European Association for the Study of Diabetes.
LIMITATIONS:
This abstract did not discuss any limitations. The number of individuals and parents with type 1 diabetes in the meta-analysis was not disclosed. The baseline risk for type 1 diabetes among individuals with a mother, father, or both or no parent with type 1 diabetes was not disclosed. The number of people with type 1 diabetes under and over age 18 was not disclosed, nor were the numbers of mothers and fathers with type 1 diabetes. The relative risk in individuals having no parent with type 1 diabetes was not disclosed. Moreover, the race and ethnicity of the study populations were not disclosed.
DISCLOSURES:
The Wellcome Trust supported this study. The authors declared no relevant conflicts of interest.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.
TOPLINE:
METHODOLOGY:
- Individuals with a family history of type 1 diabetes face 8-15 times higher risk for this condition than the general population, with the risk of inheritance from mothers with type 1 diabetes being about half that of fathers with type 1 diabetes; however, it is unclear if the effect continues past childhood and what is responsible for the difference in risk.
- Researchers performed a meta-analysis across five cohort studies involving 11,475 individuals diagnosed with type 1 diabetes aged 0-88 years to evaluate if maternal type 1 diabetes conferred relative protection only to young children.
- They compared the proportion of individuals with type 1 diabetes with affected fathers versus mothers and explored if this comparison was altered by the age at diagnosis and the timing of parental diagnosis relative to the birth of the offspring.
- Lastly, the inherited genetic risk for type 1 diabetes was compared between those with affected mothers versus fathers using a risk score composed of more than 60 different gene variants associated with type 1 diabetes.
TAKEAWAY:
- Individuals with type 1 diabetes were almost twice as likely to have a father with the condition than a mother (odds ratio, 1.79; P < .0001).
- The protective effect of maternal diabetes was seen regardless of whether the individuals were diagnosed with type 1 diabetes before or after age 18 years (P < .0001).
- Maternal diabetes was linked to a lower risk for type 1 diabetes in children only if the mother had type 1 diabetes during pregnancy.
- The genetic risk score for type 1 diabetes was not significantly different between those with affected fathers versus mothers (P = .31).
IN PRACTICE:
“Understanding why having a mother compared with a father with type 1 diabetes offers a relative protection against type 1 diabetes could help us develop new ways to prevent type 1 diabetes, such as treatments that mimic some of the protective elements from mothers,” study author Lowri Allen, MBChB, said in a news release.
SOURCE:
The study was led by Dr. Allen from the Diabetes Research Group, Cardiff University, Cardiff, Wales, and was published as an early release from the annual meeting of the European Association for the Study of Diabetes.
LIMITATIONS:
This abstract did not discuss any limitations. The number of individuals and parents with type 1 diabetes in the meta-analysis was not disclosed. The baseline risk for type 1 diabetes among individuals with a mother, father, or both or no parent with type 1 diabetes was not disclosed. The number of people with type 1 diabetes under and over age 18 was not disclosed, nor were the numbers of mothers and fathers with type 1 diabetes. The relative risk in individuals having no parent with type 1 diabetes was not disclosed. Moreover, the race and ethnicity of the study populations were not disclosed.
DISCLOSURES:
The Wellcome Trust supported this study. The authors declared no relevant conflicts of interest.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.
IRL Togetherness: Family Media Options and Agreements
In July, the United States Senate passed the Kids Online Safety Act, which will need to be taken up and passed by the House prior to becoming law. This bill was designed based on emerging research showing how social media impacts the developing regions of the adolescent brain, including those involved in the growing “stop and think” pathways.
Whether this bill is passed or not, parents are already having conversations with their children’s primary care providers about how to navigate digital versus In Real Life (IRL) aspects of parenting. Why should families and primary care providers care about creating opportunities to put down devices together? We have few new ways of explaining social media’s impact on adolescent development. These angles can empower families and give tweens an increased sense of efficacy around family social media agreements. Dr. Mitch Prinstein (chief science officer for the American Psychological Association) explains how apps take children’s data from other apps to make a profit.1 When kids understand what motivates technology companies, they are more likely to buy into efforts to curtail use. He also explains that adolescent brain size and function decreases with increased social media use and resulting lack of sleep.2
Prioritizing IRL togetherness is increasingly showing up in media itself. In Inside Out 2 the coach collects players’ phones at the beginning of their intensive training weekend, allowing for Riley to have IRL social successes and failures, and resulting growth. Gather, a recently published young adult novel by Kenneth M. Cadow, is written from the perspective of Ian Gray, a teen whose mother struggles with addiction. We experience Ian’s perspective at the house of a friend. This fictional family all put their devices in a basket upon entering their home, allowing the family to interact in a more present and positive way with one another.
Increasingly, social media use is being recognized as a societal, rather than simply an individual problem. Smartphones are being banned in middle schools as there is growing recognition that students cannot learn when they have such easy access to addictive apps. More families are choosing options for the right amount of connectivity for a child’s developmental level by waiting on devices altogether or by purchasing devices without access to social media like flip phones, Gabb phones and watches, using the Bark app, and similar alternatives to fully connected devices.
Parental anxiety plays a role as well. Some of the devices listed above allow for parents to listen in on their child’s device if, for example, the child does not answer the phone. While this may potentially be important if a child requires additional support, for example with a higher-need developmental disability, for those with typical development, it robs children of independence.
What can be done about these huge technology pressures in a 15-minute primary care visit as we await more science to inform laws governing social media’s influence on child development?
Enter the Family Media Agreement. Media agreements for kids have been around for years, and there is growing understanding that when parents follow similar rules to put down devices and be present at home, adolescents are more amenable to follow suit. It’s a communication tool for parents and their growing children to help determine right-sized parameters around device and social media use.
Primary care providers can have paper copies of these available. There are also online options that can be updated as needed. Primary care providers might follow up at the next visit to see how the agreement, and more importantly mixing ideas and communication around the agreement, is working. Providers can explain that these agreements are documents that are expected to be changed with time as family needs evolve. They can help not only set rules but provide an opportunity to practice transferring more autonomy over time, as the child reaches different stages of development. Some frequently used Family Media Agreements are available to print through Common Sense Media,3 or online through the American Academy of Pediatrics’ healthychildren.org website.4
Ultimately, if children call their parents every time they are faced with a problem, rather than looking around for a helpful person or problem solving on their own, they miss a chance to practice developing skills needed as an adult. If an adult listens in on a child’s life rather than waiting to have a conversation, the adult misses out on the opportunity to experience and instill trust that the child can handle adversity and gain age-appropriate independence. Similarly, if kids become too focused on social media “likes” to engage in noticing and being friendly and helpful to those around them, as Dr. Prinstein points out in his workbook for tweens and parents, Like Ability,5 they are not developing the skills needed to build a society where we all have an opportunity to thrive and build what is needed together. In the setting of addictive products capturing everyone’s attention, Family Media Agreements are a concrete place to start these conversations: Clinicians can empower families and growing adolescents to reclaim their time for their own IRL priorities.
Dr. Spottswood is a child psychiatrist practicing in an integrated care clinic at the Community Health Centers of Burlington, Vermont, a Federally Qualified Health Center. She is also the medical director of the Vermont Child Psychiatry Access Program and a clinical assistant professor in the department of psychiatry at the University of Vermont.
References
1. Raffoul A et al. Social media platforms generate billions of dollars in revenue from U.S. youth: Findings from a simulated revenue model. PLoS One. 2023 Dec 27;18(12):e0295337. doi: 10.1371/journal.pone.0295337.
2. Telzer EH et al. Sleep variability in adolescence is associated with altered brain development. Dev Cogn Neurosci. 2015 Aug:14:16-22. doi: 10.1016/j.dcn.2015.05.007.
3. Common Sense Family Media Agreement. https://www.commonsensemedia.org/sites/default/files/featured-content/files/common_sense_family_media_agreement.pdf.
4. Healthy Children Family Media Plan. https://www.healthychildren.org/English/fmp/Pages/MediaPlan.aspx.
5. Getz L, Prinstein M. Like Ability: The Truth About Popularity. Washington: Magination Press, 2022. https://www.apa.org/pubs/magination/like-ability.
In July, the United States Senate passed the Kids Online Safety Act, which will need to be taken up and passed by the House prior to becoming law. This bill was designed based on emerging research showing how social media impacts the developing regions of the adolescent brain, including those involved in the growing “stop and think” pathways.
Whether this bill is passed or not, parents are already having conversations with their children’s primary care providers about how to navigate digital versus In Real Life (IRL) aspects of parenting. Why should families and primary care providers care about creating opportunities to put down devices together? We have few new ways of explaining social media’s impact on adolescent development. These angles can empower families and give tweens an increased sense of efficacy around family social media agreements. Dr. Mitch Prinstein (chief science officer for the American Psychological Association) explains how apps take children’s data from other apps to make a profit.1 When kids understand what motivates technology companies, they are more likely to buy into efforts to curtail use. He also explains that adolescent brain size and function decreases with increased social media use and resulting lack of sleep.2
Prioritizing IRL togetherness is increasingly showing up in media itself. In Inside Out 2 the coach collects players’ phones at the beginning of their intensive training weekend, allowing for Riley to have IRL social successes and failures, and resulting growth. Gather, a recently published young adult novel by Kenneth M. Cadow, is written from the perspective of Ian Gray, a teen whose mother struggles with addiction. We experience Ian’s perspective at the house of a friend. This fictional family all put their devices in a basket upon entering their home, allowing the family to interact in a more present and positive way with one another.
Increasingly, social media use is being recognized as a societal, rather than simply an individual problem. Smartphones are being banned in middle schools as there is growing recognition that students cannot learn when they have such easy access to addictive apps. More families are choosing options for the right amount of connectivity for a child’s developmental level by waiting on devices altogether or by purchasing devices without access to social media like flip phones, Gabb phones and watches, using the Bark app, and similar alternatives to fully connected devices.
Parental anxiety plays a role as well. Some of the devices listed above allow for parents to listen in on their child’s device if, for example, the child does not answer the phone. While this may potentially be important if a child requires additional support, for example with a higher-need developmental disability, for those with typical development, it robs children of independence.
What can be done about these huge technology pressures in a 15-minute primary care visit as we await more science to inform laws governing social media’s influence on child development?
Enter the Family Media Agreement. Media agreements for kids have been around for years, and there is growing understanding that when parents follow similar rules to put down devices and be present at home, adolescents are more amenable to follow suit. It’s a communication tool for parents and their growing children to help determine right-sized parameters around device and social media use.
Primary care providers can have paper copies of these available. There are also online options that can be updated as needed. Primary care providers might follow up at the next visit to see how the agreement, and more importantly mixing ideas and communication around the agreement, is working. Providers can explain that these agreements are documents that are expected to be changed with time as family needs evolve. They can help not only set rules but provide an opportunity to practice transferring more autonomy over time, as the child reaches different stages of development. Some frequently used Family Media Agreements are available to print through Common Sense Media,3 or online through the American Academy of Pediatrics’ healthychildren.org website.4
Ultimately, if children call their parents every time they are faced with a problem, rather than looking around for a helpful person or problem solving on their own, they miss a chance to practice developing skills needed as an adult. If an adult listens in on a child’s life rather than waiting to have a conversation, the adult misses out on the opportunity to experience and instill trust that the child can handle adversity and gain age-appropriate independence. Similarly, if kids become too focused on social media “likes” to engage in noticing and being friendly and helpful to those around them, as Dr. Prinstein points out in his workbook for tweens and parents, Like Ability,5 they are not developing the skills needed to build a society where we all have an opportunity to thrive and build what is needed together. In the setting of addictive products capturing everyone’s attention, Family Media Agreements are a concrete place to start these conversations: Clinicians can empower families and growing adolescents to reclaim their time for their own IRL priorities.
Dr. Spottswood is a child psychiatrist practicing in an integrated care clinic at the Community Health Centers of Burlington, Vermont, a Federally Qualified Health Center. She is also the medical director of the Vermont Child Psychiatry Access Program and a clinical assistant professor in the department of psychiatry at the University of Vermont.
References
1. Raffoul A et al. Social media platforms generate billions of dollars in revenue from U.S. youth: Findings from a simulated revenue model. PLoS One. 2023 Dec 27;18(12):e0295337. doi: 10.1371/journal.pone.0295337.
2. Telzer EH et al. Sleep variability in adolescence is associated with altered brain development. Dev Cogn Neurosci. 2015 Aug:14:16-22. doi: 10.1016/j.dcn.2015.05.007.
3. Common Sense Family Media Agreement. https://www.commonsensemedia.org/sites/default/files/featured-content/files/common_sense_family_media_agreement.pdf.
4. Healthy Children Family Media Plan. https://www.healthychildren.org/English/fmp/Pages/MediaPlan.aspx.
5. Getz L, Prinstein M. Like Ability: The Truth About Popularity. Washington: Magination Press, 2022. https://www.apa.org/pubs/magination/like-ability.
In July, the United States Senate passed the Kids Online Safety Act, which will need to be taken up and passed by the House prior to becoming law. This bill was designed based on emerging research showing how social media impacts the developing regions of the adolescent brain, including those involved in the growing “stop and think” pathways.
Whether this bill is passed or not, parents are already having conversations with their children’s primary care providers about how to navigate digital versus In Real Life (IRL) aspects of parenting. Why should families and primary care providers care about creating opportunities to put down devices together? We have few new ways of explaining social media’s impact on adolescent development. These angles can empower families and give tweens an increased sense of efficacy around family social media agreements. Dr. Mitch Prinstein (chief science officer for the American Psychological Association) explains how apps take children’s data from other apps to make a profit.1 When kids understand what motivates technology companies, they are more likely to buy into efforts to curtail use. He also explains that adolescent brain size and function decreases with increased social media use and resulting lack of sleep.2
Prioritizing IRL togetherness is increasingly showing up in media itself. In Inside Out 2 the coach collects players’ phones at the beginning of their intensive training weekend, allowing for Riley to have IRL social successes and failures, and resulting growth. Gather, a recently published young adult novel by Kenneth M. Cadow, is written from the perspective of Ian Gray, a teen whose mother struggles with addiction. We experience Ian’s perspective at the house of a friend. This fictional family all put their devices in a basket upon entering their home, allowing the family to interact in a more present and positive way with one another.
Increasingly, social media use is being recognized as a societal, rather than simply an individual problem. Smartphones are being banned in middle schools as there is growing recognition that students cannot learn when they have such easy access to addictive apps. More families are choosing options for the right amount of connectivity for a child’s developmental level by waiting on devices altogether or by purchasing devices without access to social media like flip phones, Gabb phones and watches, using the Bark app, and similar alternatives to fully connected devices.
Parental anxiety plays a role as well. Some of the devices listed above allow for parents to listen in on their child’s device if, for example, the child does not answer the phone. While this may potentially be important if a child requires additional support, for example with a higher-need developmental disability, for those with typical development, it robs children of independence.
What can be done about these huge technology pressures in a 15-minute primary care visit as we await more science to inform laws governing social media’s influence on child development?
Enter the Family Media Agreement. Media agreements for kids have been around for years, and there is growing understanding that when parents follow similar rules to put down devices and be present at home, adolescents are more amenable to follow suit. It’s a communication tool for parents and their growing children to help determine right-sized parameters around device and social media use.
Primary care providers can have paper copies of these available. There are also online options that can be updated as needed. Primary care providers might follow up at the next visit to see how the agreement, and more importantly mixing ideas and communication around the agreement, is working. Providers can explain that these agreements are documents that are expected to be changed with time as family needs evolve. They can help not only set rules but provide an opportunity to practice transferring more autonomy over time, as the child reaches different stages of development. Some frequently used Family Media Agreements are available to print through Common Sense Media,3 or online through the American Academy of Pediatrics’ healthychildren.org website.4
Ultimately, if children call their parents every time they are faced with a problem, rather than looking around for a helpful person or problem solving on their own, they miss a chance to practice developing skills needed as an adult. If an adult listens in on a child’s life rather than waiting to have a conversation, the adult misses out on the opportunity to experience and instill trust that the child can handle adversity and gain age-appropriate independence. Similarly, if kids become too focused on social media “likes” to engage in noticing and being friendly and helpful to those around them, as Dr. Prinstein points out in his workbook for tweens and parents, Like Ability,5 they are not developing the skills needed to build a society where we all have an opportunity to thrive and build what is needed together. In the setting of addictive products capturing everyone’s attention, Family Media Agreements are a concrete place to start these conversations: Clinicians can empower families and growing adolescents to reclaim their time for their own IRL priorities.
Dr. Spottswood is a child psychiatrist practicing in an integrated care clinic at the Community Health Centers of Burlington, Vermont, a Federally Qualified Health Center. She is also the medical director of the Vermont Child Psychiatry Access Program and a clinical assistant professor in the department of psychiatry at the University of Vermont.
References
1. Raffoul A et al. Social media platforms generate billions of dollars in revenue from U.S. youth: Findings from a simulated revenue model. PLoS One. 2023 Dec 27;18(12):e0295337. doi: 10.1371/journal.pone.0295337.
2. Telzer EH et al. Sleep variability in adolescence is associated with altered brain development. Dev Cogn Neurosci. 2015 Aug:14:16-22. doi: 10.1016/j.dcn.2015.05.007.
3. Common Sense Family Media Agreement. https://www.commonsensemedia.org/sites/default/files/featured-content/files/common_sense_family_media_agreement.pdf.
4. Healthy Children Family Media Plan. https://www.healthychildren.org/English/fmp/Pages/MediaPlan.aspx.
5. Getz L, Prinstein M. Like Ability: The Truth About Popularity. Washington: Magination Press, 2022. https://www.apa.org/pubs/magination/like-ability.
Most Youths Who Die by Suicide Had No Mental Health Diagnosis
, according to a large analysis of Centers for Disease Control and Prevention data.
Sofia Chaudhary, MD, with the Department of Pediatrics and Emergency Medicine at Emory University School of Medicine in Atlanta, Georgia, and colleagues, analyzed data from the National Violent Death Reporting System and found in the cross-sectional study of 40, 618 youths that 24,192 (59.6%) had no such diagnosis previously. Findings were published online in JAMA Network Open.
Gaps by Race, Sex and Age
The odds of having a mental health diagnosis before death by suicide differed by race and sex. Compared with White youths, the odds were lower among youths who were American Indian or Alaska Native (adjusted odds ratio [aOR], 0.45; Asian, Native Hawaiian, or Other Pacific Islander (aOR, 0.58); and Black youths (aOR, 0.62). And more than half of female youths who died by suicide had a mental health diagnosis (4429 youths [52.4%]), compared with 11,994 male youths (37.3%).
The researchers also found wide gaps by age, specifically lower odds of having a mental health diagnosis before suicide in children ages 10-14 compared with those 20-24.
“This finding is particularly notable because suicide rates have risen to become the second leading cause of death in youths aged 10 to 14 years,” the authors wrote. “Suicide prevention strategies for young children in primary care and community settings should focus on fostering resilience, promoting peer and family connectedness, and empowering children with strategies to cope with stress and adversity.”
Youths who died by firearm suicide, the most common mechanism, had the lowest rate of diagnosis. “Similar to a prior study, we found that decedents without a documented mental health diagnosis were far more likely to utilize a firearm than those with a documented mental health diagnosis,” the authors wrote.
In an invited commentary, Lisa M. Horowitz, PhD, MPH, with the Office of the Clinical Director, Intramural Research Program, National Institute of Mental Health, in Bethesda, Maryland, and colleagues wrote that the data show that identifying youth early who have mental disorders or are at-risk for suicide “is more the exception than the rule” in the United States.
The editorialists highlight that the study showed that about one-quarter of youths who have attempted suicide and nearly one-half of youths with depressed mood had no documented mental health diagnosis. Decedents were categorized with depressed mood if they were perceived by themselves or others as depressed at the time of death.
Intervention Recommendations
The study authors point to the high number of youth firearm suicide (the method used by nearly half of those who died — 19,027 (46.8%) and recommended interventions. “Suicide prevention strategies are needed for the estimated 22.6 million US children living in households with firearms, of whom 4.5 million are exposed to firearms stored loaded and unlocked,” they wrote.
A mental health diagnosis was documented for only 6308 of 19,027 youths who died by firearms (33.2%).
They noted that research has shown that more than 75% of guns used in youth suicide are owned by a family member, most commonly parents, and the presence of a firearm in the home is linked with a higher risk of youth suicide.
They wrote that the risk can be mitigated by storing all guns locked and unloaded, with ammunition stored and locked in a separate location.
The editorialists said the study highlights the need for action in several primary areas. “Suicide prevention strategies should not solely rely on a history of mental illness to identify at-risk youths, and universal suicide risk screening in healthcare settings deserves greater consideration,” they wrote.
Equitable access to care is essential to youth suicide risk detection. Interventions such as lethal means safety counseling, safety planning, and a helpline number, such as 988, should be accessible to every family and healthcare clinician.
Community-level interventions are critical, including school-based suicide prevention programs, as well as population-based training for families on the safe storage of lethal means at home.
“Every trusted adult working with children and adolescents can and should be trained to recognize the warning signs of suicide risk and help young people develop the coping strategies needed to manage difficult life experiences so that suicide is never an option,” Dr. Horowitz and colleagues wrote.
A coauthor of the study, Jennifer A. Hoffmann, MD, reports receiving grants from Children’s Research Fund Junior Board outside the submitted work. Another coauthor, Joel Fein, MD, reports fees for a patent owned by Children’s Hospital of Philadelphia licensed to Potential for the Behavioral Health Screen-Emergency Department. Among the editorialists, Jeffrey A. Bridge, PhD, reported grants from the National Institute of Mental Health, Patient Centered Outcomes Research Institute, and Centers for Disease Control and Prevention; and being a member of the Scientific Advisory Board of Clarigent Health and the Scientific Council of the American Foundation for Suicide Prevention outside the submitted work.
, according to a large analysis of Centers for Disease Control and Prevention data.
Sofia Chaudhary, MD, with the Department of Pediatrics and Emergency Medicine at Emory University School of Medicine in Atlanta, Georgia, and colleagues, analyzed data from the National Violent Death Reporting System and found in the cross-sectional study of 40, 618 youths that 24,192 (59.6%) had no such diagnosis previously. Findings were published online in JAMA Network Open.
Gaps by Race, Sex and Age
The odds of having a mental health diagnosis before death by suicide differed by race and sex. Compared with White youths, the odds were lower among youths who were American Indian or Alaska Native (adjusted odds ratio [aOR], 0.45; Asian, Native Hawaiian, or Other Pacific Islander (aOR, 0.58); and Black youths (aOR, 0.62). And more than half of female youths who died by suicide had a mental health diagnosis (4429 youths [52.4%]), compared with 11,994 male youths (37.3%).
The researchers also found wide gaps by age, specifically lower odds of having a mental health diagnosis before suicide in children ages 10-14 compared with those 20-24.
“This finding is particularly notable because suicide rates have risen to become the second leading cause of death in youths aged 10 to 14 years,” the authors wrote. “Suicide prevention strategies for young children in primary care and community settings should focus on fostering resilience, promoting peer and family connectedness, and empowering children with strategies to cope with stress and adversity.”
Youths who died by firearm suicide, the most common mechanism, had the lowest rate of diagnosis. “Similar to a prior study, we found that decedents without a documented mental health diagnosis were far more likely to utilize a firearm than those with a documented mental health diagnosis,” the authors wrote.
In an invited commentary, Lisa M. Horowitz, PhD, MPH, with the Office of the Clinical Director, Intramural Research Program, National Institute of Mental Health, in Bethesda, Maryland, and colleagues wrote that the data show that identifying youth early who have mental disorders or are at-risk for suicide “is more the exception than the rule” in the United States.
The editorialists highlight that the study showed that about one-quarter of youths who have attempted suicide and nearly one-half of youths with depressed mood had no documented mental health diagnosis. Decedents were categorized with depressed mood if they were perceived by themselves or others as depressed at the time of death.
Intervention Recommendations
The study authors point to the high number of youth firearm suicide (the method used by nearly half of those who died — 19,027 (46.8%) and recommended interventions. “Suicide prevention strategies are needed for the estimated 22.6 million US children living in households with firearms, of whom 4.5 million are exposed to firearms stored loaded and unlocked,” they wrote.
A mental health diagnosis was documented for only 6308 of 19,027 youths who died by firearms (33.2%).
They noted that research has shown that more than 75% of guns used in youth suicide are owned by a family member, most commonly parents, and the presence of a firearm in the home is linked with a higher risk of youth suicide.
They wrote that the risk can be mitigated by storing all guns locked and unloaded, with ammunition stored and locked in a separate location.
The editorialists said the study highlights the need for action in several primary areas. “Suicide prevention strategies should not solely rely on a history of mental illness to identify at-risk youths, and universal suicide risk screening in healthcare settings deserves greater consideration,” they wrote.
Equitable access to care is essential to youth suicide risk detection. Interventions such as lethal means safety counseling, safety planning, and a helpline number, such as 988, should be accessible to every family and healthcare clinician.
Community-level interventions are critical, including school-based suicide prevention programs, as well as population-based training for families on the safe storage of lethal means at home.
“Every trusted adult working with children and adolescents can and should be trained to recognize the warning signs of suicide risk and help young people develop the coping strategies needed to manage difficult life experiences so that suicide is never an option,” Dr. Horowitz and colleagues wrote.
A coauthor of the study, Jennifer A. Hoffmann, MD, reports receiving grants from Children’s Research Fund Junior Board outside the submitted work. Another coauthor, Joel Fein, MD, reports fees for a patent owned by Children’s Hospital of Philadelphia licensed to Potential for the Behavioral Health Screen-Emergency Department. Among the editorialists, Jeffrey A. Bridge, PhD, reported grants from the National Institute of Mental Health, Patient Centered Outcomes Research Institute, and Centers for Disease Control and Prevention; and being a member of the Scientific Advisory Board of Clarigent Health and the Scientific Council of the American Foundation for Suicide Prevention outside the submitted work.
, according to a large analysis of Centers for Disease Control and Prevention data.
Sofia Chaudhary, MD, with the Department of Pediatrics and Emergency Medicine at Emory University School of Medicine in Atlanta, Georgia, and colleagues, analyzed data from the National Violent Death Reporting System and found in the cross-sectional study of 40, 618 youths that 24,192 (59.6%) had no such diagnosis previously. Findings were published online in JAMA Network Open.
Gaps by Race, Sex and Age
The odds of having a mental health diagnosis before death by suicide differed by race and sex. Compared with White youths, the odds were lower among youths who were American Indian or Alaska Native (adjusted odds ratio [aOR], 0.45; Asian, Native Hawaiian, or Other Pacific Islander (aOR, 0.58); and Black youths (aOR, 0.62). And more than half of female youths who died by suicide had a mental health diagnosis (4429 youths [52.4%]), compared with 11,994 male youths (37.3%).
The researchers also found wide gaps by age, specifically lower odds of having a mental health diagnosis before suicide in children ages 10-14 compared with those 20-24.
“This finding is particularly notable because suicide rates have risen to become the second leading cause of death in youths aged 10 to 14 years,” the authors wrote. “Suicide prevention strategies for young children in primary care and community settings should focus on fostering resilience, promoting peer and family connectedness, and empowering children with strategies to cope with stress and adversity.”
Youths who died by firearm suicide, the most common mechanism, had the lowest rate of diagnosis. “Similar to a prior study, we found that decedents without a documented mental health diagnosis were far more likely to utilize a firearm than those with a documented mental health diagnosis,” the authors wrote.
In an invited commentary, Lisa M. Horowitz, PhD, MPH, with the Office of the Clinical Director, Intramural Research Program, National Institute of Mental Health, in Bethesda, Maryland, and colleagues wrote that the data show that identifying youth early who have mental disorders or are at-risk for suicide “is more the exception than the rule” in the United States.
The editorialists highlight that the study showed that about one-quarter of youths who have attempted suicide and nearly one-half of youths with depressed mood had no documented mental health diagnosis. Decedents were categorized with depressed mood if they were perceived by themselves or others as depressed at the time of death.
Intervention Recommendations
The study authors point to the high number of youth firearm suicide (the method used by nearly half of those who died — 19,027 (46.8%) and recommended interventions. “Suicide prevention strategies are needed for the estimated 22.6 million US children living in households with firearms, of whom 4.5 million are exposed to firearms stored loaded and unlocked,” they wrote.
A mental health diagnosis was documented for only 6308 of 19,027 youths who died by firearms (33.2%).
They noted that research has shown that more than 75% of guns used in youth suicide are owned by a family member, most commonly parents, and the presence of a firearm in the home is linked with a higher risk of youth suicide.
They wrote that the risk can be mitigated by storing all guns locked and unloaded, with ammunition stored and locked in a separate location.
The editorialists said the study highlights the need for action in several primary areas. “Suicide prevention strategies should not solely rely on a history of mental illness to identify at-risk youths, and universal suicide risk screening in healthcare settings deserves greater consideration,” they wrote.
Equitable access to care is essential to youth suicide risk detection. Interventions such as lethal means safety counseling, safety planning, and a helpline number, such as 988, should be accessible to every family and healthcare clinician.
Community-level interventions are critical, including school-based suicide prevention programs, as well as population-based training for families on the safe storage of lethal means at home.
“Every trusted adult working with children and adolescents can and should be trained to recognize the warning signs of suicide risk and help young people develop the coping strategies needed to manage difficult life experiences so that suicide is never an option,” Dr. Horowitz and colleagues wrote.
A coauthor of the study, Jennifer A. Hoffmann, MD, reports receiving grants from Children’s Research Fund Junior Board outside the submitted work. Another coauthor, Joel Fein, MD, reports fees for a patent owned by Children’s Hospital of Philadelphia licensed to Potential for the Behavioral Health Screen-Emergency Department. Among the editorialists, Jeffrey A. Bridge, PhD, reported grants from the National Institute of Mental Health, Patient Centered Outcomes Research Institute, and Centers for Disease Control and Prevention; and being a member of the Scientific Advisory Board of Clarigent Health and the Scientific Council of the American Foundation for Suicide Prevention outside the submitted work.
FROM JAMA NETWORK OPEN
The Mysterious Latch
While there may be some lactation consultants who disagree, in my experience counseling women attempting to breastfeed is more art than science. Well before the American Academy of Pediatrics (AAP) began to offer mini courses on breastfeeding for practitioners I was left to help new mothers based on watching my wife nurse our three children and what scraps of common sense I could sweep up off the floor.
Using my own benchmarks of success I would say I did a decent job with dyads who sought my help. I began by accepting that even under optimal conditions, not every woman and/or child can successfully breastfeed. None of the infants died or was hospitalized with dehydration. A few may have required some additional phototherapy, but they all completed infancy in good shape. On the maternal side I am sure there were a few mothers who had lingering feelings of inadequacy because they had “failed” at breastfeeding. But, for the most part, I think I succeeded in helping new mothers remain as mentally healthy as they could be given the rigors of motherhood. At least I gave it my best shot.
If I had a strategy, it was a focus on maintaining a routine (schedule can have an ugly aura about it) that allowed mothers to achieve spells of restorative rest. Helping mothers with the difficult task of deciding whether their infant was hungry, or tired, or uncomfortable was always a struggle, but well worth the effort when we succeeded. Finally, I tried to help mothers step back off the ledge and look at the bigger picture — breastfeeding was not the only way to feed their baby while we were working to overcome the bumps in the road.
Where I failed was in my inability to effectively counsel when it came to the mysteries of the latch. In large part it was because I was a man and helping the dyad succeed at latching on to the breast can require a hands-on approach with which I felt a bit uncomfortable. I could certainly test a baby’s suck and oral architecture with my pinky but otherwise I had to rely on women to help if latching was a problem. I think even trained lactation consultants have difficulty with this mysterious process, which is completely hidden from view inside the baby’s mouth.
Fortunately for me and the dyads I was working with, we rarely considered ankyloglossia as a problem. My training had been that tongue-tie seldom, if ever, contributed to speech problems and even less commonly hindered latch. I think I recall snipping a couple of lingual frenulums early in my career in a bloodless and seemingly painless procedure. But, for the life of me I can’t recall the motivation. It may have been that the ankyloglossia was so obvious that I couldn’t convince the parents it would resolve or it was at the request of a lactation consultant.
But, obviously after I stopped seeing newborns a decade and a half ago the lingual frenulum became a target of surgical assault with, at times, unfortunate results that made breastfeeding painful and more difficult. It’s hard for me to imagine why anyone would consider using a laser for such a simple procedure. But, then I haven’t invested in a laser that allowed me to charge $800 for the procedure. I doubt I even charged for it. It wouldn’t have been worth the time and effort to look up the code. But, then, technology and money can be powerful motivators.
The good news is the AAP has been watching and recently issued a clinical report in which they state what many of us have known from personal observation — They further note that “the symptoms of ankyloglossia overlap those of other breastfeeding difficulties.”
So there you have it. Another fad has been squashed and we’ve come full circle. The latch still remains mystery hidden from view. I think we have to suspect that there exists a small number of dyads in which tongue-tie creates a problem with nursing. And, there may be some safe imaging technique coming along that gives us a glimpse of what happens in the dark recesses of a nursing baby’s mouth. Until then we must rely on masters of the art of lactation consulting, the “Latch Whisperers.”
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].
While there may be some lactation consultants who disagree, in my experience counseling women attempting to breastfeed is more art than science. Well before the American Academy of Pediatrics (AAP) began to offer mini courses on breastfeeding for practitioners I was left to help new mothers based on watching my wife nurse our three children and what scraps of common sense I could sweep up off the floor.
Using my own benchmarks of success I would say I did a decent job with dyads who sought my help. I began by accepting that even under optimal conditions, not every woman and/or child can successfully breastfeed. None of the infants died or was hospitalized with dehydration. A few may have required some additional phototherapy, but they all completed infancy in good shape. On the maternal side I am sure there were a few mothers who had lingering feelings of inadequacy because they had “failed” at breastfeeding. But, for the most part, I think I succeeded in helping new mothers remain as mentally healthy as they could be given the rigors of motherhood. At least I gave it my best shot.
If I had a strategy, it was a focus on maintaining a routine (schedule can have an ugly aura about it) that allowed mothers to achieve spells of restorative rest. Helping mothers with the difficult task of deciding whether their infant was hungry, or tired, or uncomfortable was always a struggle, but well worth the effort when we succeeded. Finally, I tried to help mothers step back off the ledge and look at the bigger picture — breastfeeding was not the only way to feed their baby while we were working to overcome the bumps in the road.
Where I failed was in my inability to effectively counsel when it came to the mysteries of the latch. In large part it was because I was a man and helping the dyad succeed at latching on to the breast can require a hands-on approach with which I felt a bit uncomfortable. I could certainly test a baby’s suck and oral architecture with my pinky but otherwise I had to rely on women to help if latching was a problem. I think even trained lactation consultants have difficulty with this mysterious process, which is completely hidden from view inside the baby’s mouth.
Fortunately for me and the dyads I was working with, we rarely considered ankyloglossia as a problem. My training had been that tongue-tie seldom, if ever, contributed to speech problems and even less commonly hindered latch. I think I recall snipping a couple of lingual frenulums early in my career in a bloodless and seemingly painless procedure. But, for the life of me I can’t recall the motivation. It may have been that the ankyloglossia was so obvious that I couldn’t convince the parents it would resolve or it was at the request of a lactation consultant.
But, obviously after I stopped seeing newborns a decade and a half ago the lingual frenulum became a target of surgical assault with, at times, unfortunate results that made breastfeeding painful and more difficult. It’s hard for me to imagine why anyone would consider using a laser for such a simple procedure. But, then I haven’t invested in a laser that allowed me to charge $800 for the procedure. I doubt I even charged for it. It wouldn’t have been worth the time and effort to look up the code. But, then, technology and money can be powerful motivators.
The good news is the AAP has been watching and recently issued a clinical report in which they state what many of us have known from personal observation — They further note that “the symptoms of ankyloglossia overlap those of other breastfeeding difficulties.”
So there you have it. Another fad has been squashed and we’ve come full circle. The latch still remains mystery hidden from view. I think we have to suspect that there exists a small number of dyads in which tongue-tie creates a problem with nursing. And, there may be some safe imaging technique coming along that gives us a glimpse of what happens in the dark recesses of a nursing baby’s mouth. Until then we must rely on masters of the art of lactation consulting, the “Latch Whisperers.”
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].
While there may be some lactation consultants who disagree, in my experience counseling women attempting to breastfeed is more art than science. Well before the American Academy of Pediatrics (AAP) began to offer mini courses on breastfeeding for practitioners I was left to help new mothers based on watching my wife nurse our three children and what scraps of common sense I could sweep up off the floor.
Using my own benchmarks of success I would say I did a decent job with dyads who sought my help. I began by accepting that even under optimal conditions, not every woman and/or child can successfully breastfeed. None of the infants died or was hospitalized with dehydration. A few may have required some additional phototherapy, but they all completed infancy in good shape. On the maternal side I am sure there were a few mothers who had lingering feelings of inadequacy because they had “failed” at breastfeeding. But, for the most part, I think I succeeded in helping new mothers remain as mentally healthy as they could be given the rigors of motherhood. At least I gave it my best shot.
If I had a strategy, it was a focus on maintaining a routine (schedule can have an ugly aura about it) that allowed mothers to achieve spells of restorative rest. Helping mothers with the difficult task of deciding whether their infant was hungry, or tired, or uncomfortable was always a struggle, but well worth the effort when we succeeded. Finally, I tried to help mothers step back off the ledge and look at the bigger picture — breastfeeding was not the only way to feed their baby while we were working to overcome the bumps in the road.
Where I failed was in my inability to effectively counsel when it came to the mysteries of the latch. In large part it was because I was a man and helping the dyad succeed at latching on to the breast can require a hands-on approach with which I felt a bit uncomfortable. I could certainly test a baby’s suck and oral architecture with my pinky but otherwise I had to rely on women to help if latching was a problem. I think even trained lactation consultants have difficulty with this mysterious process, which is completely hidden from view inside the baby’s mouth.
Fortunately for me and the dyads I was working with, we rarely considered ankyloglossia as a problem. My training had been that tongue-tie seldom, if ever, contributed to speech problems and even less commonly hindered latch. I think I recall snipping a couple of lingual frenulums early in my career in a bloodless and seemingly painless procedure. But, for the life of me I can’t recall the motivation. It may have been that the ankyloglossia was so obvious that I couldn’t convince the parents it would resolve or it was at the request of a lactation consultant.
But, obviously after I stopped seeing newborns a decade and a half ago the lingual frenulum became a target of surgical assault with, at times, unfortunate results that made breastfeeding painful and more difficult. It’s hard for me to imagine why anyone would consider using a laser for such a simple procedure. But, then I haven’t invested in a laser that allowed me to charge $800 for the procedure. I doubt I even charged for it. It wouldn’t have been worth the time and effort to look up the code. But, then, technology and money can be powerful motivators.
The good news is the AAP has been watching and recently issued a clinical report in which they state what many of us have known from personal observation — They further note that “the symptoms of ankyloglossia overlap those of other breastfeeding difficulties.”
So there you have it. Another fad has been squashed and we’ve come full circle. The latch still remains mystery hidden from view. I think we have to suspect that there exists a small number of dyads in which tongue-tie creates a problem with nursing. And, there may be some safe imaging technique coming along that gives us a glimpse of what happens in the dark recesses of a nursing baby’s mouth. Until then we must rely on masters of the art of lactation consulting, the “Latch Whisperers.”
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].
Case Series: Upadacitinib Effective for Granulomatous Cheilitis
TOPLINE:
in a small retrospective case series.
METHODOLOGY:
- Granulomatous cheilitis is a rare, nonnecrotizing granulomatous inflammatory disorder characterized by intermittent or persistent swelling of the lips.
- In a retrospective case series of five patients (median age, 30 years; four women) with granulomatous cheilitis resistant to systemic treatments at a Belgian hospital between June 2023 and March 2024, all five were treated with a high dose of upadacitinib (30 mg daily).
- The primary endpoint was objective clinical improvement in lip swelling and infiltration over a median follow-up of 7.2 months.
- Three patients had concomitant dormant Crohn’s disease (CD); a secondary outcome was disease activity in these patients.
TAKEAWAY:
- Upadacitinib treatment resulted in a complete response in four patients (80%) within a median of 3.8 months and a partial response in one patient.
- CD remained dormant in the three patients with CD.
- The safety profile of upadacitinib was favorable, and no serious adverse events were reported. Two patients experienced headaches, acne, mild changes in lipids, and/or transaminitis.
IN PRACTICE:
“Upadacitinib was effective in treating patients with recalcitrant and long-lasting granulomatous cheilitis, even in cases of concomitant CD, which could substantially improve the quality of life of affected patients,” the authors wrote. More studies are needed to confirm these results in larger groups of patients over longer periods of time, “and with other JAK inhibitors.”
SOURCE:
The study was led by Axel De Greef, MD, Department of Dermatology, Cliniques universitaires Saint-Luc, Université catholique de Louvain (UCLouvain), Brussels, Belgium. It was published online in JAMA Dermatology.
LIMITATIONS:
The small sample size and short follow-up may limit the generalizability of the findings to a larger population of patients with granulomatous cheilitis.
DISCLOSURES:
The study did not report any funding sources. Some authors reported receiving nonfinancial support and personal fees from various pharmaceutical companies outside the submitted work.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.
TOPLINE:
in a small retrospective case series.
METHODOLOGY:
- Granulomatous cheilitis is a rare, nonnecrotizing granulomatous inflammatory disorder characterized by intermittent or persistent swelling of the lips.
- In a retrospective case series of five patients (median age, 30 years; four women) with granulomatous cheilitis resistant to systemic treatments at a Belgian hospital between June 2023 and March 2024, all five were treated with a high dose of upadacitinib (30 mg daily).
- The primary endpoint was objective clinical improvement in lip swelling and infiltration over a median follow-up of 7.2 months.
- Three patients had concomitant dormant Crohn’s disease (CD); a secondary outcome was disease activity in these patients.
TAKEAWAY:
- Upadacitinib treatment resulted in a complete response in four patients (80%) within a median of 3.8 months and a partial response in one patient.
- CD remained dormant in the three patients with CD.
- The safety profile of upadacitinib was favorable, and no serious adverse events were reported. Two patients experienced headaches, acne, mild changes in lipids, and/or transaminitis.
IN PRACTICE:
“Upadacitinib was effective in treating patients with recalcitrant and long-lasting granulomatous cheilitis, even in cases of concomitant CD, which could substantially improve the quality of life of affected patients,” the authors wrote. More studies are needed to confirm these results in larger groups of patients over longer periods of time, “and with other JAK inhibitors.”
SOURCE:
The study was led by Axel De Greef, MD, Department of Dermatology, Cliniques universitaires Saint-Luc, Université catholique de Louvain (UCLouvain), Brussels, Belgium. It was published online in JAMA Dermatology.
LIMITATIONS:
The small sample size and short follow-up may limit the generalizability of the findings to a larger population of patients with granulomatous cheilitis.
DISCLOSURES:
The study did not report any funding sources. Some authors reported receiving nonfinancial support and personal fees from various pharmaceutical companies outside the submitted work.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.
TOPLINE:
in a small retrospective case series.
METHODOLOGY:
- Granulomatous cheilitis is a rare, nonnecrotizing granulomatous inflammatory disorder characterized by intermittent or persistent swelling of the lips.
- In a retrospective case series of five patients (median age, 30 years; four women) with granulomatous cheilitis resistant to systemic treatments at a Belgian hospital between June 2023 and March 2024, all five were treated with a high dose of upadacitinib (30 mg daily).
- The primary endpoint was objective clinical improvement in lip swelling and infiltration over a median follow-up of 7.2 months.
- Three patients had concomitant dormant Crohn’s disease (CD); a secondary outcome was disease activity in these patients.
TAKEAWAY:
- Upadacitinib treatment resulted in a complete response in four patients (80%) within a median of 3.8 months and a partial response in one patient.
- CD remained dormant in the three patients with CD.
- The safety profile of upadacitinib was favorable, and no serious adverse events were reported. Two patients experienced headaches, acne, mild changes in lipids, and/or transaminitis.
IN PRACTICE:
“Upadacitinib was effective in treating patients with recalcitrant and long-lasting granulomatous cheilitis, even in cases of concomitant CD, which could substantially improve the quality of life of affected patients,” the authors wrote. More studies are needed to confirm these results in larger groups of patients over longer periods of time, “and with other JAK inhibitors.”
SOURCE:
The study was led by Axel De Greef, MD, Department of Dermatology, Cliniques universitaires Saint-Luc, Université catholique de Louvain (UCLouvain), Brussels, Belgium. It was published online in JAMA Dermatology.
LIMITATIONS:
The small sample size and short follow-up may limit the generalizability of the findings to a larger population of patients with granulomatous cheilitis.
DISCLOSURES:
The study did not report any funding sources. Some authors reported receiving nonfinancial support and personal fees from various pharmaceutical companies outside the submitted work.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.
Psychiatric, Autoimmune Comorbidities Increased in Patients with Alopecia Areata
TOPLINE:
and were at greater risk of developing those comorbidities after diagnosis.
METHODOLOGY:
- Researchers evaluated 63,384 patients with AA and 3,309,107 individuals without AA (aged 12-64 years) from the Merative MarketScan Research Databases.
- The matched cohorts included 16,512 patients with AA and 66,048 control individuals.
- Outcomes were the prevalence of psychiatric and autoimmune diseases at baseline and the incidence of new-onset psychiatric and autoimmune diseases during the year after diagnosis.
TAKEAWAY:
- Overall, patients with AA showed a greater prevalence of any psychiatric disease (30.9% vs 26.8%; P < .001) and any immune-mediated or autoimmune disease (16.1% vs 8.9%; P < .0001) than those with controls.
- In matched cohorts, patients with AA also showed a higher incidence of any new-onset psychiatric diseases (10.2% vs 6.8%; P < .001) or immune-mediated or autoimmune disease (6.2% vs 1.5%; P <.001) within the first 12 months of AA diagnosis than those with controls.
- Among patients with AA, the risk of developing a psychiatric comorbidity was higher (adjusted hazard ratio [aHR], 1.3; 95% CI, 1.3-1.4). The highest risks were seen for adjustment disorder (aHR, 1.5), panic disorder (aHR, 1.4), and sexual dysfunction (aHR, 1.4).
- Compared with controls, patients with AA were also at an increased risk of developing immune-mediated or autoimmune comorbidities (aHR, 2.7; 95% CI, 2.5-2.8), with the highest for systemic lupus (aHR, 5.7), atopic dermatitis (aHR, 4.3), and vitiligo (aHR, 3.8).
IN PRACTICE:
“Routine monitoring of patients with AA, especially those at risk of developing comorbidities, may permit earlier and more effective intervention,” the authors wrote.
SOURCE:
The study was led by Arash Mostaghimi, MD, MPA, MPH, Brigham and Women’s Hospital and Harvard University, Boston. It was published online on July 31, 2024, in JAMA Dermatology.
LIMITATIONS:
Causality could not be inferred because of the retrospective nature of the study. Comorbidities were solely diagnosed on the basis of diagnostic codes, and researchers did not have access to characteristics such as lab values that could have indicated any underlying comorbidity before the AA diagnosis. This study also did not account for the varying levels of severity of the disease, which may have led to an underestimation of disease burden and the risk for comorbidities.
DISCLOSURES:
AbbVie provided funding for this study. Mostaghimi disclosed receiving personal fees from Abbvie and several other companies outside of this work. The other four authors were current or former employees of Abbvie and have or may have stock and/or stock options in AbbVie.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.
TOPLINE:
and were at greater risk of developing those comorbidities after diagnosis.
METHODOLOGY:
- Researchers evaluated 63,384 patients with AA and 3,309,107 individuals without AA (aged 12-64 years) from the Merative MarketScan Research Databases.
- The matched cohorts included 16,512 patients with AA and 66,048 control individuals.
- Outcomes were the prevalence of psychiatric and autoimmune diseases at baseline and the incidence of new-onset psychiatric and autoimmune diseases during the year after diagnosis.
TAKEAWAY:
- Overall, patients with AA showed a greater prevalence of any psychiatric disease (30.9% vs 26.8%; P < .001) and any immune-mediated or autoimmune disease (16.1% vs 8.9%; P < .0001) than those with controls.
- In matched cohorts, patients with AA also showed a higher incidence of any new-onset psychiatric diseases (10.2% vs 6.8%; P < .001) or immune-mediated or autoimmune disease (6.2% vs 1.5%; P <.001) within the first 12 months of AA diagnosis than those with controls.
- Among patients with AA, the risk of developing a psychiatric comorbidity was higher (adjusted hazard ratio [aHR], 1.3; 95% CI, 1.3-1.4). The highest risks were seen for adjustment disorder (aHR, 1.5), panic disorder (aHR, 1.4), and sexual dysfunction (aHR, 1.4).
- Compared with controls, patients with AA were also at an increased risk of developing immune-mediated or autoimmune comorbidities (aHR, 2.7; 95% CI, 2.5-2.8), with the highest for systemic lupus (aHR, 5.7), atopic dermatitis (aHR, 4.3), and vitiligo (aHR, 3.8).
IN PRACTICE:
“Routine monitoring of patients with AA, especially those at risk of developing comorbidities, may permit earlier and more effective intervention,” the authors wrote.
SOURCE:
The study was led by Arash Mostaghimi, MD, MPA, MPH, Brigham and Women’s Hospital and Harvard University, Boston. It was published online on July 31, 2024, in JAMA Dermatology.
LIMITATIONS:
Causality could not be inferred because of the retrospective nature of the study. Comorbidities were solely diagnosed on the basis of diagnostic codes, and researchers did not have access to characteristics such as lab values that could have indicated any underlying comorbidity before the AA diagnosis. This study also did not account for the varying levels of severity of the disease, which may have led to an underestimation of disease burden and the risk for comorbidities.
DISCLOSURES:
AbbVie provided funding for this study. Mostaghimi disclosed receiving personal fees from Abbvie and several other companies outside of this work. The other four authors were current or former employees of Abbvie and have or may have stock and/or stock options in AbbVie.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.
TOPLINE:
and were at greater risk of developing those comorbidities after diagnosis.
METHODOLOGY:
- Researchers evaluated 63,384 patients with AA and 3,309,107 individuals without AA (aged 12-64 years) from the Merative MarketScan Research Databases.
- The matched cohorts included 16,512 patients with AA and 66,048 control individuals.
- Outcomes were the prevalence of psychiatric and autoimmune diseases at baseline and the incidence of new-onset psychiatric and autoimmune diseases during the year after diagnosis.
TAKEAWAY:
- Overall, patients with AA showed a greater prevalence of any psychiatric disease (30.9% vs 26.8%; P < .001) and any immune-mediated or autoimmune disease (16.1% vs 8.9%; P < .0001) than those with controls.
- In matched cohorts, patients with AA also showed a higher incidence of any new-onset psychiatric diseases (10.2% vs 6.8%; P < .001) or immune-mediated or autoimmune disease (6.2% vs 1.5%; P <.001) within the first 12 months of AA diagnosis than those with controls.
- Among patients with AA, the risk of developing a psychiatric comorbidity was higher (adjusted hazard ratio [aHR], 1.3; 95% CI, 1.3-1.4). The highest risks were seen for adjustment disorder (aHR, 1.5), panic disorder (aHR, 1.4), and sexual dysfunction (aHR, 1.4).
- Compared with controls, patients with AA were also at an increased risk of developing immune-mediated or autoimmune comorbidities (aHR, 2.7; 95% CI, 2.5-2.8), with the highest for systemic lupus (aHR, 5.7), atopic dermatitis (aHR, 4.3), and vitiligo (aHR, 3.8).
IN PRACTICE:
“Routine monitoring of patients with AA, especially those at risk of developing comorbidities, may permit earlier and more effective intervention,” the authors wrote.
SOURCE:
The study was led by Arash Mostaghimi, MD, MPA, MPH, Brigham and Women’s Hospital and Harvard University, Boston. It was published online on July 31, 2024, in JAMA Dermatology.
LIMITATIONS:
Causality could not be inferred because of the retrospective nature of the study. Comorbidities were solely diagnosed on the basis of diagnostic codes, and researchers did not have access to characteristics such as lab values that could have indicated any underlying comorbidity before the AA diagnosis. This study also did not account for the varying levels of severity of the disease, which may have led to an underestimation of disease burden and the risk for comorbidities.
DISCLOSURES:
AbbVie provided funding for this study. Mostaghimi disclosed receiving personal fees from Abbvie and several other companies outside of this work. The other four authors were current or former employees of Abbvie and have or may have stock and/or stock options in AbbVie.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.
Skin Dxs in Children in Refugee Camps Include Fungal Infections, Leishmaniasis
on the topic, a literature review showed. However, likely culprits include infectious diseases with cutaneous manifestations, such as pediculosis, tinea capitis, and scabies.
“Current data indicates that one in two refugees are children,” one of the study investigators, Mehar Maju, MPH, a fourth-year student at of the University of Washington School of Medicine, Seattle, said in an interview following the annual meeting of the Society for Pediatric Dermatology, where the results were presented during a poster session.
“The number of refugees continues to rise to unprecedented levels every year,” and climate change continues to drive increases in migration, “impacting those residing in camps,” she said. “As we continue to think about what this means for best supporting those residing in camps, I think it’s also important to consider how to best support refugees, specifically children, when they arrive in the United States. Part of this is to know what conditions are most prevalent and what type of social support this vulnerable population needs.”
To identify the common dermatologic conditions among children living in refugee camps, Ms. Maju and fellow fourth-year University of Washington medical student Nadia Siddiqui searched PubMed and Google Scholar for studies that were published in English and reported on the skin disease prevalence and management for refugees who are children. Key search terms used included “refugees,” “children,” “dermatology,” and “skin disease.” Of approximately 105 potential studies identified, 19 underwent analysis. Of these, only five were included in the final review.
One of the five studies was conducted in rural Nyala, Sudan. The study found that 88.8% of those living in orphanages and refugee camps were reported to have a skin disorder, commonly fungal or bacterial infections and dermatitis. In a separate case series, researchers found that cutaneous leishmaniasis was rising among Syrian refugee children.
A study that looked at morbidity and disease burden in mainland Greece refugee camps found that the skin was the second-most common site of communicable diseases among children, behind those of the respiratory tract. In another study that investigated the health of children in Australian immigration detention centers, complaints related to skin conditions were significantly elevated among children who were detained offshore, compared with those who were detained onshore.
Finally, in a study of 125 children between the ages of 1 and 15 years at a Sierra Leone–based displacement camp, the prevalence of scabies was 77% among those aged < 5 years and peaked to 86% among those aged 5-9 years.
“It was surprising to see the limited information about dermatologic diseases impacting children in refugee camps,” Ms. Maju said. “I expected that there would be more information on the specific proportion of diseases beyond those of infectious etiology. For example, I had believed that we would have more information on the prevalence of atopic dermatitis, vitiligo, and other more chronic skin diseases.”
She acknowledged certain limitations of the analysis, mainly the lack of published information on the skin health of pediatric refugees. “A study that evaluates the health status and dermatologic prevalence of disease among children residing in camps and those newly arrived in the United States from camps would provide unprecedented insight into this topic,” Ms. Maju said. “The results could guide public health efforts in improving care delivery and preparedness in camps and clinicians serving this particular population when they arrive in the United States.”
She and Ms. Siddiqui reported having no relevant disclosures.
A version of this article first appeared on Medscape.com.
on the topic, a literature review showed. However, likely culprits include infectious diseases with cutaneous manifestations, such as pediculosis, tinea capitis, and scabies.
“Current data indicates that one in two refugees are children,” one of the study investigators, Mehar Maju, MPH, a fourth-year student at of the University of Washington School of Medicine, Seattle, said in an interview following the annual meeting of the Society for Pediatric Dermatology, where the results were presented during a poster session.
“The number of refugees continues to rise to unprecedented levels every year,” and climate change continues to drive increases in migration, “impacting those residing in camps,” she said. “As we continue to think about what this means for best supporting those residing in camps, I think it’s also important to consider how to best support refugees, specifically children, when they arrive in the United States. Part of this is to know what conditions are most prevalent and what type of social support this vulnerable population needs.”
To identify the common dermatologic conditions among children living in refugee camps, Ms. Maju and fellow fourth-year University of Washington medical student Nadia Siddiqui searched PubMed and Google Scholar for studies that were published in English and reported on the skin disease prevalence and management for refugees who are children. Key search terms used included “refugees,” “children,” “dermatology,” and “skin disease.” Of approximately 105 potential studies identified, 19 underwent analysis. Of these, only five were included in the final review.
One of the five studies was conducted in rural Nyala, Sudan. The study found that 88.8% of those living in orphanages and refugee camps were reported to have a skin disorder, commonly fungal or bacterial infections and dermatitis. In a separate case series, researchers found that cutaneous leishmaniasis was rising among Syrian refugee children.
A study that looked at morbidity and disease burden in mainland Greece refugee camps found that the skin was the second-most common site of communicable diseases among children, behind those of the respiratory tract. In another study that investigated the health of children in Australian immigration detention centers, complaints related to skin conditions were significantly elevated among children who were detained offshore, compared with those who were detained onshore.
Finally, in a study of 125 children between the ages of 1 and 15 years at a Sierra Leone–based displacement camp, the prevalence of scabies was 77% among those aged < 5 years and peaked to 86% among those aged 5-9 years.
“It was surprising to see the limited information about dermatologic diseases impacting children in refugee camps,” Ms. Maju said. “I expected that there would be more information on the specific proportion of diseases beyond those of infectious etiology. For example, I had believed that we would have more information on the prevalence of atopic dermatitis, vitiligo, and other more chronic skin diseases.”
She acknowledged certain limitations of the analysis, mainly the lack of published information on the skin health of pediatric refugees. “A study that evaluates the health status and dermatologic prevalence of disease among children residing in camps and those newly arrived in the United States from camps would provide unprecedented insight into this topic,” Ms. Maju said. “The results could guide public health efforts in improving care delivery and preparedness in camps and clinicians serving this particular population when they arrive in the United States.”
She and Ms. Siddiqui reported having no relevant disclosures.
A version of this article first appeared on Medscape.com.
on the topic, a literature review showed. However, likely culprits include infectious diseases with cutaneous manifestations, such as pediculosis, tinea capitis, and scabies.
“Current data indicates that one in two refugees are children,” one of the study investigators, Mehar Maju, MPH, a fourth-year student at of the University of Washington School of Medicine, Seattle, said in an interview following the annual meeting of the Society for Pediatric Dermatology, where the results were presented during a poster session.
“The number of refugees continues to rise to unprecedented levels every year,” and climate change continues to drive increases in migration, “impacting those residing in camps,” she said. “As we continue to think about what this means for best supporting those residing in camps, I think it’s also important to consider how to best support refugees, specifically children, when they arrive in the United States. Part of this is to know what conditions are most prevalent and what type of social support this vulnerable population needs.”
To identify the common dermatologic conditions among children living in refugee camps, Ms. Maju and fellow fourth-year University of Washington medical student Nadia Siddiqui searched PubMed and Google Scholar for studies that were published in English and reported on the skin disease prevalence and management for refugees who are children. Key search terms used included “refugees,” “children,” “dermatology,” and “skin disease.” Of approximately 105 potential studies identified, 19 underwent analysis. Of these, only five were included in the final review.
One of the five studies was conducted in rural Nyala, Sudan. The study found that 88.8% of those living in orphanages and refugee camps were reported to have a skin disorder, commonly fungal or bacterial infections and dermatitis. In a separate case series, researchers found that cutaneous leishmaniasis was rising among Syrian refugee children.
A study that looked at morbidity and disease burden in mainland Greece refugee camps found that the skin was the second-most common site of communicable diseases among children, behind those of the respiratory tract. In another study that investigated the health of children in Australian immigration detention centers, complaints related to skin conditions were significantly elevated among children who were detained offshore, compared with those who were detained onshore.
Finally, in a study of 125 children between the ages of 1 and 15 years at a Sierra Leone–based displacement camp, the prevalence of scabies was 77% among those aged < 5 years and peaked to 86% among those aged 5-9 years.
“It was surprising to see the limited information about dermatologic diseases impacting children in refugee camps,” Ms. Maju said. “I expected that there would be more information on the specific proportion of diseases beyond those of infectious etiology. For example, I had believed that we would have more information on the prevalence of atopic dermatitis, vitiligo, and other more chronic skin diseases.”
She acknowledged certain limitations of the analysis, mainly the lack of published information on the skin health of pediatric refugees. “A study that evaluates the health status and dermatologic prevalence of disease among children residing in camps and those newly arrived in the United States from camps would provide unprecedented insight into this topic,” Ms. Maju said. “The results could guide public health efforts in improving care delivery and preparedness in camps and clinicians serving this particular population when they arrive in the United States.”
She and Ms. Siddiqui reported having no relevant disclosures.
A version of this article first appeared on Medscape.com.
FROM SPD 2024